Don't Crash That Gurney

It's all fun and games when pushing an old Gurney in a straight line.

Objects moving through space at high speed with a sense of urgency are prone to mishaps. No, I'm not talking about the space shuttle Challenger. I'm thinking of  old school hospital Gurneys which were also known as prams, trolleys, or carts. These unwieldy conveyances had tiny wheels which were really more like casters. Each wheel had an independent locking mechanism that was activated by stomping on a tiny lever.

Adding the weight of a patient to the cart  resulted in a very high center of gravity that conferred an inherent lack of stability. Vintage Gurneys had no counterweights in their base like the meticulously engineered transport devices present in today's hospital. Tiny wheels, poor brakes and a high center of gravity were the recipe for disaster.

Pushing an old fashioned Gurney in a straight line at low speed was a walk in the park. Speed, uneven terrain, sharp corners or heavy loads were complicating issues and relevant factors in Gurney crashes

Crack ups while rounding corners with a loaded hospital trolley had some of the same elements as motorcycle wrecks. I've had personal experience with both types of mishaps. High side motorcycle and Gurney crashes are among the most catastrophic because the patient I mean, rider is thrown off the vehicle ahead of the line of travel of the vehicle and risks not only the fall but the cart or bike then plowing into him. The cause of these crashes is suddenly regaining traction after sliding or skidding around a corner. In the hospital any type of liquid spilled on heavily waxed terrazzo floors is the most common hazard responsible for high side Gurney mishaps.

More benign crashes are of the low side variety where the bike or   Gurney simply skids around a corner and the conveyance  slides sideways gently spilling the patient. Thankfully, this is probably the most common type of Gurney crash and results in minimal injury because the driver is often able to contain the patient before he impacts the floor. Collateral damage from broken glass IV bottles is a common complication of low side wrecks. The Gurney driver is usually in an emotional hyper response  state with marked frontal lobe detachment  after one of these mishaps and hastily picking up glass shards can result in colorful displays. Please, don't ask me how I know about this one but the scars on my fingers are probably a dead give away.

Another factor in gurney wrecks is overloading or raising the center of gravity by personnel standing on the cart for procedures like joint reductions.https://regionstraumapro.com/page/3.  This graphic illustration of an intrepid emergency medicine physician is a good example of a high flying reduction. Hopefully the good doctor  returned safely to terra firma when the procedure was completed.

CPR perfomed on a rapidly moving Gurney always reminded me of a rodeo where a sudden fall is awaiting  the rider.  The nurse performing compressions (somehow it was always a nurse in the saddle) straddled the patient while maintaining the exquisite balance of a Brahama  bull rider as the Gurney surged forward toward more definitive care. Once again the center of mass is raised and the urgency of the situation always manages to exacerbate the propensity for a mishap. The nurse furiously doing chest compressions above the patient was the canary in the coal mine since she was likely to take a tumble before the patient fell. Caution usually prevailed when the Gurney driver sensed the CPR provider was about to take a tumble and slowed everything down befor a crash ensued.

Just like Gundam mech robots patrolling an infinite universe,Gurneys were just about everywhere in the hospital orbit. Gurneys always held a warm spot in my heart because I saw them as a symbol of unification and, oh boy,  we could sure  use some of that in these difficult times.. We are all going to take that last Gurney ride someday no matter what event terminates our earthly existence. Pay close attention to the next soul you see on a Gurney because they can show us all how to take that final ride with a dignified sense of peace. All bets are off if an OFRN like me crashes the cart.

April Fools

"Yikes..that's going to be a challenging intubation. Get her to a trauma bay!"

A pseudo zombie got a jump start on April fools day tomfoolery when she presented to a level one trauma center in Michigan. Professional dancer Jai Fears was in the process of having gruesome make- up applied for a grisly photo shoot and was overcome by an acute panic attack

Maybe the artisan who applied the cosmetics did such a good job that it scared the daylights out of  Jai or perhaps it was an allergic reaction. Over use of make-up is never a good idea.  At any rate, the autonomic storm it prompted was enough to send her to nearby Beaumont Hospital.

As she hit the entry doors to the ER the ever vigilant staff expedited her transfer to a nearby trauma bay. While rituals of ACLS alogorithims danced through their heads a cursory assessment left them flummoxed. Quickly pressing 2 fingers behind the mandible showed a nice regular pulse and an auscultation of her chest revealed the lovely muted swoosh of active gas exchange without rhonchi or rales.

As the apparent acuity of the victim rapidly vamoosed, the trauma team's unconsciously formed tableau dissipated  faster than a snowball on the 4th of July. The hollering that ensued from the trauma bay was not the typical shout out for life saving measures. A shriek more akin to that of an elderly matron who had just been scammed out of her monthly Social Security check reverberated about the trauma room. "My God," hollered the duped trauma surgeon. "It's all just make up."

In a public relations gambit the hospital released the following statement: The emergency room is not a place for fun and games. They see many patients with severe medical issues where lives are at stake. doctors and nurses need to be able to focus on those patients with true emergencies.

In a strange torque of therapeutics, I wonder if the young patient was cured of her panic attack by transferring her feelings to the trauma team.

Getting to the Bottom of the Tidal Wave Enema Story

The trinity of nursing care for big invasive abdominal surgeries included scultetus binders, Montgomery straps, and last, but certainly not least, tidal wave enemas. I briefly mentioned tidal wave enemas in a previous post and I received an email asking about the unsavory details of this backward procedure. I just love esoteric, little known nursing procedures and  nothing came up when I googled tidal wave colonics. So, an idea for this  post about this bowel ballooning buffoonery was born

Before the late 1960s enema administration apparatus consisted of a 2 liter metal can with a tapered spout at the bottom that mated with a 2-3 foot length of opaque rubber tubing. This tubing was connected to a nozzle that ranged  in size from a small straight length to a longer tapered instrument that resembled a bandicoot's snout. Small straight nozzles were useful in uncomplicated cases, but it was tough to beat a large tapered nozzle when retention problems caused unpleasant blow backs. Once a tapered nozzle was snugly ensconced within the leaky aperture, it tended to stay there, putting the brakes on the flustering back blow.

"The only tidal wave I wanna see better be in the ocean."

Rank had privilege in hospital  nursing and full fledged RNs had the benefit of an IV pole to suspend an enema can above their anxious patient awaiting the hydraulic highjinks. Student nurses were mandated to hand hold the enema can at the prescribed height; no easy feat with a fully loaded 2 liter can. That loaded can got heavy rather quickly unless you had the arm strength of Miss Bruiser, my favorite instructor.

 Enemas could be embarrassing for both patients and student nurses alike with Miss Bruiser's running commentary about our lack of arm strength. One of her favorite lines as we struggled with the heavy enema can was, "Is the responsibility of nursing care WEIGHING HEAVILY UPON YOU?" Of course it was and in more than one way.

The  transition to disposable enema sets with crystal clear tubing  illustrated  an interesting phenomenon. While struggling to hold the clear enema  bag airborne, an observant nurse noted the oscillation of the infused solution rising up and down with the patient's respirations. As the enema was nearing completion, expansion of the chest pressurized the colon causing the fluid level in the tubing to rise. Exhalation resulted in a marked descent of the fluid level.

Hand held enema bags and the graphic illustration of the  to and fro flow of the solution provided one of those rather profound "EUREKA" moments in nursing history. The tidal wave enema was born. Nurses soon discovered that any enema could be super charged, so to speak, by aggressively raising and lowering the enema bag while the solution was flowing in. Suddenly raising the enema bag to it's maximum height from a level which was sometimes below the patient produced dramatic results. Patients often complained bitterly of cramping during the peak of the tidal wave, but the end results were often impressive in restoring normal bowel function.

Peristalsis, the progressive wave like movement of the bowel was frequently brought to a halt by old school open abdominal surgeries. When the surgeon noted an absence of bowel sounds during the post -op period, action was required. An order for TWE was written. A plain old TWE order was for the run of the mill tap water enema. A TWE order  with wavy lines scribbled alongside was a directive to bring on the big guns of the tidal wave flush.

The proof was in the pudding with tidal wave enemas which worked wonders in restoring normal peristalsis. They really did the trick.

A Heminephrectomy and a Stock Tip

I really, really, disliked scrubbing in surgeries that involved partial removal of a kidney. The positioning of the patient  on the OR table involved a number of hacks worthy of a MacGyver  Award.  A side lying position, with a break in the table at the inferior thoracic level was a worthy challenge to maintain with sand bags, chunks of foam egg crate mattress, bean bags sans the beans, rolled up surgical towels, and long lengths of 2 inch adhesive tape which were all  included in the patient  placement armamentarium. Anesthesia was worried about compromised gas exchange with gravity pulling abdominal contents downward on the diaphragm while nurses fretted about a tumble from the table.

Once the procedure was underway the nephrology surgeon began his solemn narrative of all the challenges involved; too much monkeying around near the adrenal glands atop the kidney could blow blood pressures sky high, the renal artery had lots of anatomical variations so it was tough to figure out where it ended and the arcuate artery began, and finally, modifications to the fascia were required to hold what was left of the kidney in place. Old school surgeons just loved to hang the crepe before a difficult procedure because then even a bad result might look OK.

After a lengthy discussion of renal pyramids and poles (I could never make sense out of the difference between the two,)  the surgeon excised the pathologic portion of the kidney that most commonly  harbored a benign tumor or cysts. At least most of the partial nephrectomies offered a cure.

Now the fun part for the hapless scrub nurse begins.  To seal the exposed surface of the incised kidney, miniscule pea sized chunks of fat are sutured in place. This time consuming task requires lots and lots of sutures and by the time about half the job was done my bony fingers were aching from loading endless needle holders.

Fatigue can be the impetus for saying stupid things and my preternatural foolishness didn't help matters as I muttered, "Why don't you just throw a couple of stitches around one big hunk of fat and be done with it."

The surgeon gave me one of those churlish looks and quickly changed the subject to one of his particular areas of expertise, stock marked tips. According to this  financially savvy surgeon,  Abbott labs was a sure fire winner and a must buy stock because the share value had been temporarily  eroded by a contaminated IV fluid SNAFU. As soon as the problem was corrected, the share value would soar. As  he enthusiastically  expounded about this must buy stock, the old Airshields ventilator pumped a potent halogenated anesthetic agent into the deeply obtunded patient.

The case proceeded along uneventfully and I helped gently transfer Mitch, the still anesthetized patient unto the gurney. A nurse was always with a patient like this to maintain an airway on the  open road to the recovery room.  I was carefully making sure his silver metal oral airway (no cheesy plastic throwaways like those in current use)  was in place  as I  guided his mandible forward to keep him breathing.

With unexpected gusto Mitch suddenly aroused, pushing my hand away and yanking out that pesky airway. His first words upon regaining consciousness? "Call my broker. I want in on some of that Abbott Labs stock."

Transorbital Intubation - An Artful Airway

Just when I thought the days of art in medicine were extinct,  the above image made it's appearance in my email courtesy of a long time reader. This  patient had extensive facial surgery for an invasive tumor and her maxilla and eye were sacrificed in the process. In a subsequent procedure, the creative anesthetist used this artsy approach in securing her airway. Instead of passing the endotracheal tube pharynx-larynx-trachea, the path was eye socket - pharynx, (or what's left of it) - trachea. Very clever, but how in blue blazes can the pilot balloon be visualized when it's deep inside the patient's face. Art in surgery always has a down side

Whippersnapperns live in a data driven, evidence based world of healthcare, but I know of  a different world where art played a dominant role  like the transorbital airway gambit shown above. Medical arts buildings dotted the landscape and old school surgeons pulled the art card to explain complications or pathology beyond their understanding. I do think the "medical arts" terminology when applied to physician offices  was so much less pretentious than the "institute" label trending today.

Unlike the group practices of today, most vintage surgeons were solo practitioners operating with minimal oversight. These surgeons of bygone years shared something in common with Picasso and Monet, they worked alone and relied on their ingenuity as much as scientific principle. "Based on empirical reasoning, I'm going to take out this lymph node over here and maybe the one over there too," was a typical intraoperative response.

Artful surgery could carry a heavy price for the patient. Someone cobbled together a procedure to "cure" Parkinson's Disease that involved harvesting cells from the difficult to access adrenal glands and injecting  them intracranially in hopes they would generate some much needed dopamine. The aggressive surgery resulted in lots of complications with poor long term results. Artful, but dangerous and usually ineffective.

A more benign example of surgical artistry involved the use of surgical instruments. Orthopedic surgeons found a novel use for Satinsky vascular clamps in that they were perfect for nabbing errant bone chips. I've written about the creative use for grooved directors in a previous post. They make great tongue depressors, templates for duct filets, guiding suture, and as mini retractors. Artistry in surgery always has an unsavory component and burying the sharp prongs of a towel clip in an unsuspecting abdomen to test the level of spinal anesthesia always shivered my timbers.

Unfortunately, patient's bodies make for a poor canvas and scalpel wielding surgical artists often come up with an unintended surprise on their hands. I wonder how that patient above felt about breathing through her eye socket. Breathing is a whole lot different than seeing.

The Surgical Abdomen

While fresh, young  surgeons pour over detailed cross-sectional CT scans or overpriced, extravagant ultrasounds, old surgeons relied on the wisdom gained from a physical exam and meticulous history taking to delineate abdominal pathology. "Hot Bellys," in the vernacular of the day could be a real hornets nest to deal appropriately with, and the wily veterans had there own brand of diagnostic techniques which were crude, but effective.

Decisive clinical diagnosis was elusive, but a strange hodge-podge of clinical maneuvers (if you could call them that) were enlightening to the battle tested old surgeon. Observations were also key element  of the work up.  A "sweated brow" or "a hypovigilant countenance" suggested a septic process. Jaundice suggested some sort of hepatic dysfunction and a strange blue periumbilicular coloration signaled an internal bleed.

The exam of the acute abdomen consisted of, euphemistically, what would be termed palpitation, percussion, and auscultation, but was really poking, pushing, lifting, listening, and twisting limbs around with gusto, much like a pretzel.

The psoas test was performed by forcefully flexing the thigh while rotating the foot outward. The test was contraindicated with concaminant orthopedic injuries. A positive response elicited a vociferous verbal response from the hapless victim  patient and suggested a lower abdominal process.

A shake test was of great value when the patient had difficulty identifying the area of maximal belly pain. While in a supine position the patient's hips were slightly elevated off the bed while a vigorous to and fro shake was delivered. Dr. Slambo, my favorite general surgeon, had an interesting method of augmenting the shake delivery that only applied to ambulatory patients weighing less than 75 kg.

With the physician and patient standing back to back with arms interlocked together at the elbows a gentle elevation is initiated by the good doctor leaning forward. The optimal height was with the patient's feet about 6 inches off the floor. The abdomen is bowed such that the viscera are near  the surface while a side to side shimmy/shake elucidates the problematic quadrant. The technical name of this procedure (according to Dr. Slambow)  was the elevated, gyrating, gambol gambit and it was far better than one of those new fangled CT scans when it came to elucidating the exact focus of abdominal distress..

Dr. Slambow also knew how to augment just about any type of palpation technique with a miraculous gooey, slippery substance known as ordinary Surgilube. He began with a full tube, superior to the umbilical concavity and began squeezing until there was a generous pool of  goop.  He then began exploring the aching quadrant with his hand gliding across the abdomen like a shoe that stepped on a banana peal. The quantity of Surgilube used during the procedure also provided valuable insights when planning the surgical intervention. More than 1/2 a tube of the gelatinous goo signaled problematic obesity that called  for extra long instruments and a platform for Dr. Slambow to stand on while he looked down into the wound.

Fist percussion commonly known as a blow to the upper bread basket was performed along the anterior thoracic wall by placing one hand on the skin and beating it with a fist. Exquisite pain evidenced by vociferous howls indicated cholecystitis or hepatic issues.

Murphy's inspiratory sign can be demonstrated in acute cholecystitis  by asking the patient to take a deep breath while pressure is judiciously applied below the right rib cage. As the liver descends, the inflamed gall bladder is brought into contact with the abdominal wall causing immediate cessation of the inspiration.

I really liked scrubbing on acute abdomens because the offending problem was identifiable and fixable. There was no better feeling than seeing a seriously ill person stroll out of the hospital with a new appreciation of life. Viewing that so vulnerable  prepped abdomen supine on the table awaiting the surgeon's ministrations always put me in a contemplative mood with the realization that despite all our political and religious differences  we are all just meatsacks enjoying an undeserved period of wellness so no matter what or who, With this thought lurking in the back of my foolish mind, I tried to be nice to everyone and treat patients as though they were my mother, father, or child.

Bed Scale Blues

It's easier to push a stalled '57 Chevy than a bed scale!

I made the mistake of reading some of my old posts and some of them resemble a distant ping from a satellite knocked out of orbit. Tales from a far away planet where bedside care was the only currency that mattered and what little money there was flowed away from nurse's pockets. It sounds paradoxical, but the more interface I have with "modern" healthcare, the more I miss the old days.

Oh well, Nero's circus must go on so here's my take on vintage behemoths that were part Hoyer lift, part ironing board, and finally part piano mover's dolly with enough free weights to open a gym. Bed scales were the hospital version of battleships, difficult to change direction when in motion, fraught with danger and best left alone.

The illustration above shows an intrepid  young nurse in transit for her mission; to weigh a bedridden patient. The ironing board part of the scale is hinged so it's vertical when in storage or moving  struggling down the hall. It's visible on the right side of the scale just inside the counterweights. After an arduous journey to the bedside, the ironing board like platform was tilted to a horizontal position. The patient is pulled, pushed, or glided onto the awaiting platform. You know, that old count to three and grunt routine.

The platform is elevated like a not so magic carpet by way of a hydraulic Hoyer lift like pump. Now for the fun part -  where the rubber meets the road. The patient is suspended inches above the bed while the nurse turns her attention to balancing the counterweights. A potential  hazard included becoming distracted by the precarious position of the patient and dropping a 20# weight on your foot. Clinic nursing  shoes did not have a safety toe so that's really going to leave a dandy bruise, if you are lucky. The not so fortunate will see the ortho clinic with compound fractures of the metatarsal bones.

One of the great nursing debates involved the question of including peripherals (How about that? I managed to hijack a term from the computer industry.) like Foley bags or surgical drains in the bedside  weight. The free spirit nurse simply tossed the Foley bag or drain apparatus into the mix and included it in the final weight. Dangling Foleys and drains were always at risk for unintended extrication during the transfer or elevation process so I usually left them be and subtracted a pound for the tare at the conclusion of the procedure.

One of my most colorful nursing instructors, Miss Bruiser had a favorite saying, "Work smarter; not harder." Every nurse hated bed scales with a passion and looked for a smarter procedure when it came to patient's weights. In nursing research there are methods for assuring interrater reliability so that results are consistent. Nurses weighing bedridden patients took a lesson from carnival weight guessing hucksters and followed suit. Before the bed scale weight was determined, the nurse took a guess at the patient's weight. When her guestimate came within 5 lbs. or so she became a certified patient weight confabulator. Leave that massive bedside scale in the clean utility room and bring in the certified nurse weigh approximator. These nurse's were also trained experts at clairvoyant counting patient's  respirations.

Clandestine Patient Restraint Techniques

Nurses providing ambulation assistance 

for an afternoon nap.

Restraining patients is probably one of the most unsavory elements of nursing practice and old school practitioners were masters of obfuscation when it came to forcible restriction of movement. Even office sitting nurses of the academic/administrative complex eschewed patient restraints. Everyone did their very best to find ways around outright restraint of those under their care.

Memos from on high regarding patient restraints were filled with officialese and gobbledygook in an attempt to camouflage what was really  going on. I found a VA restraint and seclusion Professional Services  Memorandum that illustrates this point: VA Form 10-2683, Report of restraint and seclusion.  "The doctor's orders (SF508) will be initialed by the GS9-11 ward nurse. The nurse will copy the prescription (form 10-2913) on the nursing notes (SF510) indicating the type of restraint and 24 hour report of patient's condition (VA form 2915). The nurse in charge of the ward during each tour of duty will maintain a record of each application of restraint on VA form 10-2683. After the last day of the month, the nurse will sign this form and forward it to the Registrar Division - 114A."  Some head nurses referred to the monthly reports as the "Funny Papers" because restraints were not always used according to Hoyle with the frequency of use almost always understated.

Downey VA Hospital, the long term psychiatric hospital I worked at in the early 1970s made extensive use of full restraints that consisted of heavy leather cuffs secured by robust belts. My ways of caring for these patients were unique and foolish, but averted some  of the unpleasantness associated with 4 point restraints. I began a patient enlightenment program that involved patients recognizing when they were beginning to escalate and request restraints before anyone was injured. A veteran of the Viet Nam war summed things up quite  nicely, "Restraints are just like an Asian civil war-much easier to get in than get out." I couldn't have said it better myself.

This illustration clearly shows the time tested maneuver aptly called "let me hold your hand...DOWN. Whether inserting nasogastric tubes or assisting with  excruciating procedures like the removal of Jackson-Pratt surgical drains, every old nurse had experience with this one. Initially, good intentions entailed holding the patient's hand for support, but soon evolved  into a vice grip not unlike the panic induced squeeze on the overhead bar of the Ravenswood EL train as it rounded an acute bend. Hold that patient's hand like a trapeze  artist grips the bar while the good doctor gives that J-P drain one final yank.




Distraction is another useful tool in the nurse's position inhibition  armamentarium   (please note, I did not use that dreaded "R" word.) This trick procedure does not work well with painful ministrations about the head and neck, but is very effective for procedures below waist  level like bedside urethral dilitations or removal of orthopedic external fixation devices. The nurse elevates the bed so that the patients eyes are close to the height of the nurse's ocular orbs. The patient's  head is immobilized between the hands as the nurse locks eyes with the hapless patient. Extreme eye contact seems to slow things down  and put a damper on some of the unpleasantness.

Children are especially vulnerable and the isolated snippets  in my mind of pediatric restraint have long sense departed. Whew! Am I ever happy for that. There is a harrowing  pediatric restraint device known as the  Pigg-O-Stat. Google it if you dare. This thing looks like a blender with the lid off and the youngster is dropped into it for X-ray procedures. It's no wonder so many people have claustrophobia later in life. They were probably popped into a Pigg-O-stat as a mere youngster.

 One of the more humane child restraint devices is a take-off on the old Trojan Horse idea. The restraint device is a toy rocking horse that lures it's young patients by whimsical looks, not brute force. While the child plays horsey, an X-ray plate is slid into position and the exposure made before anyone is the wiser. An elegant restraint solution! I wish they all could be so easy.

Looking Good - Feeling Bad

Back in the late 1960s  cures for serious illness were few and far between. Undaunted by bodies mutilated by serious illness, old school nurses were true artisans when it came to making sick, debilitated  patients look good. That old adage, You can't make a silk purse out of a sow's stomach, did not apply to these embellishment minded nurses. Cachexia never looked so gorgeous.

Every bedside nurse was a master when it came to the quick shave. A wash cloth heated in the blanket warmer served to mollify the most robust beard. A few deft strokes with a prep razor produced a dapper looking patient despite the paroxysms of sustained DTs of an alcoholic in the process of sobering up.

Shaving had one well known complication. Intubated patients always had  that pesky pilot balloon dangling in the razor's path and slicing into that tiny little bubble resulted in lots of excitement. A massive leak around the deflated cuff of the endotracheal  called for a STAT reintubation, but, at least, the patient looked nice if you could overlook the terrified expression elicited by a crash intubation..

Another trick in the looking good procedure manual was fooling  around with the lighting. Jaundiced patients always looked much worse under incandescent illumination, so open the drapes and turn off the overheads in the room. Avoiding yellow bedspreads helps too. Patients with an elevated bilirubin of 4 mg/dl  never looked so good.

Out of sight, out of mind was the philosophy of wound management and the bigger the surgery, the bigger the dressing. Abdominal surgeries incorporated another layer of obfuscation, the scultetus binder. A patient might feel as though their belly lost a battle with a chain saw, but hey, they can't see a thing until that dreaded dressing change.

The importance of accessory items such as eyeglasses and wrist watches in the looking good gambit  is illustrated by the sad tale of a 47 year old man suffering from terminal heart disease. Haskell Karp of Skokie Illinois was the first recipient of an artificial heart. Famed Texas heart surgeon, Dr. Denton Cooley made quick work of the situation and in a 47 minute surgery the artificial heart was in place. The device functioned for 3 days when a transplant became available, but death came 2 days later from operative complications.

It was especially important that a patient  fortunate to receive  doomed by the first totally mechanical heart to look attractive. This was international news and lots of folks were watching. Nurses went all out  to convert what was a terminal event to a flattering photo op. The illustration below shows Haskell fresh off the operating table awaiting the return of consciousness and the delivery of The New York Times. Reading glasses in position for a cursory perusal of the business section. Looking good!

Haskell Karp   Circa 1969

Retention Sutrures

Old school surgeons had a tendency to overdo just about everything from meticulously double tying simple bleeders to throwing in heavy duty retention sutures for added insurance against impending complications. A patient with wound dehiscence or more bluntly a burst abdomen was like a graphic, negative advertisement of surgical ineptitude. Something  to be avoided at all cost.  The  illustration above shows a wound that is beginning to "dehis" on the right side, but the retention sutures are averting a catastrophic blow out.

There was little science in deciding when to deploy torturous retention sutures and empirical notions ruled the roost. The end result was almost every obese surgical patient suffered the excruciation of miserable retention sutures which were applied in wide suture bites through skin, abdominal fat pad, and firmly anchored in the muscular abdominal wall. The dimpling of the  delicate skin before it yielded to the vicious thrust of a gigantic cutting needle pulling heavy suture was a chilling sight. A surgeon strafing a delicate abdomen with retention sutures shivered my timbers like nothing else. Orthopedic surgery with all it's bone crunching sawing and drilling was small potatoes compared to the forcible  application of retention sutures.

These gargantuan  sutures were usually left in place for about 2 weeks of abdominal throbbing madness for the hapless patient. Removal  was the most painful part of the surgical experience. ( I just love that new fangled vernacular where just about everything in modern healthcare is an experience or journey.) How about that, I can write like a whippersnapper if I try really hard!

The suture extraction process was very painful as a result of tissue adherence during the healing process. Sutures were practically cemented in place.  The fact that the abdominal wall was richly innervated exacerbated the situation. Considerable traction was necessary to pull the unyielding suture free from it's tenacious cementation in the underlying tissue. The sordid suture removal   affair reminded me of pulling cold taffy accompanied by loud screams and anguished howls. The task was almost always relegated to the least senior resident. Thank heaven, nurses never removed retention sutures.

One aspect of retention sutures always reminded me of an executioner applying a hood to the condemned before the act final was completed. This action was ostensibly done to make it easier on the prisoner, but the only real beneficiary was the executioner who could not see condemned man's suffering. For patient "comfort" the retention sutures were cushioned with short lengths of latex tubing where they contacted the skin. These bolsters or bumpers as they were called were custom made by the scrub nurse trimming a length of tubing as the sutures were placed. Any "comfort" from these little gems existed solely in the mind of the surgeon.  Retention sutures fueled post-op pain like pouring gasoline on a fire whether bolsters were in place or not.

More recent knowledge suggests that alteration  in the integrity of connective tissue is responsible for wound dehiscence and not necessarily obesity. The retention suture for all obese patients was not appropriate. Hopefully laproscopic procedures and improved techniques have made retention sutures extinct.

Skin to Skin Post Mortem Care

Skin to skin contact meant something entirely different to me than the currently popular post partum mother / infant tactile bonding technique. When I first heard the term, I asked myself  How in the world did someone discover one of my personal secrets?  I  felt compelled to lift the patient from the death bed or OR table with my bare arms contacting their skin. It was part of my way of saying goodbye.  There was a trick to this that involved spreading the morgue shroud open on a nearby Gurney with the distance dependent on the patient's weight. A 50 kg. patient could have the waiting litter across the room while a 100 kg "heavy hitter"  better be close to the bed. I tunneled my right arm under the patient's shoulders for a mid axillary target and my left arm went under the knees. A helper carefully supported the head while I carried the patient to the cart. There was something special about being there in actual contact with the patient skin to skin as they say. I always said a silent prayer for a peaceful journey to a peaceful place as I gently lowered them to the awaiting shroud.

Every old nurse had something unique and special to impart during post mortem care. Jane who was a dental hygienist before becoming a nurse always offered meticulous mouth care to the departed patient. When she was done the waste container was always filled with lemon glycerine swabs and an empty peroxide bottle. Bonnie hated to leave any tell tale sign of invasive medical procedures. The first thing she went for from the supply closet was adhesive tape remover and cartons of 4X4s. Every little bit of residual adhesive tape was lovingly removed. We did not have those fancy task specific devices to stabilize endotracheal tubes and all that tape about the lips and around the neck made an unsightly mess that Bonnie always made disappear. Lois hated those flimsy shoelace-like ankle and wrist ties and always substituted soft strips of wide Kerlix. After her gentle ties were in place she often kissed the patients hand. I hope I have a nurse like Lois when it's time for me to enter that shroud. I'm certain the journey to the other side will be pleasant with a send off like that.

Fevers - Antiquated Defervescent Interventions

Venerable, old nurses were taught that fevers were a destructive response that required immediate intervention to bring the body temperature back to that magic number of 98.6F or 37C. Since there were few real cures for much of anything back in the good old days, rigid authoritarian protocols, whether they worked or not, were established to control the chaotic world of febrile hospitalized patients.

Temperatures of all patients on the ward were routinely checked first thing in the morning with glass mercury  thermometers. We had one complete class session on the proper way of shaking thermometers down.  It's all in the wrist snap.  Fevers did not follow a rigid time  schedule and could spike rapidly just about any time of the day or night. It was easy to miss fevers with routine schedules because they could rise and fall with reckless abandon within a very brief time frame.

Protocol called for cultures for temperatures over 101F even if the cause was suspected to be neurologic and their was no sign of sepsis. Fevers climbing to that dreaded 102F threshold triggered a series of unpleasant and down right miserable interventions for suffering patients. Denial exists on both sides of the bedside rail and lots of compassionate nurses reported thermometer readings of 101.8 to put a halt or delay to some of the more miserable interventions to drop temperatures. Hyporeportinosis in it's finest glory.

This illustration shows the fight fire with fire fever treatment. That's a teapot propped up on the stand at the foot of the bed. The steam cools as it infiltrates the tented sheets and the nurse is applying ice packs to the patient's head. The thinking (if you could even call it that) behind the steam bath was that it opened pores and promoted a profuse diaphoretic response. From the patient's perspective, I suspect it felt like receiving a hot foot while having your head stuffed in a freezer. Miss Bruiser, my favorite nursing instructor had many tales about patients in steam baths; none of them pleasant. I don't think she ever had a temperature reported as 101.8.

Alcohol sponge baths were another weapon in the armamentarium to battle fevers. Equal parts of water and 70% isopropyl alcohol were combined in a bath basin. After placing axillary and groin icepacks the nurse swabbed the patient's entire body with the alcohol laced cooling solution. The shivering induced by the strategically place ice packs  was bad enough, but the fumes from the evaporative  cooling action of isopropyl alcohol was even worse. I'm certain the shivering and hacking cough produced enough muscular activity to counteract any of the cooling attempts. Some old nurses replicated the experience of greenhouse workers by borrowing misting bottles from housekeeping and spritzing the febrile patient with a toxic mist of alcohol and water.

Introducing ice water into just about any available orifice was another hoary nursing intervention favored by those practitioners with a masochistic vein. Nasogastric tubes were swiftly passed and flooded with boluses of ice water. Miss Bruiser would rest her oversized meat hook of a hand on the patient's epigastrum as the frigid water infused and arrogantly nod her head, "Ahh..he feels cooler already." It was always a mystery to me how she could feel past the barrier of the stomach wall, abdominal muscles, fat, and skin, but it was never prudent to question Miss Bruiser or her whacky methods.

Just about any ailment had a specific enema treatment and fevers were no exception. Febrile patients were subjected to backside buffoonery that entailed ice water enematizations. This approach from the rear did seem to reduce fevers, but I always suspected it was limited to the localized cooling of sphincter muscles when temperatures were measured with rectal temperatures. I always had the notion if Miss Bruiser could catch a glimpse of the patient's misery filled facial response to this frigid intrusion that she would temper or soften her approach to patients. Fat chance of this occurring, Miss Bruiser's field of view was limited to the icy enema tip and it's intended target.

Asking questions of old time nurses about the science behind their crude interventions could land an innocent student in a heap of trouble. Fever interventions were largely based on empirical notions and asking to see supporting data was seen as an indirect way of telling the person they really did not know what they were doing. Both parties full well knew there was no science to support their dubious activities and asking for the data when there was obviously none, was seen as rubbing salt in the wound.

Trauma Blankets - A Macabre Masquerade

Let's face it trauma can be a visually offensive mess.  Before the age of enlightenment with paramedics and trauma centers, seriously injured patients were initially seen and promptly covered up in a trauma blanket by none other than ambulance attendants. The out of sight, out of mind  philosophy at it's finest. Trauma blankets were designed to camouflage the blood and gore making the victim appear aesthetically  pleasing to horrified onlookers  while essentially overlooking  the underlying trauma.

Bleeding? Get that trauma blanket STAT

  Ambulances were just converted station wagons like  Chevy Brookwoods or the Dodge Dart (below) and were maintained and operated  by funeral homes. Attendants were frequently apprentice undertakers and perhaps the skillset of closing body bags helped with trauma blanket application. Ambulance medical supplies were limited to a poorly designed stretcher with tiny wheels that fluttered back and forth like a butterfly's wings when in motion and of course the trauma blanket. Just the sound of those stretcher wheels clicking and clacking as they moved was enough to trigger nightmares and then a glance at a blood soaked trauma blanket was the coup de grace for a peaceful night's sleep.

Trauma blankets were heavy woolen affairs that could absorb their own weight (which was substantial) of just about any liquid or semi-liquid goo like sanguineous  substance. A chartreusy/maroon  color could obscure practically any blood  no matter the volume lost. Attendants made sure the victim was lying on the trauma blanket to mitigate the mess from pooling blood and rapped them up mummy style for the mad dash to the nearest hospital with that big V-8 roaring and drum brakes a smoking. The air  siren sounded like one of those air raid shelter blasts from old WW2 movies.

Removing trauma blankets upon arrival in the ER was like opening a Pandora's Box. Ambulance attendant transfers were done quickly with little finesse and no report from attendants who vamoosed as quickly as they arrived. Upon opening a blood soaked trauma blanket we found glass shards and a severed rear view mirror on the patient's chest. Alas..this must have been a motor vehicle mishap.

Ambulance attendants never heard of trauma shears so the bloody victim often had clothing that had clotted in place. A sort of crude hemostasis mechanism for the not so enlightened. Starting an IV on someone with blood stained extremities is a challenge and darn near impossible with the hypovolemic state induced by traumatic exsanguation.  Trauma blankets were probably one of the most useless, insensitive, and dimwitted items used in yesteryear's hospitals. They certainly creeped me out.

Before people regaled themselves with the flicker of glowing screens, events occurring in the immediate environment garnered diversion.  There was an oversize metal bath basin in the ER and a staff nurse noticed me inspecting the container with a quizzical expression. "That's for treating the trauma blankets. It's worth the show, so hang around after the next trauma," she said with a smarty pants look on her face.

Old time hospitals never discard anything; it's clean and reuse, trauma blankets were no exception. The blood assimilative nature of trauma blankets was reversed by placing it in the oversize bath basin and dousing it with a couple of liters of hydrogen peroxide. The explosive bubbling of the peroxide as it did it's work rivaled a Mt. Vesuvius eruption with the red foam serving as a stand in for volcanic lava. An impressive sight indeed.

History always repeats itself and trauma blankets have strong connective tissue to modern hospitals with their fancy atrium like  lobbies decorated with lush mini-forests of tropical plants. Those gaudy chandeliers  and fancy hardwood moldings add to the ambience. Patients who cannot pay for their treatment are not welcome here. These contemporary trauma blankets hide the uncontrolled diabetic or end stage pulmonary patients that lack resources for care and are forced to fend for themselves. The end result of untreated chronic illness is not pretty, but there is no blood on the ornate hospital's balance sheet.

Tonsillectomy According to Peter Ponsil

This cheery little musical interlude from the 1950's starts out with a chipper chorus of "Have you heard of Peter Ponsil?" A jaunty xylophone riff with breezy notes ascending and descending reinforces the carefree, whimsical mood.  Pete himself then chimes in with an upbeat tale of having his tonsils ripped out removed by the good ol' Dr. Sneeze&Blow. A pretty nurse cheerfully dressing the patient in a "Johnny Coat" also is described in Pete's upbeat, sing-song voice. It's an engaging little song that I hear repeating in the back of my head when I'm engaging some high minded activity like watching the Three Stooges. It was played for us in grade school as part of health class and it stuck with me all these years.

It's probably one of the pioneers in patient education, but the rosy picture it painted of tonsillectomy was bending the truth more than a triffle. Pediatric patients were told many half truths and outright fibs to gain their cooperation. Every old peds nurse knows that sneaky  trick of telling little Peter Ponsil that it's time to check his temperature and then administering a painful intramuscular injection. That old Vistaril pre-op shot used to burn like a branding iron  Misleading youngsters to gain their cooperation was just plain wrong, but I never had much of a say with older nurses.

Peter Ponsil conveniently neglected to mention some of the complications and post op pain discomfort associated with tonsillectomy. The procedure involved outlining the margins of the tonsil with a #15 blade, looping a snare around the offending tonsil and squeezing the mini beartrap of a snare closed to finish the -ectomy.

The most unusual complication I witnessed involved removing the uvula along with a tonsil. The surgeon told the family not to worry because the little thing hanging down in the back of the throat was unnecessary and just got in the way. He was half right - it did indeed get in the way of his snare.

Another youngster had to make an emergent trip back to the OR for a bronchoscopy because the eschar sloughed off a tonsillectomy wound and lodged in his  right main stem bronchus. I think our friend Peter Ponsil would be singing a different tune post-bronchoscopy.

Our pediatric unit was divided into 3 separate wards: pre-op, post-op, and isolation which was affectionately known as the diarrhea ward. The unsuspecting kids in pre-op frolicked about in their Johnny Coats consumed by blissful ignorance courtesy of Peter Ponsil and his ilk. Post-op was where the reality of the situation reared it's ugly head. Kids howling in pain suddenly aware of how deceitful their friend, Pete, had been. The more rambunctious were even restrained on papoose boards. Peter Ponsil was a spin doctor of the highest order.

There was a great deal of deception in old school healthcare and Peter Ponsil bunches it all up in his little song that represents an entourage of  hospital falsehoods. From nurses telling patients that a Bicillin injection would feel like a mosquito bite to surgeons obscuring an ominous finding, half truths and outright deception was everywhere. The pain word was beclouded by referring to it as discomfort. Of course this was all done for the patient's own good.

A Lady of Pleasure, An Anaerobic Culture, and A New Life

Babies can be very expensive. Our obstetrical set fee schedule and the way it was implemented made prenatal, delivery, and post natal care affordable to virtually anyone. Theoretically, the patient paid a fixed  amount of money ranging from 50 dollars to 500 dollars for all the OB services necessary to deliver and care for the baby.  In practice many of the patients paid nothing. A charity hospital really did offer care when needed to just about anyone showing up. What a refreshing situation and such a contrast to health care today. Uh, oh don't get me started on that one!

The clinic was staffed primarily by OB residents and nursing students. A diverse group of medically underseved women attended the clinic. I often questioned why women of limited means were always referred to as "medically underserved." There were many plenty of doctors and nurses in the vicinity so this was really a contrived term. I guess medically underserved sounds better than needy or impoverished.

As student nurses we were responsible for weights, checking vitals and then getting patients settled in one of the exam rooms for a resident to assess. A petite, quiet, very young woman with shockingly blue eyes named Lisa caught my attention as she looked unusually apprehensive. Her stylish dress was a marked contrast to the other prospective mothers in the waiting area. I chatted with her while checking her vitals and without hesitation she revealed that she was a prostitute and this was her third pregnancy. The previous 2 pregnancies had been terminated in the first trimester with the assistance of "her boss" assumed by me to be her pimp.

"I really want this baby" she said with dogged determination. "The father is  a very smart lawyer. I was very busy at that last big  convention a couple of months ago so it must have been fathered by one of those lawyers." Tenaciously she proudly stated, " My girlfriend and I will raise this child and I want this baby to become someone." This lady seemed committed to raising the child. "I never had much of a chance and I want more for my baby."


I helped her up onto the exam table and positioned her stirrups. Dr. Rebondo came in and did one of his comprehensive check ups. At the conclusion of the exam we always obtained an anaerobic culture from the cervix  to check for gonorrhea. The doctor handed off the culture applicators to me and I immediately plunged them into an anaerobic culture bottle to maintain an oxygen free environment. Lisa was watching me with a puzzled look on her face as I fiddled with the culture bottles.

We used to call them trans-grow culture bottles because the bacteria would replicate in the  media while in transit to the lab. These bottles were clear glass and the growth media was a nasty looking brown/green color. To maintain anaerobic conditions the wooden applicators were snapped off at the bottle neck after being submerged in the culture media and the caps tightly closed. The crunch and crack of breaking the wooden applicator always seemed to startle some patients so I usually explained what I was doing.

As I helped Lisa back up from the gyne table she happened to glance off to the side where I was standing. With shock in her voice she asked me, "Did that come out of me?" I quickly deduced she was referring to the  anaerobic culture bottles with their nasty looking brownish culture media. I realize prostitutes have negative self-image problems, but I could not imagine what frame of mind caused her to think the bottles were from her body. She was genuinely worried.

I explained that she was looking at the culture medium and this was not a bodily substance that came from her. Her relief was immense and she thanked me repeatedly for the explanation. She asked how much longer I would be in school and told me she would ask to see me after the baby was born.

One day before senior banding ceremonies there was a note in my mailbox that Lisa was on the post partum  floor and asked to see me. I  eagerly hustled over to the unit only to fimd Lisa cradling a beautiful baby girl. She was glowing with pride and said she was working on a name. Time went by and Lisa faded from my memory.

Many years later I was orienting a new group of student nurses to the OR. I happened to comment that our 2 cysto rooms at the end of the hall had previously served as delivery rooms. Our OB suite with integrated delivery rooms was fairly new.

 A petite, young student nurse that looked very familiar with those crystalline blue eyes remarked, "I was born at this hospital. Is this where I was born?" I affirmed her birth place and just to make conversation asked when  her birthday was. "It was June 3rd."  Something about the date and her familiar appearance immediately clicked, but I still  could not place her.  Memorable moments from nursing school are seared into my consciousness and June 4th was the date of Senior banding which occurred one day after Lisa gave birth. It took me some time to put all this together, but eventually,  I learned something interesting. The young student nurse was Lisa's daughter named Colleen. I hoped that Colleen's birth  had renewed Lisa's life and brought forth a new beginning. She certainly did a fine job of raising her daughter under challenging circumstances.

Obesity in the OR - Problems Beyond Your Wildest Dreams

Everyone is acutely aware that obesity is unhealthy and can compromise recovery from just about any illness from cancer to cardiovascular problems. Dr. Slambow frequently quipped that surgery on obese patients is like changing the spark plugs in your car engine while standing on a ladder. Some risks of obesity in the OR are subtle and not well known. Here are a few of the obscure risks.

Obesity dramatically increases the depth of that well known lint trap the umbilicus. The deeper that belly hole becomes the more area to accumulate lint, oil, and down right nasty,  foul smelling dirt. The depth of the hole not only increases the volume it can hold, it also further isolates it from oxygen in the atmosphere. Anaerobic bacteria have that characteristic foul smell that any sewer plant worker knows all too  well. Doing a surgical prep scrub on one of these deep, foul holes dislodges sludge that has probably been there since childhood. Unfortunately the patient is 38 years old. That belly button sludge has been fermenting longer than fine, aged cheese. I don't think that I will ever see Roquefort cheese in the same light after doing a prep on one of those coal mine belly buttons.

I'm not on the skinny end of the spectrum and when I required abdominal surgery one of my main fears was of those oversize instruments. My last memory before the Brevital clouded my consciousness was of those foot long pick-ups and how they would look buried in my sore belly. They looked plenty threatening from a patient's perspective and reinforced the humane practice of keeping instruments out of sight until the patient is asleep. I made a note to myself to keep that back table covered whenever the patient was awake in the OR.

 It's not those retractors that are big enough to hold the Grand Canyon open or those very long pick up forceps. Its the mindset they induce in the operative team. Surgeons and nurses see these huge instruments and then subconsciously adopt a Dr. Hulk or Nurse Bruiser mindset. Just because people are big doesn't mean their tissue is tough as nails. An obese patient's pancreas is just as friable as a beanpole patient. Bigness does not translate to toughness. A light, gentle touch benefits all surgical patients. Don't go roughly yanking on things like gall bladders and liver beds. "See with your fingers and lightly touch with your eyes." as Dr. Slambow often said.

Anesthesia personnel seemed to favor spinal anesthesia in some obese patients and after witnessing difficult intubations I can appreciate why. I once witnessed an intubation of a bull necked patient that involved attaching the laryngoscope handle after the blade was inserted. The patient's neck was simply too large to accommodate the laryngoscope handle and blade while it was assembled.. The problem with spinal anesthetics is that while sensory nerves are blocked, pressure sense remains intact. That poor patient can feel the hapless surgeon leaning against him with all his might while he is tying off that bleeder deep down in that wound. Anesthesia always seemed hesitant to heavily sedate obese patients and being awake while the surgeon takes out his frustration on the scrub nurse and leans into me would not be my idea of a good time.

About the only positioning aids available to us in the good old days of big open surgeries were 3 inch adhesive tape, bean bags, sand bags, and assorted permutations of rolled up towels and wash cloths. Lateral positioning of obese patients always scared the devil out of me because wherever that big belly went, the patient was sure to follow. That table was so narrow and that massive belly preparing to slide off was the stuff nightmares are made of. One of the safeguards  I used was aggressively taping the patient's  arm on top to the ether screen. Anesthesia always hated this maneuver because that giant ham hock of an arm could partially  obscure their view of the patients chest. Before all the fancy electronic monitoring aids were available, anesthesia constantly watched the patients chest rise and fall. Flexing the side lying patient's legs and running another course of 3 inch adhesive around the ankles and thighs was added security.

Distractions in the operating room are not a good idea. The surgeon and circulator often begin the "How are we going to get this guy off the table?" discussion just before closing the wound begins. They should be more concerned with sponge counts than who can bench press 150 pounds or more or how many people will be required to complete the table to litter transfer.

Even a dolt realizes that it is much more difficult to properly illuminate a surgical site that is essentially a valley in the middle of 2 mountains of fat. After carefully positioning the lights for optimal illumination of a deep wound things might not look quite the same as they would in a lean patient.. Dr. Slambow was an amateur photographer and had this mystery solved. The yellow fat tissue that surrounds the surgical site was actually changing the color temperature of the lighting. Instead of that nice, neutral white color the lighting had a yellowish cast.

Here is another way obesity may be a boon to the surgeon at the expense of the patient. While the patient is in the consent signing stage, the nurse is certain to mention that obesity confers additional risk to the procedure. This can be used to the surgeons advantage to explain almost any complication of the surgery. Instead of saying something like "That tie was not secured well enough on your cystic duct," the surgeon can dodge the issue and blame everything on the obesity.

This post has really stimulated my appetite and there is a cold Big Mac in the refrigerator. I am so old that if Big Macs were lethal that they would have certainly killed me by now.

It's a Bird!..It's a Plane!..No, It's a Patient!

Hospitals tend to elicit the fight or flight syndrome in some patients. This is a contemporary image but you better believe the problem is timeless. I have had to contend with birds like this decades ago.

When assessing patients for flight risk here is a helpful pneumonic mnemonic  device from The OldfoolRN Institute for Enlightenment. It's elegantly termed APE because all primates love to climb and it's easy for old fools like me to remember. Now if I could only recall what I ate for breakfast!

A -  represents alcohol which causes patients to do all kinds of silly things.  If your patient has imbibed welcome to the world of unpredictable events. I know you whippersnapperns are fond of algorithms and computers to predict the outcome of events, but if alcohol is involved you are on your own when figuring out when your patient may take to the skies.   From my experience in the OR with trauma patients, alcohol causes more pain and suffering than cancer or heart disease. Trouble in a bottle.

Drugs are also capable of altering consciousness to the extent that elevation events are possible. Amphetamines, cocaine, and even heavy marijuana use can be the wind beneath the wings of contemporary ascenders. It is prudent to limit the opportunity for patients to climb, but a determined and drug intoxicated patient can always find a way to the ceiling. Onward and upward.

P is for psychosis. It's really sad that someone would comply with voices telling them to do dangerous activities. When I worked at Downey VA hospital there were two water towers and each of them was surrounded by security fencing. I remember one patient that tunneled under the fence (ground hog style) and proceeded to ascend the ladder on the tower. Luckily, he was easily lured back down with the promise of a pack of cigarettes. When we asked him the rationale for his climb, he provided the  mountain climbers mantra, "Because it was there."

E is for elevation opportunity. This can be tricky to assess, but anything overhead could be climbable. Here in Pittsburgh, many of the old industrial jobs required climbing. I've cared for many steelworkers and they are some of my most memorable and treasured patients. A dozen steel workers would be more fun to care for than a single stock broker, but that's a story for another post.

One time I walked into a patient's room and found him on top of the traction frame. He had been incontinent and was carefully positioning little compacted spheres of stool down on the dangling trapeze.  When I asked him what he was doing the indignant response was, "I am mixing cement." The elevated positon made clean up much easier and a Posey belt tethered him to the bed. Anything overhead can be used for elevation.

I never had to worry about legal implications or litigation, but times have certainly changed. Just about any untoward event could be fodder for litigation. No matter how careful a nurse is , bad things can happen and the nurse in the above illustration has a clever risk management strategy. It's called going dark. Whip off that nametag and slap on a mask.

One final tip. Avoid going vertical after the patient. It only encourages them onward and upward.