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.
There is a cornucopia of awards for modern day nurses. I've previously blogged about this trend which seems to have proliferated to the point of ridiculousness. An organization supposedly representing operating room nurses is now offering an award for an expensive system that attempts to contain the smoke liberated by the cauterization of human tissue. They have "partnered" with a commercial entity that manufactures these devices. The coveted award is called "Go Clear," and there are gold, silver, and bronze permutations. I can visualize the winners standing on a podium resembling an OR table in their AORN approved bouffant head coverings looking more like chumps than champs. Any nurse that had the unmitigated gall to seek personal enrichment by huckstering anything by enticing folks with awards would have been shown the door in a vintage hospital.
After a cursory review of the literature, I found there is little in the way of hard science to prove Bovie smoke is harmful and no published randomized trials. Sure it contains some nasty substances and most folks find it unpleasant but old OR nurses would laugh in the face of someone selling an expensive toy to "go clear." If Bovie smoke is one of the worse things you smell as a nurse you must be spending too much time sitting in an office and please, don't get me started on nurse office sitters.
OR nurses were so acclimated to Bovie smoke they could correctly identify the type of tissue being cauterized by the scent of cautery smoke and regarded this ability as a badge of honor. Remember that old TV game show, "Name That Tune" where contestants said they could identify the song in 3 notes or less? Vintage scrub nurses played a variation of that game by playing "Name That Tissue Smoke." Pleura was the easy one for me and I could name that tissue in 1 whiff because of the characteristic sweet/sour smell released by the smoke plume.
There are cost effective ways to mitigate Bovie smoke that do not involve the unsavory element of money changing hands. We were conditioned to believe nurses were meant to be poor and efforts toward personal remuneration were sinful. My what a different world today where patients check in and check out of medical office visits with all the dignity of a Wal Mart Trip. Nurses have more money today but something has been lost in the process. Proud, caring professionals have been rendered mercenary automatons by corporate healthcare.
One of the most efficient Bovie smoke minimization strategies has presidential overtones and it's appropriately called the Clinton strategy; don't inhale. Just wait until that perilous plume dissipates to resume normal respiratory activity. Works every time and doesn't cost a cent. If you don't inhale it can't hurt you or cause adverse political consequences. Bill was unto something.
Surgical masks are designed to implement a barrier that prevent endogenous operator bacteria from reaching the surgical site. Masks function both ways and are also effective filters to block inhalation of Bovie smoke. As proof I offer the post operative sniff test which involves reversing the mask and thrusting your proboscis dead center into the mask after a long case. Guess what? It smells just like Bovie smoke that's in the mask and not your lungs.
Oldster nurses were frugal by nature and trained to use existing resources to the maximum. If you are interested in saving your hospital big money there is post on my blog that explains how to perform a sterile procedure with finger cots. Gloves are not cheap. There is suction available on surgical cases so if you don't care for Bovie smoke just suction away with what you have. Be prepared to be belittled because tolerance of Bovie smoke was an expected virtue and self serving actions like this were seen as a public declaration of your lack of commitment to patient care. Nurses were expected to put themselves in uncomfortable and self endangering situations. It was all part of being a nurse. A hospital is not Disneyland!
A scan of my battle scarred, trusty Tycos stethoscope.
No, I don't have one of those new-fangled telephones
that takes a picture to post on the computer..
My initial excitement soon subsided after reading a blog post about stethoscopes. An important nursing symbol and vital tool of the trade was reduced to a laundry list of currently available stethoscopes along with their prices listed in USD. Christmas is not the only thing that can be reduced to nothingness by crass commercialization. There is a heck of a lot more to talk about stethoscopes than the current products available from Chinese sweat shops. No wonder people in some foreign countries hate us. How would you like to sit and polish stethoscope bells for the measly sum of 45 cents per hour?
My all time favorite stethoscope was a Tycos combination model and I spent many happy hours auscultating with my eyes glued to the back of the diaphragm housing that proudly proclaimed "Made in Asheville NC." Gazing at the proud proclamation of manufacturing location seemed to make heart sounds more distinct, I bet those North Carolinians are nice folks. They certainly produced a mighty fine stethoscope back in the 1960's.
I used to wear my Tycos draped around my neck with the earpieces on the left and the bell on the right and now my stethoscope has a permanently induced curve to it just like Princess Leia's buns. Here is a tip for you whippersnapperns; occasionally change the direction of dangle from left to right as your stethoscope hangs atound your neck to avert that nasty permanent curvature problem.
The tubing on my old Tycos scope had a nice supple, almost slippery feel to it. One night while feverishly hanging units of packed cells, I discovered a new use for my stethoscope. Each unit of blood was supplied with little stickers that provided the identification number of the unit. All I had to do was place the ID stickers anywhere on the stethoscoupe tubing and it was temporarily stuck there until I had a break in the action and could apply them to the chart. That stethoscope tubing was the medical equivalent of sticky note adhesive - it was the perfect parking spot for any type of sticker which could be removed later for the chart. A present day application for this nifty feature might be if your drug seeking patient claims an allergy to an NSID, just make out the allergy sticker and plaster it to your stethoscope until the moment of truth arrives.
Yesterday's nurses were experts at using whatever was available to meet a patient's needs. One of my class mates was working as a school nurse when a young student collapsed with a tongue swollen so acutely that it occluded the airway. No problem for this Macgiver style nurse as she quickly cut a length of tubing from her handy dandy stethoscope and deftly inserted the lifesaving tube intranasally to bypass the occluding tongue and establish an airway. To prevent the distal end of the nasal airway stethoscope tube from advancing too far into the nose, she fashioned a safety pin stop.
The kid was gas exchanging like a marathon runner. At the hospital, the nasal airway was swapped for a naso tracheal tube and after steroids and Benadryl, the youngster lived happily ever after.
There is so much more to stethoscope stories than a listing of their prices.
Before the advent of TPN and tube feedings there were enemas for nourishment, Avertin or pentothal enemas produced anesthesia (Abbot actually produced a prefilled pentothal rectal syringe and it was not prudent to confuse it with a Fleets,) stimulant enemas of various caffeinated beverages were also used. Would you like cream and sugar in your coffee enema? Neomycin antibiotic enemas were commonly used before prostate biopsies or intestinal surgery, and Kayexelate enemas were a very messy way of reducing blood potassium levels. Anthelmintic enemas were used against pinworms and sometimes included a secret ingredient (dilute turpentine.)
I'm certain I have forgotten some types of these backward treatments, but there was an enema for just about any ailment. Old time nurses often had special enema recipes that they guarded with as much vigilance as a restaurant would with a specialty entrée recipe. When the time tested enema can was replaced by the clear, disposable plastic bag enema in the early 1970's, old nurses were mesmerized by the visible rise and fall of the solution with the patient's respirations. You could not see this phenomenon with the opaque metal can and old nurses thought that watching the enema solution oscillate in the bag with inhalation and exhalation was more fascinating than open heart surgery.
Carminative or anti-gas enemas were in a class by themselves and this is the procedure for a "Harris Flush Enema" as described in a 1930's AJN article. We did a similar procedure sans the electric light bulb as a heat source and called it a "tidal wave enema." The enema bag was alternately raised and lowered so the solution flowed in and out of the colon. The degree of browness in the enema bag served as a visual indicator of the in and out flow of the solution. Bubbling in the enema tube or bag was also a good sign that gas was being expelled. Some patients experienced "blowouts" where by the gas was blasted past the inserted rectal tube with frequent unpleasant (for the nurse) results.
The thought behind the heating of the solution was that if maintained at body temperature or above, the enema set up could remain in place for an extended period of time allowing the patient to expel gas. Old time abdominal surgeries disrupted peristalsis and pain from retained gas could be severe. Here is the procedure as outlined by the old AJN, I have inserted a few editorial comments in italics.
THE HARRIS DRIP Purpose: To carry off gas and waste
Equipment:
3 feet rubber tubiing
Irrigating can
Rectal tube with Vaseline ( I guess lubafax was yet to be invented. We received demerits if Vaseline got anywhere near rubber tubing because it caused deterioration and could bankrupt the hospital and don't even think about using a pair of those budget busting gloves!)
Emesis Basin
Clamp
Towel
Extension cord and light (This is where it gets interesting)
1 inch strips to tie the electric light
2 Large safety pins
Fire extinguisher (I added that one. Better to be safe than sorry)
Procedure: Connect the tubing and the rectal tube with the can and clamp off.
Put onto the can sodium bicarbonate 6 drams; water to make 40oz
Place the can on the bedside table. Allow air and solution to run out of the tubing into the emesis basin. Lubricate the end of the rectal tube and introduce it into the rectum.
Remove the clamp.
Raise the can and allow the solution to flow into the rectum. Lower the can about 1 foot and allow the fluid to run back into the can. Gas will also return. Repeat several times.
See that the tubing does not dip down off the bed; it may be held in place by pinning it to the muslin draw sheet.
Place the electric-light bulb in the solution so the metal part does not become wet. (sounds like a good tip, might want to have consult for the burn unit and an anal plastic surgeon as well.)
Place the plug in the wall outlet and turn on current.
Cover the can and electric light bulb with a towel.
Points to remember:
Change the solution as often as it becomes soiled.
Keep at an even temperature.
I think a better name for this procedure would be lightening in an enema can. One false move with that light bulb and it's a tossup; which is a greater risk electrocution or a rectal infusion containing broken glass?
Urologists can pull some truly terrifying instruments from their bag of tricks; sounds, bougie-a-boules, dilators, resectoscopes, and filiforms come to mind. Some items are best lost in history, such as urology tools that were rigid, unyielding, and only for use by the very experienced physician. I recollect a truly terrifying instrument, the Kollman dilator that deserves a separate post.
It took years of experience to successfully and safely pass old time metal urethral catheters without damaging the prostrate or wreaking havoc with tender urethral mucosa. I have vivid memories of a story an aging urologist told me about the time he inadvertently transected a hypertrophied prostate while attempting to relieve a distended bladder by using a metal urethral catheter. The notion of a metal catheter plowing through very sensitive tissue with an awake patient arouses primal fear in everyone. I suspect that really does smart!
Ram-rodding rigid metal catheters into a highly innervated
orifice lined with delicate mucosa is not my idea of a fun time.
It's time to page the doctor to pass these steely stiletto-like
catheters, unless, you have one of those newfangled nurse
friendly, slippery and flexible silk catheters.
Old time urethral catheters also were made of glass. whenever glass objects are inserted in a body cavity, the potential for breakage is always present. I have heard anecdotal accounts from older nurses relating that glass catheter breakage was the impetus for the development of silk catheters.
One glass catheter story involves a difficult labour that necessitated a Cesarean Section. While having a glass urethral catheter inserted, the patient had a very robust uterine contraction breaking the glass catheter off in the bladder. After the baby was delivered the physician was faced with the difficult task of removing the glass catheter without causing injury.
The very first silk catheters were constructed by using a glass catheter as a sort of template. The silk was woven around a glass catheter and a varnish like substance applied to maintain the shape of the catheter. I'm not sure when the first silk catheter was constructed, but by the mid 1930's, silk urethral catheters were in widespread use. Natural silk has an off-white color and silk urethral catheters were often dyed by applying Methylene blue prior to the varnishing stage. The end result was a flexible, pretty blue urethral catheter.
If you are interested in perusing an unusual Methylene blue story, just type "A Blue Finger Bigot" into the search box on this blog. Someday I will get around to figuring out links! It's hard for an oldfoolrn to learn new tricks and so easy to stray from the task at hand....My apologies. Now it's time to return to the tale about silk catheters.
Our instructors in nursing school loved to show off the school's collection of silk urethral catheters. They differed from modern flexible Silastic or rubber catheters in that the wall of the silk catheter was very thin. An 18 FR. silk catheter probably had the same sized lumen as a modern 20 or 22FR catheter. While modern catheters are inelegantly packaged by sandwiching them between a piece of paper and a plastic-like covering, the old time silk catheters were individually packaged in an elaborate long thin felt lined blue box that exuded class. They certainly don't worry about fancy packaging today.
I have never used a silk catheter, but every older nurse sang their praises. The silk catheters had just the right amount of rigidity for insertion, but were very soft and forgiving to urethral mucosa. They were much less traumatic than a rigid metal catheters and nurses began to routinely perform catheterizations.
I guess everyone has to start somewhere and these silk catheters opened the door to other nursing procedures such as starting IVs. Oldfoolrns just called the procedure an IV start, but I see you whippersanapperns have coined the fancy terminology of "initiating a peripheral intravenous cannulation." That sounds much more sophisticated and I wish I had thought that one up. My old school terminology sounds pretty dumb. It's a good thing we were not as dumb as we sounded.
The next time you are starting an IV (OOPS.. I mean initiating an intravenous cannulation.) or setting up an arterial line take a moment to reflect on that old time nurse that started the nurses on the path to performing procedures with the silk urethral catheter.
Anonymous commenters, I would love to hear from you. I did not realize that there were restrictions. I hope that I have fixed it so anyone can comment on my foolishness.
I simply love one man bands. The notion of one person or one object having more than one function is fascinating and has led to things like Swiss Army Knives and the Shop Smith woodworking tool that is a drill press, lathe, router, bench saw and who knows what else all in one. Unfortunately, the operating room is an area of specialization. Each instrument and person has one specialized purpose. It's time for a new paradigm in surgery where doctors, nurses, and instruments take on more than one function. Here are a few possibilities.
Too much perfectly good product (I learned that term from those smart alecky business types that run hospitals today) gets tossed. It seems like we had to set up suction on just about every case and then throw it out regardless of condition. On some minor cases the suction container was empty at the end of the case. It just so happened that these minor cases had the most frequent episodes of nausea upon emergence from the anesthetic. It's tough to work up much of an emesis after being NPO, but I have seen it happen. I think that raw gastric content without food to act as a buffering agent can be even nastier than the usual garden variety of emesis mixed with an assortment of foodstuffs.
Now grab that empty suction container and proudly present it to your upchucking patient. This trick worked like a charm until the end of my career when some genius designed a closed system suction bottle. Bring back the old school coatainer that you can zip the top off and you have a dual use product. Not exactly the equivalent of a one man band, but at least we are back on the right track.
A nobel prize awaits the inventor of a truly functional combination needle holder/scissors. This device would have marvelous utility and could free up a harried scrub nurse for important things like counting sponges and cleaning bloody instruments rather than assisting with the actual surgery. I can't tell you the number of times I have been happily buffing up a Babcock with a 4X4 so it shines like the bumper on a '57 Cadillac, only to be rudely interrupted by the surgeon bellowing: "Fool get down here, I need you to cut suture for me." There are now combination needle drivers (as you whippersnapperns are so fond of calling them) that are capable of cutting suture. The present design greatly limits their usefulness. The scissors part of the instrument lies inside the needle driver making it necessary for the surgeon to work with essentially 2 instruments of different lengths. Muscle memory is a powerful mistress and if you want to drive a surgeon totally nuts, supply him with instruments of differing lengths. There is never a happy ending with this type of muscle memory confusing instrument and the end result is an outburst of swearing. Hey, maybe we could repurpose that suction container as a cuss bank.
What we need here is a needle holder with the gripping jaws exactly the same length as the scissors part. I am thinking of something with a dual head design akin to a bicephalic creature with both the scissors cutting element the same length as the needle holder jaws.
An old school hybrid anesthetist / circulating nurse was sometimes called into duty on late day or emergency call cases when there was a shortage of personnel. I am certain this would not be tolerated in today's regulated health care world with all the electronic monitoring devices behind that ether screen, but with a BP cuff and precordial stethoscope these were much simpler times. Once a case was under way the anesthetist would call the circulator over and ask for coverage while he attended to an induction in another room. Once surgery was underway he would scamper back to the original room. This did not happen often and once a sleepy resident was aroused to cover it was back to business as usual.
I was scrubbed once with a novice circulator who seemed anxious about her newly found role as an anesthetist. The attending anesthesia doc ran out of the room for an emergency, but offered succinct instructions for the newbie anesthetist: "Every time you take a breath squeeze that big black bag."
I know nothing of laproscopic surgery, but this discipline seems fond of multifunction devices. I recall a few years back, Olympus announced the Thunderbeat a combination ultrasonic tissue cutting tool and bipolar cautery. Maybe something was lost in the English translation, but I would be plenty nervous if someone wanted to insert a device named Thunderbeat near my spleen or pancreas.
It does seem like a good idea and in retrospect, I wonder why someone never came up with a dual purpose Metzenbaum dissecting scissor and bipolar cautery. It could be named the "Smokeysnips." If someone could figure out how to add a smoke evacuator to this instrument it could serve several needs; a cutting device, a cauterizing device, and a smoke evacuator.
Here is another 3 in 1 device. We used our trusty Mayo scissors to snap the metal band off multidose vials so the contents could be poured into color coded medicine cups on the scrub nurse's Mayo stand. Unfortunately this really dulled a good pair of sharps so a dedicated multidose vial remover would have great utility.
Since our ORs were on the 7th floor, the windows lacked screens. Occasionally a Chuck Yeager of the insect world would make his entrance to the OR. We did have flyswatters, but you could never find one when you needed one. Combine a multidose vial opener and a flyswatter with perhaps an Oxygen tank wrench and Presto, a multi function instrument of unprecedented value.
I'm saving the best for last. After a long case the first thing I loved to do was tear off my mask without untying it. That ripping noise of the attachment strings separating from the mask was down right satisfying. Next on the agenda was a quick eyeglass clean up. Blood, prep solution, bone chip residue and unidentified material had an affinity for eyeglasses. If an enterprising mask supplier could add a strip of microfiber to the part of the mask, it could be used to clean eyeglasses post ripping off shenanigans. I really could have used something like that.
Beethoven had the fifth symphony, Sousa had the Washington Post March, and Oldfoolrn had the distinction of being a surgical elevation platform builder extraordinaire. I'm on the taller side and developed an early appreciation of having the scrub nurse on a level above the operative field. It is so much easier to properly deliver an instrument to the surgeon when working from above. It also gives you the best seat in the house when visualizing the technical aspects of the surgery. I think just about everything works better when going downhill except perhaps a patient's vitals. Sorry for the momentary lapse into foolishness.
For the height compromised scrub nurse I could construct an elevated platform extending from her Mayo stand all the way to the back table using standard, readily available platforms which were supplied in every room. If more than the alloted 6 platforms were required, I would be off on a scouting mission to an adjoining OR to steal borrow a couple of extra platforms. It was considered bad form to aggressively yank a stool out from under an observing medical student. The best strategy to use here was distraction, " There is an interesting aneurysm clipping in the next room, why don't you check it out?" The med student quickly vamoosed leaving behind the coveted platform. Just remember to act dumb (it was easy for me) when the angry medical student returns and replies, "I thought you said they were doing an aneurysm clipping. That I&D of an abcess made me sick to my stomach. It was disgusting." Meanwhile the scrub nurse is regally perched on the medical student's platform enjoying her lofty perspective and happily passing instruments from above to the surgeons in the lowlands.
For the really short scrub nurses I devised a custom built platform that got pint sized nurses high in the sky. I removed the horizontal metal pan from a non functioning litter. This piece of steel was the perfect length reaching from the midget scrub nurse's Mayo stand all the way to the back table. From either end I elevated the litter bed on ordinary platforms. This Rube Goldberg height enhancer even had a built in safety feature. I left one of the siderails functioning and it served as a safety fence to prevent the miniature scrub nurse from falling backwards off the platform. It worked like a charm and my short colleagues just loved it.
For a couple of weeks all went well with my jury rigged scrub nurse elevation platform. Short nurses were clamoring to climb aboard and they even claimed the surgeons were better behaved and yelled less when they towered above them. It's much more difficult to badger and berate someone who is taller than you. When my ever present supervisor, Alice, learned about my custom elevation device, she went ballistic, "What's this ridiculous hodge-podge of components? Dismantle that abomination immediately." That was the end of that. It was fun while it lasted and gave the vertically challenged nurse a new perspective. Alice always got her way.
If you think my litter elevation contraption was unsafe, note the photo on the left. Using anesthesia stools as the person on the far left is doing invites mishaps. Anesthesia stools are height adjustable by rotating the seating platform. Spinning round and round while sitting might be fun, but not while standing. These anesthesia stools used as elevation devices are tuntables of death or serious bodily harm. Stay off of them.
Circus trapeze artists have safety nets, baseball players have warning tracks and elevated scrub nurses need a safety net too, especially while they are elevation novices. In time nurses learn they can only shuffle from side to side on elevation platforms. It usually takes one good fall to learn this valuable lesson. Here is an interim safety tip for platform elevation beginners. Strip the padded mattress from a litter and carefully place this behind your meticulously constructed platforms. We used to have bright red foam litter pads that worked perfectly. The bright red mat functioned just like the ball player's warning track and the foam silenced and cushioned a fall. I do not know any scrub nurse that fell off a platform more than once. To paraphrase Neil Armstong, "That's one small back step off the platform and one giant crash when you fall to the floor holding a heavy surgical instrument." Be careful out there when you are working high in the sky. That unpadded terrazzo floor is an unforgiving surface.
There was one type of neuro case that called for elevation for even the tallest of scrub nurses. Any craniotomy with the patient in a seated position called for special elevation tricks. In the early days we had a heavy duty Mayo stand that could be positioned about 5 1/2 feet in the air. Even the tall nurses needed platforms to work from this dizzying height. At about the time I was nearing retirement a specialty neuro instrument table was introduced.
This table was one piece and eliminated the separate back table and Mayo stand set up that I knew and loved. I always had to imagine a corner of this monster Phelan Neuro table as the Mayo stand to keep things orderly. If we were working with Methylene blue which was one of Dr. Oddo's favorite marking agents, I was in business. I physically drew a Mayo stand top outline on the oversize single table drape. It worked like a charm for me, but some of my co workers thought it was really a silly thing to do.
Another one of my signature tricks was to take my straight Mayo scissors and cut an intricate filigree design into the top of the wax paper bag that we tossed used suture scraps into. Dr. Oddo always said that it was going to be a tough case if he noticed a plain trash bag on my Mayo stand. "Uh Oh, somethings up.. oldfoolrn did not have time to decorate the suture bag," was his ususal reply. I never felt the artistic urge when dealing with late night or trauma cases so I just went with the plain old suture trash bag.
I'm starting to get off track again, so it must be time to wrap this up. I really do appreciate all of you who indulge in my foolishness and it amazes me how many of you read this in the middle of the night. Sometimes I fantasize about that phone ringing in the middle of the night to jump out of bed and scramble over to the hospital for a trauma case with Dr. Slambow. It really sounds like fun now that I cannot clearly recall scrambling to set up instruments or feeling totally beat up by the late hour and gruesome trauma.
Maybe some of you bright young whippersnapperns could enlighten an Old Fool about what is going on here. I have narrowed it down to a couple of possibilities. Either the seated nurse is about to catheterize the supine patient or the supine surgeon is performing a new age hemorrhoidectomy on the seated patient. I guess it's a toss up.
I like the notion of OR table portability. With those wheels and the person on top in a driver's position it looks like this thing could me driven from one OR to another in a jffy. This would be perfect for the patient having two different surgeries in the same session. After having that total knee replacement in the ortho suite he could be driven straight to the general surgery room for that much needed hemorrhoidectomy. For added flexibility and quick access to different sites may I suggest the addition of a rotisserie option to this table.
I just hope the anesthetists know how to use those old school ambu bags during transport and can hook the patient back up to the anesthesia machine in the new room before the patient awakens. On second thought, why not just attach a vaporizer to the table for in transit anesthesia?
An old school operating room light source the size of a pitcher's mound riding on extruded
steel rails. Look out here comes Casey Jones.
I just love operating room lights especially ones with unique features like this super-adjustable rail mounted beauty. The rail mounting provides for the ultimate in adjustability. This baby can be moved up and down the full length of the table which is ideal in trauma cases that cover a wide territory. This is what I would call a "fill' light" to complement the pedestal mounted smaller main light visible just below and to the left. Modern surgeons and scrub nurses probably look down their masks on these old pole and rail mounted lights, but they could be moved virtually anywhere to illuminate any operative site from any angle. Try that with your super duper overhead LED modern light.
A modern operating room light after being attacked by a
weighted speculum swinging surgeon who was frustrated
that it could not properly illuminate a vag hyst. Next time
try a pedestal mounted light.
One of the general surgery rooms that we used for trauma had that massive rail mounted overhead light. Trauma surgeons move around a lot and that rail mounted ball of sunshine can follow them up and down the table as they tend to wounds in various locations. Modern trauma surgeons frequently substitute with those fiberoptic forehead mounted lights, but they really don't know what their missing.
Dr. Slambow even taught me some non surgical uses for operating room lighting systems. When
that call room phone rings at 3AM and you can't seem to clear out the cobwebs, just drag your keister out of bed and into an unused OR. Now the fun begins, switch on that overhead monstrous OR light and stare straight into it. Those brilliant photons will travel directly to the target organ (your snoozing brain) immediately jostling it awake. This works better than holding your head under the scrub sink faucet and blasting it with cold water. I know because I have tried both and would opt for the light treatment every time. The bright light treatment even leaves your hair doo intact.
If it's Winter and your frozen fingers need thawed after that cold stroll to the hospital, just try holding them a couple of inches above an operating room light. A minute or two and that much needed dexterity returns. The scrub nurse has the warm water from the scrub sink and the circulator has the lights. Both methods are equally effective. It is not considered good form to use a patients body heat to warm your hands. Dr. Slambow told war stories about how he could not wait to warm his hands digging the shrapnel from some poor soul's belly. It used to give me the creeps thinking about war injuries and made me grateful for warm water and lights. Dealing with traumatic gunshot wounds in Chicago was enough of a challenge for me and really made war time doctors and nurses seem like a very special breed.
Every important event requires a dramatic start; The Indy 500 has pace cars, track stars have guns and operating rooms have brilliant overhead lights. When that rail mounted illuminating source was fired up it was time to cease that useless chit-chat about that funny smelling Roquefort cheese like substance you just removed from the patient's belly button during the prep scrub. Everyone knew when that big light glowed that it was all business.
I used to love that smooth hum of the ball bearings as the light moved up and down the rails over the table and then there was that reassuring clunk noise as that brilliant monster locked into place. For your enlightenment, the Oldfoolrn acoustic research laboratory has discovered a way to replicate the noise sound of one of these glorious OR lights being adjusted. Simply visit your friendly Home Depot Store and proceed directly to the appliance department. If a helpful employee approaches (not likely at my local store) just ask to see the KitchenAid dishwashers. Open the appliance and pull that top rack in and out a few times. The stainless steel interior of the dishwasher acts as a sound board and amplifies that purring of the ball bearings. Now to replicate the OR light locking into place just slam the dishwasher door shut, You have just experienced the melodious sounds of a massive operating room light being adjusted and locked into place. If you want to experience the noise the rail mounted light makes when it slams into one of the bumpers at rails end be sure to stop in the hardware section and pick up a heavy rubber mallet. To simulate that bumper thump just drop the mallet onto the floor with the business end toward the floor Now you whippersnapperrns really have something to tell your mother about.
When you hear the surgeon proclaim, "That operation went just like a shopping trip to the Home Depot store," you know where his terminology came from.
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This is the plastic surgery OR at Barnes Hospital in St. Louis MO circa mid 1930's. I have worked with many plastic surgeons and they were a zany lot. This surgeon even commissioned an artist named Gisella Loefler to decorate his room.
A number of sights grabbed my attention here. Why are there 2 scrub nurses? I suspect one must be a student. That instrument trolley is actually a precursor to what is a modern Mayo stand. Modern that is to Old Fools like me. In the 1930's operating rooms had a common back table which was loaded up with instruments for a full day of cases. The nurse selected instruments for the current case from the common supply on the back table. The back table was always covered between cases. Nurses and surgeons stayed put in the room until the day's caseload was done. None of that traipsing in and out of the room between cases like you whippersnapperns are so accustomed to. This eliminated extensive room turnover times and there was minimal delay between cases.
One of the scrub nurses has committed one of the 7 deadly sins of OR nursing; her gloved hands have been dropped below the waist band of her gown. For punishment, may I suggest damp dusting that overhead Operay multibeam shadowless light. This was difficult to do with traditional lighting, but imagine the fun in cleaning the nooks and crannies in that Operay
I have always been fascinated with OR lighting devices and I immediately recognized that Operay shadowless lighting system. Our very old unused (except for Dr. Slambow's office) operating room had one of these devices. I spent many happy hours fooling around with it and will post about it soon.
Old time abdominal surgery was a big deal with a lot of little nursing interventions that are unheard of today. The first order of business was to prepare a "surgical bed." I remember our instructors lecturing us that "The first thing to do is to determine which side of the bed the cart will be on when the patient is transferred back to his bed." The top sheet was then carefully fan-folded to the opposite side of patient entry and the top layer of sheet formed into a triangle that could be grasped and quickly pulled over the patient. Sometimes the orderly would attempt to transfer from the "wrong" side of the bed and panic ran wild among the students. Don't bother with the patient's airway, if you folded that sheet and it was on the wrong side of the bed you were in a heap of trouble.
The bed had to have a heavy muslin draw cloth with a scultetus ( skalte' tus) binder carefully centered in the middle. We used to remember the bizarre name of these things by thinking of a skull and a cup of tea that "us" applied." These binders were made in Central Supply by aging nurses from old draw sheets. The draw sheet was divided in half and two lines of parallel stitching about 18 inches apart were run down the center. Six to eight cuts were made from the outside to the inside of the drawsheet to the bilateral stitching at a right angle to create "tails."
The post op patient was transferred from the OR cart to a position in bed lying prone with his abdomen centered on the binder. This thing was going to be applied very snugly around the patient so the gown had to out of the way. The binder was applied directly on top of the abdominal dressing which was secured with another hospital made product, "Mongomery Straps." It was prudent to do the initial binder application while the patient was still at least partially anesthetized to avoid pain associated movement.
The tails of the binder were wrapped around the patient very tightly as if in a Giant Python's grip and the top and bottom tails secured with safety pins. The middle tails were interwoven and friction held them in place. If the binder was only going to be on for a short period of time as in a minor procedure, towel clips could be used to secure the ends. Towel clips were much more secure but less comfortable for the patient.
This photo shows application of a binder. We were taught to apply it next to the dressing, never over a hospital gown. You just earned a bunch of demerits for this stunt!
We learned how to apply binders by practicing on each other. Miss Bruiser, one tough cookie of a nursing instructor demonstrated how to apply these things by using me as a victim patient. When she was done, I felt like all the stuffing was being squeezed out of me. It was definitely unpleasant. This was the same instructor that told us to slap the injection site before giving an IM injection to "reduce discomfort." This old nugget of advice never worked. Perplexed patients used to ask "Why did you spank me?" and in peds the kids would only cry and scream louder. Miss Bruiser did not tolerate fools and was very insistent so we followed her instruction whether it worked or not.
The rationale for a binder was for patient comfort and to decrease the chance of evisceration. Patients really liked binders and they did seem to help with those ghastly huge incisions. Around 1970 or so commercially made binders were available at our hospital and they were much easier to use. They had very nice functional metal buckles to secure the tails of the binder.
Next to the binder, a common procedure after abdominal surgery was low intermittent Gomco suction. Hospital wards and rooms did not have piped in suction so we had wheeled portable devices called Gomcos, named after the company that manufactured them. The drainage from a NG tube was collected in a big glass bottle that had to be emptied every shift. I dropped a couple of glass IV bottles, but luckily never a huge Gomco bottle. I guess sometimes God looks out for fools.
After all the manipulation and retraction done during abdominal surgery, it often took a couple of days for peristalsis to return. The NG tube to low Gomco was kept in place until bowel sounds could be heard again. Patients were always delighted to get rid of their NG tubes.
I used to love the rhythmic clicking and purring noise those old Gomco machines made. When the low suction would initiate they would make a subtle "click" and then as the suction started they made a low pitched purr with a nice gradual crescendo. The cycle would then repeat. Sometimes the NG would occlude and this cycle would be interrupted for irrigation.
I realize binders and Gomcos are now a part of history, but in their time were very useful and provided a lot of bang for the buck. Binders were recycled form draw sheets and those old Gomco machines never broke down.
If I had any sense, this post would end here, but I have to relate this story of foolishness that has nothing to do with binders or Gomco suction. I once worked with an aging neurosurgeon, Dr. OCD that had a way of getting whatever he pleased from the tight wads in hospital administration. After receiving a new piece of equipment or obscure instrument he would strut around the OR bellowing that "We now have a left-handed Raney Clip Applier in our neurosurgical armamentarian." I guess armamentatian is a reference to medical resources available, but OR nurses had a hard time from giggling when he spouted off like this about some instrument or equipment that would never be used.
One day when Nancy and I were damp dusting the overhead lights in the OR, I started blabbering that we had new rags in our "armamentarian" to dust for the next case. I did not notice that Dr. OCD was standing in the doorway. He gave me one of the nastiest, mean looks he could muster under that surgical mask. I quickly shut up and tried to be extra pleasant to him. Luckily, I was one of his favorite scrub nurses so I did not get fired. Whenever I hear that armamentarian word it brings a big smile to my wrinkled up old face!
I've been meaning to write a post comparing modern scrub sinks to those of yesteryear, but I haven't been able to get Cherry Ames off my mind since that last post. It's an addiction of sorts that rears it's ugly head from time to time.
A 12 step approach is probably in order here. I've been practicing that opening line, "My name is Oldfoolrn and I'm a Cherry Amesohloic." Oh well, I could give her up anytime, maybe next week. I'll get some help. She is interfering with my blogging, but I'll just have to try harder to put those Cherry Ames books down.
How is this one for a classic? "Cherry Ames, Rest Home Nurse." Cherry even avoids the pejorative connotations of using that nursing home terminology in the title. I bet there is nary a mention of decubitus ulcers or manually removing a fecal impaction. Just look how delighted that cheerful oldster beams as Cherry greets him. I like how that head gear tells a story. Cherry in her nursing cap and the oldster tipping his stylish hat to Cherry. There was nothing like a cap to establish a nurse's identity.
Well that's enough of Cherry. Recently a whippersnapperrn invited me to view a new operating room suite at the local hospital healthcare system. Wow! the first thing I noticed were the scrub sinks. They looked like something out of my grandchild's toy kitchen. Stainless steel might look nice in a gourmet kitchen. But from my perspective completely unsuited for a surgical environment.
The noise made by the cascading water striking the stainless steel sink sounded vaguely familiar. Then suddenly like an epiphany, it came to me. The sound was an exact replication of a drunk voiding on a garbage can lid. This used to happen constantly in the alley behind my Chicago apartment.
The willy-nilly placement of these modern scrub sinks is another issue. Just hang them on a wall near the OR. Back in the day of huge porcelain sinks, placement was an important consideration. I have seen old time scrub sinks positioned with a beautiful view of the Chicago skyline or with a view into the OR. It was nice to be able to fix your gaze on pleasant distant scenery before all that close up work ahead in the OR. It was also fun gazing into that tiled temple of an operating room imagining how you were going to set up your Mayo stand.
That puny little foot activated faucet head is pathetic. It puts out as much water as an octogenarian with an enlarged prostate. It's probably energy star approved, but we never worried about that. Our sinks had a length of perforated pipe running above and parallel to the sink. Water could be toggled from a trickle to Niagara Falls level with a knee operated valve. Nothing makes a lowly scrub nurse feel more powerful than knowing you have the capability of replicating a natural wonder like Niagra Falls by just a wiggle of your knee.
These new fangled little sinks don't have the depth of yesteryears sinks. We never had to worry about contaminating ourselves on the back of the sink because it was a mile away. Likewise, the bottom of the sink was also a mile away. You never had to worry about contacting it with your arms.
Now this is a scrub sink. Proudly emblazoned with a name like AMERICAN STANDARD or SPEAKMAN. I can close my eyes and still see that proud name printed in blue on that brilliant white porcelain sink. When you were called in on a late night trauma, it was a real pleasure standing before this sink scrubbing. The brilliant white finish waking you up and preparing you to face those bright overhead lights in the OR.
We were required to scrub a full 10 minutes before each case usually with Phisohex which was later found to be a neurotoxin. I guess I could blame some of my dementia fueled foolishness on the scrub soap. We were also required to scrape out that subungal area under our nails before the first case. Your nails were required to be trimmed 1mm. and we actually had a supervisor that measured fingernails. Who knew that area under your nails had a fancy name like subungal? We never learned that one in anatomy class!
These scrub sinks were so big that they had another use. When a surgeon removed a questionable specimen, pathology would come up to the OR and dissect it in the sink. That white porcelain offering a beautiful neutral background for the specimen. I recall one instance when a pre op patient was parked in the hall and started to witness one of these intraoperative dissections. "Yecch! what's that?" she shrieked. I sheepishly informed her it was a portion of a stomach and quickly relocated her down the hall. I felt really bad for her and stayed at her side until her room was ready for her. I guess she was more curious about what was going on than any thing else.
Comparing old and new scrub sinks is like comparing a modern Mini Cooper to an old Cadillac Eldorado. Sure. The Mini Cooper is far advanced and sophisticated, but it still feels like something is missing. Well I have to get back to reading Cherry Ames: Department Store Nurse oops I mean watching TV.
I have been perusing the many nursing blogs and they all seem to be posted by youngsters who are very bright but perhaps may lack perspective. Geriatric nurses, and I am referring to the nurses, not patients have not been communicating well with the younger generation of nurses. Heck, where I live there are hardly any youngsters. Most of my colleagues have went on to their great reward and I am not far behind them. So I am going to start this off with some foolish memories from yesteryear. I have experience in OR, med-surg nursing, and neuro ICU with a brief stint in forensic psych when it used to be called getting beat up by assaultive psychopaths. Anyhow, on with the recollections
The aroma of a metal bedpan being steam "cleaned" in a hopper. When you opened that hopper door with your clinic shoes a big brown cloud materialized right before your watering eyes. Impressive.
Using methylene blue to dye white silk sutures so the surgeon could see it and. when you thread that suture needle make sure to pull enough through the eye. If the suture falls out when you pass it to the surgeon you're going to hear a roar like a mountain lion in heat!
Wearing beanies during nursing school hell week (initiation) and being sent to Central Supply to pick up a set of Fallopian tubes. Your big sister (preceptor in present times) threatened to practice nursing procedures on you and had an array of latex tubing and vessels of water to back up these threats.
Bovies in the OR that looked like Maytags and made that reassuring deep HUMM noises to verify they worked properly. No beeping, clicking, flashing lights and the ground looked like a cookie sheet with camel spit smeared all over it. This was ceremoniously placed under the patients rump just prior to induction. What a great memory before recieving anesthesia. "Oooh that sure is cold"
Setting the sigh setting on mechanical ventilators. PEEP was a yellow Easter candy.
Collecting saliva to test for Digoxin toxicity based on the notion that more potassium would be in their saliva if they were toxic. This could be confusing to some and graphic descriptions of the difference between spit and sputum were common. Yechh
Being taught how to insert a Foley with 3 sterile finger cots.
Being yelled at, belittled, and accused of trying to bring financial ruin to the hospital if you wore gloves while cleaning up a "Code Brown" I learned that last term from the youngster nurses-very clever we used to have to call it poop.
Well, it's getting past my bedtime but there is much more foolishness to follow.
