John R. Brinkley - A Pioneering Transplant Surgeon

Dr. Brinkley in action. Just say BAA

The recent outbreak of Corona virus piqued my interest in past outbreaks so I began reviewing the events underlying the great influenza outbreak of 1918-19 and lo and behold the strange career of Dr. John Brinkley came to light. This man was no ordinary surgeon, in fact his only medical credential was a $500 phony diploma he purchased from the Eclectic University of Kansas. His skills as a pitchman exceeded his surgical skills by huge margin.

Dr. Brinkley, a physician of questionable  competence, to say the least, began his career treating victims of the great influenza outbreak. On  a house call to a farmer named Stittsworth, he found the hapless patient  complaining of impotence, Brinkley had an epiphany that would make him a millionaire. Eyeing the proud testicles of a nearby penned up Toggenburg goat he remarked, "You wouldn't have any tumescence troubles down there with one of those goat glands in you."

The troubled farmer replied, "Well why don't you just put one of them goat balls in me?" To an eager surgeon, the external anatomic character of male genitalia is like dangling the keys to a Pontiac Trans Am before the eyes of a hot rodder. All that exposed  anatomy is just begging to be incised, dilatated, or ram-rodded with a scope.

In 1920, the eager surgeon went to work on the readily accessible scrotum and implanted a goat testicle in the impotent Farmer Stittsworth. There was no neurovascular connection or fancy anastomosis to the vas deferens; the transplanted gland was popped in and left to hang there like a drunk dangling from a bar stool. A rubber crutch would be more functional.

Soon the farmer was singing the good doctors praises albeit a few ovtaves higher about his new found libido. (The placebo effect of sham surgery is even greater than it's pharmaceutical counterpart.)  When the farmer's wife gave birth to a healthy baby boy who was named after the good doctor, word spread far and wide. Large groups of forlorn men showed up at Brinkley's office eager to pony up with the surgeons goat gland  implant fee of  $750 ( equivalent of $10,000 in today's money.)  Exploiting desperate patients like this was a foul ball of the highest order, but Dr. Brinkley was a master of self promotion with little regard for the welfare of his patients.

What he lacked in respect from the medical community he made up with acquisition of material goods which included a fleet of Cadillacs, an airplane, a yacht and an opulent mansion. Before his medical license was revoked in 1923 on the grounds of unprofessional conduct he performed nearly 16,000 goat/human xenographs.

The man who fittingly sported a goatee throughout his career developed a deep vein thrombus necessitating the amputation of his leg in the early 1940s. His handicaps did little to slow down his huckstering spirit. Perhaps the inspiration of sacrificing goats on the surgical alter led him to the study of theology. His dreams of launching a mega church died with him.

Karma seems to catch up with just about everyone. This gland grafting gooofus died penniless.

Old School Automobile Lap Belts Engndered Bucket Handles and Fruit Loops

Cars from the 1960s were rolling deathtraps. Two  tone paint jobs, wide whitewall tires, and chrome bumpers looked snazzy, but in a motor vehicle accident (incident or crash in today's lingo) the passengers were propelled into rigid spear like steering columns or protruding cowl like hoods over the speedometer which, to say the least, were evisceration proficient. Any poor soul lucky enough to escape compression injury via steering column impalement or gutting by the speedometer was hurled head first through the windshield and wound up with spidery split open lacerations on their forehead and all too often, hopeless neurotrauma.

Initial efforts to restrain vehicle occupants and  transfer some of the destructive forces to crumpling sheet metal consisted of lap belts.  Curiously, lap belts were always referred to as "safety belts," instead of the current seat belt terminology. These girth gripping girdles prevented some of the unfixable neuro trauma at the expense of the abdominal organs which ,at least, were potentially fixable with timely surgical intervention. Typical abdominal trauma from car wrecks  involved banged up and bleeding hollow viscus organs, blood oozing spleens, and contused and bruised livers. Retro peritoneal renal injuries were less common. Maybe all that fat surrounding the kidneys protected them from some of  the trauma.

Typical stigmata of lap belt trauma consisted of a 2 inch wide ecchymotic banding across the lower breadbasket. This ominous finding almost always meant internal injuries and called for the immediate diagnostic peritoneal lavage. After cannulating the peritoneal cavity about half a liter of normal saline was infused. After  about 10 minutes the saline was allowed to drain back out by gravity. Any blood in the drainage meant a quick trip to the anxiously awaiting personnel in the OR.

Innovative lap belts caused a surge in a new kind of deceleration injury, bowel/mesenteric separations which were a good trade off for the neurotrauma sustained from crashing head first through the windshield. Most abdominal trauma was fixable if caught in time, while neuro trauma usually meant a grim prognosis.

The bowel is fixed at the flexures,the ligament of Treitz, and last but certainly not least, the rectum.  With the colon and small bowel moving forward at 60mph ( or whatever speed) the sudden traumatic stop of an accident pulls like a John Deere tractor on the intestine adjacent to these tack down areas dividng bowel from it's lifeline, the messentery. Without mesenteric connection, the section of isolated  bowel withers up and dies like a man in the desert without water.

Mesentery supplies vascular, nervous, and lymphatic connections to the bowel. It also holds our  intestines up out of our pelvis where there are enough problematic structures without dropping another player into the mix. Mesentery is one of the most underrated abdominal players.

Suspense reigned as the surgeon cautiously entered a traumatized abdomen and when the problem was finally delineated and deemed curable, a feeling of jubilation and relief was experienced by the team. Hearing Dr. Slambow, my general surgeon hero, deliver his diagnosis was always a musical treat. As the Airshields ventilator chugged out bass beats in the background there was proprietorial pride in his harmonius voice as he practically sung out "bucket handle," four notes, key of "C," ascending. The hootenanny proceeded as the intestinal resections marched along with needle drivers clicking away like castanets and heavy instruments adding dissonance clunking away in the lap tray on the back table. The finale was always the best part as we stepped down form the podium with a meticulously patched up patient that was sure to recover.

 How did this injury acquire it's strange moniker? The section of large bowel stripped from mesentery did indeed look like the handle of  a bucket so the name fit. Small bowel separations were more subtle and were named after the little cloth hanging loops on the back of men's shirts of the day. Even though they did not resemble the popular breakfast cereal, everyone knew what an intestinal fruit loop injury looked like.

A bucket handle injury of the transverse colon and 3 fruit loops down below 

where small bowel parted ways with mesentery. That lower separation
is beginning to show the effects of devascularization.

(Photo courtesy Dr. Michael McGonigal)

When the call room phone incessantly rang  at 2AM and the harried voice on the other end intoned "Motor vehicle accident ETA 10 minutes," my feeling was similar to one of those daredevils going over Niagara Falls in a barrel. Lots of mental anguish leading up to the case because the final landing outcome  was unknown. Bucket handles and fruit loops usually led to a successful plunge over the falls.

Professional Courtesy - A Lost Custom

Forty years ago physicians would have never considered denuding fellow doctors and nurses of their limited financial resources to pay for health care. Any doctor would see any colleague without money changing hands. Physicians were apex predators in the hospital food chain and they always got what they wanted without question.

One of the ideas behind professional courtesy was to prevent doctors from treating their own family members. Physicians and surgeons tend to overthink and overdo things when caring for close relatives. Laproscopic minimally invasive surgery was in the distant future and overdoing procedures like radical mastectomies or laryngectomies was not a pretty picture. Professional courtesy spared fellow health workers from lots more than financial pain. It was a grand idea that was a tradition for many years.

I worked with the internationally known ENT surgeon, Maurice Cottle, who thought virtually anyone could benefit from a "Cottle Nose." The purported gas exchange improvement by breathing through remodeled nostrils was  claimed to improve everything from longevity to energy levels  Student nurses were among his favorite subjects  patients and many took him up for the free, albeit painful rhinoplasty which of course was done as a professional courtesy. I treasured my native proboscis and politely declined his frequent offers for cost free, fragile nasal bone crunching surgery. When scrubbed with him I made darn sure my mask was covering my nose completely so as to not give him any bright  ideas. There was something about hearing those loud snap, crackle, pop noises as he plied his trade on a wide awake, locally anesthetized patient that gave me goose bumps. This was not for me.

A triangular alliance of administrative busy bodies, health insurance companies, and governmental regulation put a halt to the long standing tradition of  professional courtesy. Physicians now had to kowtow to a host of  policy makers outside the medical world as managed care became the norm. Healthcare became technology proficient, but empathetically deficient. Balance sheets and quarterly reports were the metric that defined hospitals. Professional courtesy was gone for good as business minded bean counters controlled the medical landscape.

Some old time docs did not go quietly into the night when it came time to abandon professional courtesy. When an old school surgeon like Dr. Slambow received a medical bill for banding a series of uncomfortable internal hemorrhoids he went ballistic with the poor young lady from the billing office. I only heard one side of the memorable  phone conversation argument, but the snippets were permanently engraved in my long term memory including  phrases like: "I demand professional courtesy - I'll bend over and extricate that overpriced elastic ligature and  mail it back to you C.O.D.- if I ever see you on the OR table." I don't know if his medical bill was forgiven, but the hapless young lady from billing received an earful.

There have been many attempts to reform medical billing such as the ill fated Medicare DRG schedule where hospitals received fixed amounts for procedures. Maybe it's time to go one step further and take a lesson from attorneys with their contingency fees. Simply place all the funds paid to correct a health problem in a reserve fund. When a physician accomplishes the final cure, he gets the whole pot. This would incentivize finding a cure rather than finance a medical goose chase with pricey diagnostic studies that produced minimal result. Now that's something to think about.

What Blood Loss??

 What blood loss? That's all irrigation in the suction bottle. At least 2 liters.

A good scrub nurse always agrees with the surgeon even if the patient lost a unit or more  of blood. I felt just like Nancy when concurring with a surgeon understating the blood loss. I always felt there were 3 categories of blood loss estimates: ABL, anesthesia estimated blood loss -  EBL, estimated blood loss by the surgeon  and NBL negotiated blood loss after the surgeon vs. anesthetist argument concluded. Actual blood loss was one of the great mysteries.

I promise this is the last of my political foolishness. Blame it on my brain freeze.

What if Pathologists Performed Surgery?

A pathologist's Mayo Stand.  " Pass me the hack saw, nurse."

Delay of game is not limited to football. Action in the operating room can be subject to breaks in the action too. Waiting for a frozen section report to come back from the pathologist  or a time out while the circulating nurse scrambled to flash sterilize an esoteric instrument that the surgeon just had to have were common interrupters of what had been feverish goal oriented action in the tiled temple.

I liked to busy myself with buffing surgical instruments until they shined in the overheads or wrestling with wiry twisted chromic suture in a vain attempt to get the kinks out during these postponements. Dr. Slambow did not like my heightened activity during these surgical layovers. One of his life lessons was to take a break whenever you have the opportunity, and as an oldster, I've put that lesson into practice way too many times.

As the intense intraoperative activity ground to a halt, he dropped his usually tense voice  an octave or two as  he admonished, " Take a break Fool, and rest those oversize lunch hooks of yours, I've got a little joke for you; In a perfect world the English would be police officers. The Germans would be engineers, and the French would be the cooks. In a more ghastly universe things would be different. The English would be cooks. The Germans would be law officers and the French would be engineers." Ha..Tee..Hee.

Every scrub nurse knows the obligation to laugh at the surgeon's jokes and make a comment about his clever wittiness, but my mind sometimes wandered and thought about what would happen if physicians other than surgeons performed surgery, just as the characters in his joke switched roles. Standing at my Mayo stand in a post joke moment, I came up with an off the wall  idea that made the notion of German police officers sound like a good thing.

What if pathologists performed surgery? The instruments they would bring to the table are enough to shiver just about anyone's timbers. I had never heard of a #60 knife blade because it's exclusive to the morgue. This monster blade made a meat cleaver seem like small potatoes. It's the only scalpel blade I'm aware of that has an edge sharpened along it's entire length. This blade eschews attachment to an ordinary scalpel handle and prefers mating with an autopsy handle that resembles the throttle of a Harley Davidson Electra Glide. This sabre like snickersnee  reduced cutting to it's most barbaric level. In surgery millimeters mattered. A pathologist's  mindset was calibrated in meters. Monster incisions were OK in the morgue, but wouldn't make for a happy ending in the OR.

A pathologist is experienced with slicing through chilled skin that doesn't bleed. I wonder how the novel experience of dealing with those little bright red bursts erupting from the yellow subcutaneous fat would be dealt with. I wonder if a foul smelling liquid like formalin would cauterize a bleeder. There certainly is an abundance of that nasty stuff in a morgue, but surgery is no time for foolhardy experiments. I suspect they would have to learn how to use a Bovie like everyone else.

That's just about enough of my foolish ramblings. I don't want to even think about those giant hedge pruner implements found in a morgue would be used for. Pathologists are conditioned to simply cut structures  out of the way to expose anatomy. Could they adapt to using retractors for accessing organs?

I pondered that last notion while sipping bean soup for my midday sustenance. Glancing down at my fasciculating fingers and realizing I forgot to take my Sinemet, the thought suddenly occurred to me. Dr. Slambow was right, I do have oversize lunch hooks for hands.

Aortic Tears on New Years Day According to Dr. Slambow

New Years crashes sometimes resulted in torn aortas. Dr. Slambow

explains and acts out the mechanism.

When one year dissolves into the next, I often lapse into some serious retrospection of New Year's Days  past.  It's not the big time lifesaving trauma  surgeries  (I hate that all too common lifesaving balderdash. It's like a literate canker sore that shows up conjoined to it's favorite twin, trauma surgery.)  No, it's not those bigtime dramatic measures. It's the feckless and stupid little frivolities that come to mind like the way ratcheted instruments so neatly clicked in your hand or the way overhead lights glimmered and danced off a freshly prepped surgical site or being called in to work with my all time favorite surgeon, Dr. Slambow. I really miss him.

I've never been one to celebrate on New Year's Eve. Maybe it has to do with the fact that every one of these occasions resulted in a trauma call  when I was on duty.  I remember a variety of injuries; beer bottle broken over victims head and then stabbed with the left over glass shards, a young man that sustained a 12 gauge shotgun blast to his butt (not a good way to lose 20 pounds,) and of course the usual automobile wrecks on Lake Shore Drive with the victim sustaining an aortic tear that usually resulted in the poor souls  rapid demise.

One long night scrubbed with Dr. Slambow, I began asking questions as they popped into my young foolish, but curious brain, "Why do automobile mishaps cause torn aortas?" Dr. Slambow's eyes lit up like a New Year's Eve fire cracker and I knew I was in for a rare treat- the good doctor was going to act out his answerer. I could not wait.

He asked for a bloody 4X4 to use as a prop and as soon as I tossed down a needle holder that had been in play and fished around for the requested blood soaked  sponge it was show time. Just  as I expected, the rolled up sponge was going to play the part of the aorta and Dr. Slambow's partially closed fist was going to be a stand in for the chest cavity. This was going to be as good as his lecture on Sengstagen/Blakemore tubes when he inflated a used surgical glove (size 8)  that was partially filled with blood until the thumb portion of the glove exploded creating a colorful scene. The mess he created rivaled that of the grandma wrecked on  the Harley case we had last month. What a mess.

Dr. Slambow explained in his deliberate, eloquent tones that the great vessels in the chest were not tethered to anything and could rock back and forth in the mediastinum like a pendulum. He almost teeter- tottered of his booster stand as he rocked back and forth. Coleen, the circulating nurse was standing nearby to catch him in the event of a backward fall. OR nurses are taught to always anticipate the surgeon's action and we knew Dr. Slambow and his antics  all too well.

The good Dr. made a partially closed fist and suspended the twisted sponge between his index finger and thumb so that it resembled the tubular aorta hanging freely within the confines of his partially opened fist model of the chest. His next move was to make a punching motion with his fist just inches from my masked proboscis and suddenly arresting it's movement just before impact with one of the overhead lights. "There you have the mechanism of a torn aorta-the movement of the patients chest is suddenly stopped by impacting the steering column, but the heart is still moving forward a 65 MPH. The shear force tears the aorta."

Thanks for enlightening us Dr. Slambow, maybe next time you could explain why ostomy patients have so much trouble with excess gas. On second thought-never mind.

A Teeter Toter Surgeon

What goes up..Comes down..Hard

Play grounds from my youth could be very dangerous places with heavy moving objects,  very hard  unforgiving landing places, and young toughs on the prowl in search of  unsuspecting  victims to intimidate. Teeter toters were a favorite playground  implement for bullies to ply their trade. A hard wooden plank moving up and down with a  fulcrum in the middle was too much to ignore for those with devilment on their mind.

The bully's pitch went like this, "You wanna have some real fun, lets go play on the teeter toter. I'll even let you get on first." The unsuspecting victim was seduced by the bully's jubilant grin and happy go lucky demeanor.

Once the hapless victim was in position on the end of the teeter toter, the corpulent bully promptly planted his overstuffed backside on the opposing seat. The victim was suddenly thrust high into the air with amazing force. If he was strong enough to hold on, the finishing  move was about to present itself. The victim would be held captive on the elevated end of the teeter toter as the bully began his verbal torture.

"You sucker, now you are really going to get it," the bully taunted. As the victim screamed and cried the bully suddenly hopped off the depressed end of the teeter toter sending his high- flying victim crashing to the ground with a sickening thud/crash/cry cacophony.

We had an aging, well  past his prime, ENT surgeon that everyone  referred to as the teeter toter surgeon. His well earned nick name was indicative of his smooth preop pep talk followed by a harrowing experience once the patient was situated in the operating room proper.

His life long obsession was rhinoplasy and he even invented specialized surgical instruments that carried his surname. Whenever Dr. Cuddle asked his scrubnurse for an instrument, he made a point of accentuating the "Cuddle" in it's nomenclature. "I'd like the cuddle speculum followed by the cuddle elevator." was a typical command issued in his carefully modulated, stilted speech pattern. "Yes Dr. Cuddle," was the canned scrub nurse's reply.

He could convince just. about anyone with a nose that they were a candidate for rhinoplasty. His sppech, like the playground bully, was filled with false promises and fantastic benefits. I remember how he extolled the vitality benefits of his nose jobs because they increased the oxygen carrying capacity of the blood. Then he went on and on about how beautiful their new nose would look. Hollywood would soon be calling. That beautiful new look and rejuvenated persona would be too much for a movie producer to resist. Better days were as close as a lateral osteotomy fracturing the nasal bone structure to smithereens all the while an awake patient teetered at the maximum elevation of the teeter toter OR table.

For those who question my comparison of  Dr. Cuddle to the playground bully, understand this: The positioning of both victims is identical when receiving their punitory ministrations. The play ground victim receives his coccyx shattering impact sitting bolt upright and Dr. Cuddle performs his proboscis punishment with the victim  patient in the identical configuration. The OR table is positioned with a break in the middle and the back of the table raised at a 90 degree angle.

Dr. Cuddle was one step ahead of the playground bully who was content with letting his crying victim to quickly vamoose from the scene of the crime after receiving his butt busting punishment. There was to be none of that flight or fight syndrome business for Dr. Cuddle's patient who was physically restrained to the table with an airplane type belt around the waist. This served the dual purpose of arresting the patient's departure and also prevented him from throwing blows in the direction of  Dr.  Cuddle. The ankles were also tacked down with another robust belt to avert kicking. The coup d grace' was an elastic bandage wrapped  around the forehead  and secured behind the table for stabilization.

Once he had the patient in the OR, he had that same look in his eye as the playground bully. Someone was about to experience torture on the same level as the teeter toter victim. Dr. Cuddle performed all his procedures under local anethsia if you could call it that. That look on a wide awake patient's face  as they surveyed the Mayo stand directly in front of them loaded with a multitude of glimmering sharp steel instruments was eerily similar to that of the teeter toter victim.

Their was a reason for his making sure the patient was restrained on the table. Even if the local anesthetic was effective, that sound of a mallet impacting with an osteotome and fracturing your nose has to be worse than the crash/cry after a playground victim's  teeter toter free fall. The stuff real nightmares are made of.

Whenever I was anywhere near Dr. Cuddle, my nose was covered with a surgical mask. I did not want to give him any ideas about "fixing" my nose. As a youngster, I was the victim of that teeter toter free fall prank and I did not want to repeat the performance at Dr. Cuddle's crafty hands.

Surgisplainin

Old time surgeons were at the top of the hospital food chain, the captain of the ship, and sometimes misguided blowhards with overstuffed egos. Overconfidence combined with a condescending, paternalistic attitude toward patients  added up to surgisplanations which minimized operative risks and the true extent of surgery, overstated benefits and touted the operators surgical superiority. If anyone questioned these surgisplainers their response was "I just explain procedures in the language a patient can understand."  They were elderly and often wore expensive wool suits that smelled of moth balls.  I think these are the surgeons Dr. Slambow had in mind when he pontificated that, "The only surgery that really benefits the patient is repair of traumatic injury."

A semi-demented old coot of a surgisplaining  gynecologist always explained a D&C with the same practiced, scripted, delivery, "I'm just going to do a little bit of Dusting and Cleaning in there." This was delivered in a demeaning and  condescending tone of voice to rightfully frightened ladies from an obese, imposing man. He was a jerk of the highest order and if he had been accurate in describing his operative method it would have sounded like this: "I'm going to visualize your cervix by inserting a weighted speculum that tips the scales about as much as my overhanging pandus, then stabilize your cervix by piercing it with two converging sharp points of a tenaculum. While I yank put traction on the tenaculum, I will ream out dilate your cervix with stainless steel cylindrical devices called dilators that progress in diameter to the size of my stogie  so I can scrape the inside of your uterus with a curette. I learned the finer points of curettage by mimicking my cat pawing like a sabertooth tiger at his scratching post. You don't have anything to worry about.

A foreign body  be it a stray sponge or rogue instrument found in a patient after surgery meant that the scrub nurse and circulator on the case would be immediately fired and the surgeon had to come up with some surgisplanin regarding the need for re-operation. This situation presented itself when I was working in neuro ICU with a patient that had undergone a spinal fusion.   I was so tempted to make a copy of the X-ray report and anonymously mail it to the patient, but never did. If I had it to do over, I think that I would have made that copy. The neurosurgeon's surgispanation; "the X-ray showed us something that was not visible during surgery (yeah..because you did not see it and the nurse could not count to 10) that we need to go back in and correct. When I was a scrub nurse, nothing made me feel worse than re opening a partially healed surgical wound. Incising healing tissue just goes aginst the grain. Things like that are just not supposed to happen. The patient had the sponge removed and did just fine post-op. She walked out of the hospital none the wiser of the errant sponge that was left behind during the initial surgery.

There was an old geezer of a neurosurgeon well past his prime  that always had a clever surgisplanation for his patients. His description of a crainiotomy went like this, "We are going to make a little trap door in your head so we can fix you up as good as new." That's it. Now it's time to sign the consent.

If there was a prize for the most understated surgisplanation this one would win the grand prize. Here is what the truth of the matter amounts to. We are going to shave your head bald and after anesthesia induction you will be  positioned in a very dangerous upright  sitting position where it is possible for ambient air to enter a major vessel and cause serious disability. Then I'm going to cut through your scalp which will bleed like the dickens and you better hope the scrub nurse can load Raney clips lickety split. When we get to that nasty AVM, I will try to remove it from vascular circulation before it bleeds too badly. Then we will close and finally, I will drill holes in your bone flap to wire it back in position, Most patients that have there brain handled like this have serious personality changes but don't worry you have good health insurance.

Thankfully these surgisplainers are extinct. The last time I had a procedure, the surgeon carefully explained all possible complications. It was really hard for anyone to trust old time surgisplainers whether they were patient or nurse. I know they used to creep me out.

An Obituary Translator

Aging opens new doors and inspires new pursuits. Lately, I have found a new interest in  perusing a collection of old obituaries accumulated over the years. Almost all of my coworkers have gone on to their great reward in that green ceramic tiled O.R. temple in the sky. At least for them, the OR is back where it belongs on the highest floor. I never felt comfortable when working in an OR that was located below that traditional top floor locus. Having been raised in a sky God culture maybe I will enjoy that top floor OR suite again in my afterlife having served my time in OB purgatory.

 While perusing my collection of old obituaries, I noticed that some  obituaries contained half-truths and downright lies in a belated attempt to bolster dubious accomplishments of some people that were hard core blowhards with questionable abilities.  It's not wise to speak ill of the deceased, but some of these phony embellishments are in dire need of correction. Without further ado, (don't you just love it when oldsters talk like that?) I present the actual  text from the obit followed by my foolish, but truthful translations. All identifiers have been redacted. (I hope.)

This orthopaedic surgeon was also affliliated with The County Zoo and performed surgery on gorillas and other large primates.
I did not make this one up, but did change the name of the zoo to further blur the surgeon's identity. This surgeon would operate on virtually any carbon based life-form, dead or alive. I was scrubbed on the thoracic surgery side  of a severely traumatized auto accident victim with the above orthopedic surgeon working as a separate team on a complex femoral fracture. The thoracic surgeon declared the patient dead, but we could not get this one track ortho man to cease work on the fractured femur. He was like one of Pavlov's dogs and the conditioned response to set a fracture in man or beast / dead or alive was his signature.

Unfortunately, the one track orthopaedic thought process sometimes has it's head buried in the sand. With a mind that sometimes has it's head up it's own rear end, mindlessness of  other vital medical issues produces a colo-rectal surgical  mentality  that is definitely not patient centered. Enough said!


Dr. Y was known for his compassionate and caring manner with a kind smile or a heartfelt embrace to share with family and friends.
The closest I ever came to a "heartfelt embrace" from this surgeon was the time I dodged  a hemostat flung at me with great velocity and I collided with his slow to duck resident. Maybe that kindly smile was obscured by his mask or only present when he hit pay dirt with his  hemostat missiles ,but I highly doubt it. It was more of a smirky, smart alecy smile.

When asked, "Who are your patients?" This sports medicine orthopod replied, "Anyone who is an athlete, or was an athlete, or anyone that enjoys reading sports oriented periodicals."
This well to do orthopedic  surgeon was into medical marketing before advertising corrupted healthcare. Unlike specialties like gynecology, which limits it's practice to 50% of the population, this doctor took on all comers. I used to marvel at the irony of his office décor which consisted of pictures of  steroid fueled line backers delivering crushing, bone shattering blows to hapless ball carriers.  Gross illustrations of compound fractures in the making. This might have been good for his business, but very bad for his battered patients. His office décor that  promoted and glorified such trauma inducing behavior made me wonder why oncologists did not have cigarette ads on display in their offices to help bolster their patient load.

He was a person with a vision; we are what we are today because of people like Bob who did an outstanding job of laying our foundation. Blah..Blah..Blah
This is from the obit of a bigshot health system CEO or back in the day what we referred to as hospital director. Nurses like me made about $1000 per month while the hospital director received about $1400 per month. He used to show his paycheck to prove he was one of us. Times have certainly changed, I wonder what the ratio of CEO to nurse's pay is today.

One of my secrets to long term survival as a nurse was to avoid any hospital or nursing administrative big shots like the plague. The OR was an ideal place, as administrators never showed up there. I would have rather scrubbed for an 8 hour surgical marathon than attend a 45 minute administrative meeting of any kind. Office sitters  and meetings seem to go hand in hand. Meetings bring out the core elements of their very nature of sitting and jaw-jacking without having the slightest clue of clinical activities.   Time to stop - I'm getting carried away.

When appropriate, he could be tough as steel. He ran a strict, no nonsense operating room and that was the only place he was heard to swear.

The writer of this gem must have had limited exposure to this loudmouth of a  surgical blowhard. He used nasty language just about everywhere. He was certainly no Dr. Slambow who considered it poor form to utter benign expletives like "balderdash" or "phooey." The most common and understandable stimulus for cussing in the OR is unexpected equipment malfunction at a critical stage of surgery such as a stapler not stapling or an aneurysm clip slipping out of position. The doctor mentioned in this obit cussed at anything and anyone. If a nurse was too slow in handing him the tie for his gown it was time to let her have it with both barrels. This was not a pleasant person.

Dr. X was a nationally recognized expert in coronary artery surgery. Those who knew him were stunned when he died of a cardiac arrest - a heart attack-  on July 2, 1989. He was stricken while exercising on a treadmill at his Lake Forrest home.

This cardiovascular surgeon was obsessed with deceasing heart disease risk factors. He was very thin and often counseled patients with a normal BMI of 20 or so to lose weight. When he wasn't in the OR he was engaged in aerobic exercise. This was perhaps the most ironic obituaries I have read. I guess the message here is that you cannot beat genetics or fate when it comes to death.

When a patient's family approached Dr. Slambow with accolades for his life saving abilities as a trauma surgeon he always had the same reply, "I just patched him up. Tonight was not his time to go and I did not really have much to do with that." Jack Kevorkian's patients are probably the only people who are really sure about when the time of death comes. For Old fools like me it's best to live one day at a time and savor the moment. You never know what's down the road.

The Operative Report

I'm a real sucker for a good read and I'm not talking about the high brow stuff like 19th century British literature; but comic books, Mad magazine, pharmaceutical ad copy, small town newspapers and my all time favorite operative notes which eventually evolved into the operative report.

Today, I suspect these important documents that reveal a blow by blow account of the surgery for the medical record  are done by some type of  electronic computer transcriber that probably deletes the surgeon's editorial or grandiloquent ramblings. Old time operative notes were sometimes handwritten with hand drawn illustrations that rivaled Frank Netter's medical art work. Dr. Slambow always had a red pencil on hand along with blue and black ink pens for his illustrations which proved to me the notion that surgery is  indeed part art and part science.

  Most reports were fairly accurate with technical information such as the type of suture used, sponge counts and anatomical reference.  Some surgeons down played serious problems while others could make a sebaceous cyst excision sound like open heart surgery.

When perusing operative reports that minimized problems, I used to say the surgeon had been struck by hyporeportenosis to amuse my fellow nurses. Once I finished reading a real gem of underreporting that grossly underestimated blood loss and muttered my clever new "hypo" terminology to Nancy, a fellow scrub nurse, and she said, "You better not let Dr. Bruiser hear that." The good doctor appeared on the scene just in time to hear her admonishment to me and about all I could do was act dumb. He began asking about what I didn't want him to hear, so I muttered something about the autoclave cycle taking too long. Whew..another close call. Loose lips really do sink ships or get blabber mouth scrub nurses like me fired.

Blood loss was always a hot button issue for any surgeon and rather than a defined amount  like 100cc, terms like negligible, minimal, or inconsequential were used. Another common explanation for excessive blood loss  was,  "I can't determine the exact blood loss because of all the irrigation we used. That is not blood in those suction containers-it's irrigating fluid, just ask nurse fool."  Anesthesia usually had a pretty good notion of actual blood loss and the surgeons idea of  EBL or estimated blood loss was usually way too low, so the term NBL or negotiated blood loss was the amount recorded in the report after the dust settled from all the anesthetist vs. surgeon arguments. It was about as close to the actual blood loss you could get. Incidentally, a wise scrub nurse always sided with the surgeon in any dispute with those on the other side of the ether screen.


Later in my scrub nurse life, the fun of reading operative reports declined, as dictation became the norm. I really loved those old school operative reports hand written at the scene of the crime in the OR suite immediately following surgery. Some of the old handwritten reports were even "validated" by blood or prep solution splatters because they were always physically present near the actual surgery. Transcribed reports somehow lacked the authenticity or intimacy that those blood spattered reports communicated.

Our surgical  transcriptionists were located in an office just one floor below the OR, and sometimes they would venture up to the OR to clarify a point or try to meet up with the surgeon if they liked the sound of his voice. They would intercept nurses at the double swinging entrance doors to the ORs with their inquiries. Once a harried transcriber approached me with a fist full of reports and asked me if I could help clarify the terminology of the dictator. "You've come to the right place, this OR is a dictatorship and it's loaded with dictators." I replied with a smirk on my face. She did not appreciate my foolish humor, but I used to jokingly ask Dr. Slambow if he was the dictator the transcriptioists were asking about. He tolerated my nonsense well and even grunted a phony laugh because he valued my Mayo stand instrument handling skills.

OR reports always started out boring with pre op and post op diagnosis and a brief patient history. Then they could be very interesting. One surgeon loved the adjective "meticulous." Every time he tied off a bleeder it was "meticulously ligated." When one of his patient's returned to the OR a few hours post op with hemorrhage all the nurses had the same thought. "It looks like one of those meticulously applied ties slipped off or came loose."  As soon as the offending bleeder was located and tied off again, he was back to his old tricks. Sure enough the replaced ligature was meticulously applied just like the original.

Dr. Slambow (uh oh, I almost typed in his real name) liked  to end his operative reports with this statement: "At the conclusion of the case the patient was able to transfer from the table to the gurney under his own power."  I can personally vouch for the veracity of his statement. The process leading up to the patients self-transfer activity necessitated very light anesthesia toward the end of the surgery. This produced some very exciting moments, There are copious (our instructors loved that word) nerve endings  in the skin and the final step of suturing the skin often produced a dangerous situation on that thin OR table. The pain of that suture needle thrusting through highly innervated tissue  induced that flight or fight syndrome and the patient tried to exit stage left, directly into my Mayo stand. Dr. Slambow would say something to the effect. "Fool.. The heck with sterile technique, grab his legs before he kicks someone or flies off the table." All this so the good Dr. could conclude his operative report with his time tested and favorite ending about self transferring.

Surgeons also used operative reports as a mechanism to persuade hospital administrators to purchase the very latest instrument or device they lusted after. There was a left handed surgeon that received reverse ratcheting (left handed) instruments of just about any permutation imaginable. He would describe the odd positons he had to assume with right handed instruments and the next thing we received would be a set of left handed extra long  mixters. Scalpels do not favor handedness and some older nurses used to joke with him about providing him a left handed scalpel. Novices like me knew to avoid joking with these old sourpusses.

These paper reports and their associated carbon paper, staples and occasional validating OR blood or prep stain are gone for good, but they  certainly were good reading back in the day.

Morphology Malarkey

Recently while visiting one of the teaching  hospitals here in Pittsburgh, I overheard a bright young physician claiming, "The MORPHOLOGY  of this EKG tracing is similar to the one before all the trouble started." It's a good thing Dr. Oddo, an international, Chicago neurosurgeon I used to scrub with did not overhear that young doctor muttering about morphology. I made the mistake of using that M-word term in the midst of a  surgery with Dr. Oddo and received a tongue lashing that made a life long impression. That young resident stirred up a distant memory from my ancient nervous system.

A little background. Before Dr. Oddo received his MD, he had acquired a PHD in one of the branches of a biologic science. I think it was zoology, but don't quote me on that. He was snobby, overly particular and a classic anal retentive personality. For some reason, I simply loved working with him and we were actually on friendly terms outside his OR.

When he launched into one of his blowhard lectures about trivial concerns, I always tried to act overly attentive. He could lecture for hours describing the difference between braided and single strand stainless neurosurgical wire. He would then quiz the residents about every minutia regarding the wire. On one occasion,  he tried to trick me up about which form of wire was easiest to handle and I was ready for him. "I prefer the way the overhead lights reflect off the braided wire. It's much easier to see. In order to handle something you have to see it first."  Dr. Oddo emitted one of his Haruumphs when he really didn't know what to say. His bizarre questions were usually met with stone silence. I usually had a stockpile of generic "answers" waiting for him in the back of my mind.

Neurosurgeons like to use tiny little sponges that we used to call "pattys." One day I was preoccupied with counting a new batch of patty sponges with the circulator when Dr. Oddo called out for a dura hook which is the instrument shown in the illustration on the right. I had my eye on the sponge count in progress and out of my less acute peripheral vision, mistakenly handed Dr. Oddo a nerve root retractor. (The instrument on the left.)

Dr. Oddo was not happy with my wrongful instrument passage. "That's a nerve root retractor, Fool, I asked for a dura hook. I think you need a new pair of eyeglasses or a new brain." I was attempting to come up with a good excuse and replied, "Dr. Oddo the morphology of the instruments is very similar."

That response generated WWIII from Dr. Oddo. "In your case, MORPHOLOGY is a word uttered by a dumb person trying to sound smart. Morphology is a term restricted to biologic reference. It has nothing to do with surgical instruments."  I apologized for my ignorant oversight and it was back to business as usual. One thing that I really liked about Dr. Oddo was that after he let off steam with his harsh and sometimes nasty comments you were once again his favorite scrub nurse.

It sure is a good thing that Dr. Oddo was not present to hear the bright, young physician  at that contemporary Pittsburgh hospital refer to EKG morphology. I smiled to myself and knew that 40 years ago the fur would have been flying had Dr. Oddo caught wind of it.

A Picture Story

Pictures really are worth a thousand words. This story is circa 1967 and from the golden days of big open surgeries to remove a tiny piece of pathology.  Just about every case on the schedule was for an -ectomy or removal of something. We used to carefully time the incision to  specimen in the bucket interval and the surgeons used to treasure the bragging rights of being the quickest.  It was very crude compared to the repair and replace laproscopic culture of today.

My favorite photo is #6 with that gamine looking  circulating nurse eyeballing the scrub nurse. I used to get that look from my favorite supervisor, Alice, all the time. I was always tempted to "accidently" toss a loaded, used, sponge ring forceps in her direction. "OOPS.. so sorry about that Alice.

The cloth gowns and drapes, compete lack of eye protection, glass IV bottles, and huge soda lime canister on the anesthesia machine all look very familiar to an OldfoolRN.

The Problematic Protruding Proboscis

Hair encroachment, protruding proboscis

and probable perineal fallout. Aseptic atrocities

of the highest order. Alice will be right with you.

The problem of nostrils escaping from a surgical mask was an uncommon occurrence because Alice, our beloved operating room supervisor dealt with it in a very harsh manner. The most common rationale for this practice was that it made the mask feel less occlusive for the wearer. The usual excuse for the harmlessness of this practice was "I don't breath through my nose so the practice is completely benign."

Alice had a very unique way of testing the claim of only breathing through the mouth. She would take 2 dental rolls which were dense gauze devices about the same diameter as a cigarette. Then she would instruct the careless mask wearer with the exposed nares  to tip their head back. Now for her practiced coup de grace, she deftly inserted a dental roll into each overhanging nostril. "There that should not bother you in the least since you are not breathing with your nose" Alice proclaimed.

I have been scrubbed with several residents after Alice finished her nostril occluding ministrations and it was hard to maintain a serious demeanor when you are handing surgical instruments to someone resembling a walrus. Those two dental rolls dangling from someones nostrils looked just like tusks. It did not take long for the offender to beg the circulating nurse to pull the plug on the dental rolls and cover his nose with a mask. Alice then remarked, "Some people have to learn things the hard way." The dental roll nostril plugging was most unpleasant.

Alice had the restraint and good judgment to avoid the dental roll ram - rodding procedure with attending surgeons, but all residents and nurses were fair game. Attending anesthesiologists usually got away with the exposed nostril stunt claiming, "My nose must be exposed to detect any anesthetic agent released to the ambient environment." Since old time anesthesia circuits did leak, it was a very viable excuse.  This excuse combined with a speedy dive under the ether screen  to purportedly check a line worked like magic when Alice was making rounds.

Urologists were also very fond of having nostrils overhang their mask and usually got away with the exposed nostril trick in the cysto room. The rationale used here was that an exposed nose was less likely to fog the eyepiece of the scopes. Alice rarely made rounds in the cysto rooms so this became a favorite nostril exposing zone. If a careless  urologist tried to extend the exposed nostril trick to a surgery OR, Alice would quickly pounce and volunteer to reposition their mask. If the offender was an attending, Alice would merely slide the drooping mask up. Residents were fair game for the dental roll ram-rodding procedure.

I was so paranoid and afraid of Alice that I would frequently tape my mask securely in position high  on the nose when she was on patrol. Thankfully, I was never subjected to the dental roll nostril plugging procedure. An inch of preventive tape on the nose and mask was worth a pair of patent nostrils.

Left Handed Surgeons

This illustration shows a neurosurgeon dissecting with his presumed dominant left hand, with a  suction ready to go in his right hand. I spent many happy hours with our internationally known neurosurgeon, Dr. Oddo and was always impressed with his ambidextrous abilities. He was equally adept with either hand. Whenever I asked about his versatile handedness he always replied, "It's best not to think too much about things like that. I just use whatever hand feels best. Just shut up,fool, and keep that suture coming." (I always waited until the end of cases to pose philosophical questions figuring that a combination of fatigue and relief that the critical segment of surgery was over would reduce inhibitions and produce answers to my foolish inquiries. Sometimes this strategy worked yielding valuable insights.

After spending many lengthy sojourns underneath the OR table adjusting the foot pedal of the Mallis bipolar cautery, I noticed Dr. Oddo always used his left foot to actuate the pedal. From this, I concluded Dr. Oddo was left footed. I extrapolated this finding to figure that Dr. Oddo was probably a natural southpaw who had been converted to using his right hand by societal pressure or his lengthy medical training. His left laterality preference was revealed by his left footedness.

Unlike some of my colleagues, I actually enjoyed crawling under the OR table to adjust the Mallis bipolar foot pedal. It was kind of like a mini-vacation from all the noise and mayhem going on above the table at the operative site.  No flying bone chips to dodge and no putrid Bovie smoke to inhale.The drapes made the area under the OR table feel like a  cozy tent pitched in the middle of the wilderness. It was a nice quiet place to pause for some refreshment until the surgeon hollered to adjust the lighting or the scrub nurse pestered me to open more suture. It was a nice respite while it lasted.

Now I knew why Dr. Oddo  insisted upon having a left handed set of Raney clip appliers available at all times. He was a closet lefty.  The ratchet mechanism of the left handed Raney clip applier released in the opposite direction as a right hander.  ( Those purple things around the scalp margins in the above picture are Raney clips and they prevent blood from oozing all over the operative field.)  One of my claims to fame as a scrub nurse was the ability to load 2 Raney clips at a time, even Dr. Oddo was impressed. This was the only left hand specific instrument he ever requested which was a testament to his ambidextrous abilities.

Sometimes Dr. Oddo's  ambidextrousness befuddled me. Instrument trafficking (thanks to whippersnapperns for coining that term, it fits like a glove) involves several elements; timing, correct hand placement, and with enough oomph that the surgeon can feel the instrument slapped into his hand. Whippersnappers sometimes are shy about instrument slapping, but it's called slapping for a reason. I've never had a surgeon complain about the slap being too hard, although one did call me "old school" for aggressive instrument slapping. I think it was a compliment.

My signature instrument trafficking trick was to smack a needle driver loaded and ready to go into the surgeon's right hand while simultaneously sliding a pickup forceps into his left hand. This always happened at the close of a case when everyone was in a relaxed state of relief that the critical portion of the surgery was over. Surgeons just loved receiving two instruments in one motion or maybe they were just ecstatic that they were almost done. Anyhow, I never had any complaints about my trafficking technique until I scrubbed with Dr. Oddo.

Sometimes he would work with the instruments as trafficked (needle holder driver in the right hand and pickups in the left) Other times he would give me a nasty look, I could easily read a scowl even with a mask on, and switch hands so that he was suturing with his left hand. Of course, I had instinctively placed the needle holder in his right hand.   Out of the blue, I'm thinking.. pick a hand Dr. Oddo...Pick a hand and stick with it...  and it inadvertently  capers across my tongue.  Dr. Oddo screams at me, "Mind your own business fool and keep that 3-0 coming." After the case, Dr. Oddo approached me and actually apologizes and explains that when he was a resident, the attendings  would always implore him to "pick a hand." This caused handedness to become a hot button issue with Dr. Oddo. I never again just slapped an instrument into a specific hand, but always tried to be aware of which hand he was using.

I once worked with a neuro fellow that had done his residency at the famed Mayo Clinic and was accustomed to gloving up with his left hand first even though he was a right hander. It seems that the two Mayo Brothers were left handed and as a tribute to them all surgeons gloved left hand first. I was just getting used to the practice when Dr. Oddo took note of it and started asking pointed questions of the fellow. I was shocked when he dressed the resident down saying, "This is not the Mayo Clinic and that old fool scrub nurse has enough to worry about at the beginning of a case. I want everyone gloving the same way, right hand first." The humiliated fellow readily concurred. I thought maybe Dr. Oddo was taking out some of the frustration he received as a left handed resident on the poor fellow.

There was a left handed general surgeon that had a complete major set of left handed instruments. The needle holders, clamps, and scissors were left hand specific. I could never get used to releasing the ratchet in left handed instruments and was constantly fumbling around. Luckily there were a couple of left handed nurses available to work that room. We had a left-handed specific general surgery room where even the anesthetist was left handed. It worked out well. I was a committed right handed person and could never feel comfortable releasing ratcheted instruments in my left hand.

I then tried using the left handed ratcheted instruments in my right hand, but somehow the thumb is not designed to slide the ratcheted side of the instrument upwards. Somehow left hand specific instruments just were not my thing.

I did some research on the internet about left handed surgeons and the terminology and tone was overly complex and full of bafflegab and bolderdash. Scalpels, sponges, and pick-ups are not hand specific. The only difference is with ratcheting instruments opening and closing in the opposite direction. If the left handed surgeon simply operates from the left side of the table, I would think everything should go well. As a right hander, I don't think I could ever be comfortable with clamps ratcheting the "wrong" way or working from the left side of the table. I was lucky that there were left handed nurses to work with left handed surgeons.

Santa Brings Dr. Oddo a Polavision Outfit

Edwin Land, CEO of Polaroid Corporation with his most technologically advanced product, the Polavision film movie camera and processor/viewer which looks like a small TV. circa1976

Dr. Oddo, Chicago's internationally known neurosurgeon and my favorite person to scrub with bounced into the operating room a couple of days after Christmas ecstatically announcing his latest Christmas present. It was a Polavision film movie camera with a viewer that processed the film immediately after it was shot. This enabled someone to view the movie shortly after it was shot. A filmed based substitute for digital recording.  It was his notion that the circulating nurse could document the key elements of some of his procedures to show off educate the neuro residents.

Shortly after  Polavision was introduced, Sony came out with the Betamax. Polavision was less expensive and more compact than the bulky Betamax. The Betamax held some key advantages, Polavision film ran for 3 minutes, the digital Betamax went for an hour. Betamax had sound while Polavision was silent. Initially, it looked like there would be decent competition between the two products. Dr. Oddo always liked to be on the cutting edge of technology, but over time digital killed film.  Polavison was a really advanced technology for the times and Polaroid spent a small fortune in R&D cost.

Polaroid then spent millions on advertising even enlisting famed photographer Ansel Adams to shoot movies with Polavision, Yoko Ono and John Lennon shot home movies of their son with Polavision. In the end not enough of the product was sold to cover development cost. Polavision was sold only a couple of years at a retail cost of about $700. The price might have been affordable to a neurosurgeon but that amount of money represented my monthly take home pay. I was not about to run out and buy one. This product was the beginning of a long downward spiral for Polaroid.

Polavision may have succeeded if it had been introduced decades earlier. It was introduced too close to the emergence of digital recording. Kodak came out with digital 8mm cameras later and the Polavision era had ended. Film for the Polavision system was even discontinued. Dr. Oddo cajoled us into filming some aspects of his surgeries for a couple of months and then lost interest with the arrival of a Betamax system. The hospital even hired an audiovisual aide to run the machine. That was the end of film.

The whole Polavision got me to thinking about technologies that were regarded as high tech, but now appear very crude. The first procedure that came to mind was the pneumoencephlogram which was invented by the famous neurosurgeon, Walter Dandy at Johns Hopkins. The patient underwent a spinal tap where CSF was withdrawn and air injected. The patient was the secured to a chair that moved 360 degress in a vertical and horizontal axis. Film X-rays were made as the chair was rotated and the air bubble moved around between skull and brain. This was a brutal diagnostic test bordering on torture and about the only thing it did well was diagnose menengiomas. Thank god for CT and MRI scans.

I think another contemporary diagnostic measure where the technology got ahead of the knowledge is with PSA testing. The sensitive test was very good at identifying prostate lesions that were best left alone and not so great at identifying appropriate candidates for surgery. Add the Davinci robotic surgery device to the mix and you really have to question if this is a triumph of technology. I am sure their are great anecdotal accounts of miraculous robotic surgeries, but are their any studies that support robotic surgery? I think this robotic surgery thing is another example of the marketing hype exceeding the benefit. I'm certain hospitals must recruit a good number of patients just to cover maintenance cost.

I wonder if electronic medical records are another Polavision in the making. The development cost had to be huge and the system cannot even communicate between different healthcare systems. When I visit my MD he has been converted into a data entry clerk. Heck even proud bedside nurses now have their heads buried in a computer screen and there is even an animal called a nurse infomaniac or is it infomatics. These people will be the Polavisions of the future. If you are not a physician or nurse directly caring for a patient it will someday be time to get off the bus. When the healthcare bubble pops those doing indirect care will be the first to go. The administrative cost in today's healthcare is obscene.

I better stop this nonsense before I get carried away. For people caring for patients, I hope the New Year rewards you with a true sense of personal fulfilment and peace. The only thing that makes me feel good about healthcare is the notion that I might have helped a few people over the years. Don't let the business of corporate healthcare rob you of that personal satisfaction of helping others during their most vulnerable time. When you get old that's all that really matters.