Transorbital Intubation - An Artful Airway

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

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

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

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

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

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

When the Human Body Works Like a 3D Printer

Here is a case of human reproduction that does not involve a gamete, egg, or mitosis. I would have mentioned "ploidy" too, but I'll be darned if I can remember what that involves. A 35 y/o man who was critically ill had a vigorous  coughing fit which was so  productive that he hacked up this blood clot which formed in his right main stem bronchus; a near perfect anatomic reproduction of the airway cast in blood.

Hemoptysis in the extreme, which formed a perfect casting demonstrating 5 branches of the bronchial tree. The clotting cascade was a real challenge to memorize and about the only thing I can remember  is the cross linking of fibrin forming the framework for the clot. It certainly out performed it's intended purpose in this case.

 The right main stem bronchus is like a grease trap in a fast food restaurant because almost anything that goes down the trachea winds up here. It's the first bronchial segment to branch off and has a larger lumen than the left main stem bronchus. It's also more perpendicular making it the perfect exit ramp for just about anything coming down the trachea. Anesthetists always checked for bilateral breath sounds because it was so easy to selectively intubate the right main stem bronchus. An absence of left sided breath sounds?  Time to pull the endotrach tube out a bit to clear the right bronchus.

It's difficult for me to understand how a clot of this size could form because the most likely scenario would be a clot occluding the upper segment and blocking the filling of  the middle and lower branches.  This perfect cast of the bronchus jolted my memory and brought to mind another memorable anatomic replica produced by the human body.

Fecal impactions were a miserable experience for all parties involved and were common in old school hospitals as a side effect of prolonged bed rest combined with opiate analgesia. With the passage of time, pressure from the upstream accumulation of stool in the sigmoid colon  numbed the nerve endings of the internal sphincter. The end result was a massive hardened bowel movement firmly lodged in the sigmoid colon.

Removing these forbidding fecal accumulations was no easy task because the stool hardened to a consistency of Sakrete concrete. The first step in the unpleasant (to say the least) removal process was the rectal installation of warm mineral oil  in an often times futile attempt to soften the painful putrid plug. The final step was similar to a Roto Rooter operation whereby the mass was manually extracted.

One of my colleagues, Ann, was especially proficient at removing fecal impactions. Her fingers were lithe and she had the unique ability to curl the distal metacarpal at a right angle to the rest of her finger resulting in a hook. Her fecal impaction removal technique involved twisting her index finger much like a boring brace to gain entrance to  the tenacious turd. Having bored inside the monstrous mass much like an African dung beetle  she hooked her finger and gently increased traction until the massive mess slid out.

After the patient's  screams of agony subsided, the oows and ahhs began as attending staff members marveled at a perfect sculpture in brownish stool  of the sigmoid colon. The distal part of the colon is lined with haustral markings which delineate colonic saculation.  As the stool hardened a perfect colonic cast was formed.

Most nurses chipped away at fecal impactions which resulted in a hodge podge collection of fecal shreds. Ann's technique of rmoval in toto resulted in an anatomic model not  unlike the cast of the bronchus. Simply amazing!

Le Mesurier's Hammock - An Early Scoliosis Treatment

Kids have unique gifts and abilities; some are smart, others have artistic ability, and last but certainly not least, some  are preternaturally athletic. I could not lay claim to any of these wonderful  attributes, but I did posses the gift, if you could call it that, of unusual joint flexibility. I could take my heel and twist it at an acute angle and tuck it behind my head. My favorite move was performed from a seated position and involved taking my right foot and lifting it above my straightened left leg while pulling it toward my body. Why did I enjoy such foolishness? I guess the answer was similar to the reason climbers give when they ascend Mount Everest - "Because it's there."

My Mom, a long suffering nurse from the Greatest Generation  did not appreciate my skills as a junior contortionist. Just when I had finished twisting myself up like a pretzel, she would holler, "Stop that tomfoolery before I take you to the hospital and string you up in a Le Mesurier's  Hammock. Do you want curvature of the spine?"  Her admonishment did little to curtail my extremity entanglement and circumvolition  activities, but it did whet my curiousity about that hammock thing threat. "How bad can that be?"  Le Mesurier's Hammock conjured up restful, peaceful experience. My next order of business was an investigation into the how and whys of the hammock threat. This could prove interesting.

Like me, my Mom retained her old nursing school textbooks and class notes which were carefully archived  heaped in a basement corner. One day while perusing the hodge-podge collection of nursing texts a serious looking black bound tome called out to me.  Nursing of Children  was the no-nonsense title and the table of contents listed topics like Diseases of the Glands, Spasmophilia, Hordeolum of the Eye, and Early Correction and Fusion in the Treatment of Scoliosis.

During my quest for hammock enlightenment I happened upon a chapter  about bedsores. This little tidbit of medical horror instilled a sleep disorder that persisted well into adolescence. In a mood of wonderment and sheer terror my eyes popped at the images of patients with oozing gaping wounds on their lateral hips and shoulders sustained by simply lying in bed. How could this be?  I made a note to myself to awaken q2 hours to check myself for these loathsome lesions. A peaceful night's sleep was gone forever because visions of bedsores danced in my head. Some things never change, now it's a pain in the prostate that awakens me q2 hours for that lonely journey to the can.

Finally a chapter in the orthopedic section about a condition known as spinal scoliosis revealed the LeMesurier's Hammock treatment. This was another one of those medical misadventures treatments that involve harnessing the spinning earth's gravitational pull. Weighted speculums that are ram rodded in various orifices to gain exposure during surgery are a twisted, devious use of gravity  but the LeMesurier's hammock use of this force  was far more grotesque.

When one views the history of treatment of pathological spinal curvature it is apparent that crude and brutal measures rule the roost. Lemesurier's Hammock involved placing the patient in an orthopedic bed that had risers on each corner connected via an overhead frame matching the dimensions  of the bed. These steel framed monstrosities were frightening in their own right but add traction pulleys and assorted doodads for limb fixation and they resembled medieval racks that could dish out unthinkable tortures. YIKES and double YIKES.

A scoliosis patient in position just prior to application of the hammock.

The victim's scoliosis patient's ankles  wrists were liberally padded and heavy leather cuffs are applied and connected by traction cord to pulleys on the corners of the ortho bed. The extremities begin their audacious ascent until the patient is suspended so the apex of the spinal curve is straightened. After a couple of days hanging around over the net, a body cast is applied and a large window cut to expose the operative site. A surgical spinal fusion is the final step in this uplifting treatment.

Helpful tips from this vintage nursing text advise that the leather cuffs can be sourced from the psychiatric ward and the hammock portion can be constructed from ordinary fishnet. The reference to the psychiatric ward  probably foretold impending problems. Patients subjected to 4 point suspension over a surplus fishing net are likely to sustain psychotic ego fragmentation and the nursing staff subject to PTSD. Perhaps a package deal is in order with the whole the whole kit and caboodle; patient, nurses, and leather restraint cuffs  winding up back on the psych floor.

Nurses are stuck in the quicksand of existing knowledge and looking back it's shocking to realize the barbarity of period treatments like LeMesurier's Hammock. It's amazing what patient's will submit to when the treatment is ordered by paternalistic  physicians attired in immaculate white lab coats uttering trite expressions such as, "It's all for your own good." Old school nurses in there all white uniforms and caps were a commanding presence too. It would have been tough to say "no" to authority figures like that and probably wouldn't have stopped their ministrations if you did.

Drinking Bile

No, that's not bile in a T-tube drainage bag. It's a bilious beverage 

just waiting to wet your whistle. Bottoms up!

Waste not / want not was the mantra in epoch hospitals. This philosophy led to events like performing sterile procedures with 2 fingercots and overly judicious rationing of utilities. There were almost no lights on after dark so night nurses always had a flashlight on hand. Recycling and reuse were common with "disposable"  equipment having an almost infinite life span.

Recycling was not limited to medical equipment. Gall bladder surgery was a brutal and miserable experience  with a huge subcostal incision in close proximity to the diaphragm so every breath exacerbated post-op pain. A T-tube was usually placed in the common bile duct during surgery and drained the greenish yellow unsavory goo in a nearby bag.

Bile is a vital component in the digestive process and works to emulsify and break down fat. A deficit of this greenish gooey fluid results in an unpleasant condition known as steatorrhea whereby fat passes through the intestines undigested. An unusually putrid scented diarrhea is the end result.

To avert steatorrhea old school surgeons had a very direct and straightforward solution.  They ordered the night nurse to save the contents of the biliary drainage bag and serve a glass of this gruesome green goop to the patient prior to breakfast. Hospital breakfasts were notorious for their high fat content. Just about every meal was a permutation of that All American staple, bacon and eggs which was a steatorrhea stimulator of the highest order.

The disgusting bile beverage was best served in an opaque vessel such as a coffee cup so as to obscure that yucky green visual stimulation. Minimal explanation was also important. The nurse never drained the bile into the serving container in view of the patient. Optimal bile bag emptying was done with the patient sound asleep and unaware of the impending tortuous tipple. Old school nurses were masters of deception and were even known to ask patients to turn over for a temperature check. While they were prone a painful and totally unexpected intramuscular injection was hastily administered.

The bile drinking gambit  was not much different than the stealthily plunge of the 18 gauge needle during the temperature diversion injection. Either experience was misery of the highest order no matter how it was presented. Bile had a unique earthy/nasty scent to it that could not be masked and the bitter salty taste was cringe worthy. Oh..And be sure to offer mouth care after bile consumption. It promoted dental decay.

Did bile recycling help patients? That's a tough question. Perhaps the diversion of consuming the vile liquid distracted them from their symptoms. It's always prudent to maintain a high level of suspicion when offered just about any beverage from an old nurse. Better safe than sorry.

Caring For Amputated Limbs

The brave new world of modern healthcare culture continues to dumbfound, agitate, and get stuck  in my old foolish, wrinkled up craw. The latest outrage?  I was reading an expert's answer  on Quora that amputated limbs are treated as "medical waste" and are disposed of by encasing them in a red sealed plastic bag marked with a biohazard symbol and sent on their merry  way to a landfill or incineration.

Self respect starts with caring for others in a dignified fashion.

Don't even think about tossing this in the trash!

Since everything in healthcare is governed by money, I suppose this is the cheapest  most cost effective means of limb disposable. Preoccupation with money when it comes to caring for people leads many in the wrong direction. Patients are never clients or accounts and caring for them is not an "industry."  That amputated limb was once a part of someone who is going to have a tough time, to say the least, of dealing with a new body image and learning a new lifestyle. An amputated limb is not an inflamed appendix or a gall bladder full of stones to be tossed in a kick bucket and tossed aside, it was part of someone and their identity. Who knows? Maybe an integral component of the patient's spirit was living in that limb. Treat body parts with the respect they deserve.

Alice, my favorite OR supervisor taught me how to care for an amputated limb many years ago. Alice could be a mean, cantankerous taskmaster, but I agree with her wholeheartedly about showing care and respect for an amputated body part. Despite their harsh appearances, old school nurses had and an innate sensitivity and were determined do-gooders.

When it came time to care for my first amputation patient in the OR, Alice was on hand for direction. "The first order of business is to line up 2 carts just outside the OR. One cart is for patient transport ant the other is used to transfer the amputated leg to the morgue. I don't ever want to see one of my nurses toting a large specimen through the halls like it was a suitcase. You will reap enough negative Karma to burden you forever with that trick." That last line said with Alice's all-knowing conviction made me shiver in my OR shoe coverings as I imagined an amputated limb coming back to haunt me. You better believe I conducted myself with dignity when showing respect to that amputated leg.

I carefully placed the amputated leg smack dab in the middle of the cart and carefully covered it with a white sheet. The trip to pathology was uneventful until I nudged open the door to the morgue and found the pathologist in the midst of an autopsy. He had just plopped a liver on the overhead scale when he noticed me and nonchalantly asked, "what can I do for you?" I stuttered and stammered that I was here with a large surgical specimen. He called  over to  a resident and advised , "Take aerobic and anaerobic cultures and some tissue for microscopy then show the nurse how to put the leg at rest."

One of the hospital  board members was a funeral director and donated a very nice metal casket to the hospital for one specific purpose; the dignified burial of amputated limbs. After the path resident obtained his specimens the amputated leg was wheeled over to the elevated casket in the back corner of the cooler. I gently raised the substantial lid of the coffin and gently nested the  severed limb inside. There were a number of other limbs resting comfortably in the ice cold  casket and when I was finished with the transfer I covered them all back up with a hand knitted shawl lovingly crocheted  by a dedicated member of the Ladies Auxiliary. The limbs were at peace.

The hospital purchased plots at a nearby cemetery where the limbs were carefully buried when the casket was full. I was curious how often burials occurred and was advised it was an annual event complete with a religious official and a few of the path personnel to show their respects.

Years ago I entertained myself with notions of working again as a nurse, but as I thought of the money grubbing corporations running the show my mind did an abrupt 180. My values come from a different place in time and although I failed many, I think my heart was in the right place. I plain just don't believe in nursing the way it's practiced today and the image of treating limbs like trash haunts me.

What Was the Most Useless Old School Diagnostic Test?

 The first notion that popped into my foolish mind was the "spit test" for digitalis toxicity. The patient was asked to produce about 5 cc  of pure saliva which was tested for potassium levels. The notion being that a high level of potassium excreted in the saliva was indicative of toxicity. Everyone had a different threshold to spill potassium in their saliva and hypokalemic patients could be digitalis toxic and have a "normal" potassium level on their test. This procedure was relatively benign in that it seldom led to further testing and had it's lighter side involving nurses providing graphic descriptions to befuddled patients about the difference between saliva and sputum.

The Histamine stimulation test for determination of gastric acid output was one of the chief  villains when it came to useless or even downright harmful diagnostic tests. The test was widespread in that just about anyone experiencing epigastric pain was a candidate and it frequently got the patient placed on the medical hamster wheel of cascading invasive tests all of which led to virtually ineffective treatment.

The underlying principle of peptic ulcer  treatment was the Schwartz dictum (no acid-no-ulcer.) This was accomplished by the Sippee diet which consisted of hourly swigs of 1/2 and 1/2 which was kept iced in a bath basin at he bedside. Copious consumption of antacids was also encouraged. This treatment did not provide a long term cure, but for some provided symptomatic short term relief. Peptic ulcer treatment improved dramatically when Australian researchers showed the root cause of the disease was bacterial. This insight was the gateway to effective treatment for peptic ulcers.

The test was sheer misery for patients. Step "A" involved inserting a naso-gastric tube regardless of the difficulty passing it. Miss Bruiser, my favorite nursing instructor, "assisted" novice nursing students perform this procedure by forcing the hapless patient to  take sips of water from a glass as she forced  the liquid past their  lips all the while barking, "SWALLOW..SWALLOW."  She often explained to the student nurse that inserting an NG tube was just like fishing; just wait until you get a  bite  swallow and ram rod that slippery cylindrical hose home to the patients eagerly awaiting stomach.  "The patient will have to swallow eventually, just like the fish have to bite."  Meanwhile the patient was coughing and spraying the forced water right back in the direction of Miss Bruiser's face. Karma in action.

After the position of the NG tube was verified by auscultation; I always wrote that exact line in my nurse's notes because Miss Bruiser gave brownie points to students that used esoteric medical terminology.  Most of my fellow students simply noted that the position of the tube was checked. Next on the agenda for this procedure was an uncomfortable painful injection of histamine that burned like a blow torch and resulted in a sore arm for at least 5 days.  This stimulated acid production in the stomach just as pouring gasoline on a fire exacerbates the blaze. Headache, dizziness, flushed face, and profuse sweating were frequent side effects of the injection.

The last component of the test is where the rubber meets the road. At 30 minute intervals X3  a gigantic piston syringe is coupled to the NG tube and as much gastric acid as the law allows is sucked  aspirated and placed in a carefully marked specimen cup. Patients often complained that it felt their stomach was being pulled out through their nose. My stomach used to churn and ache just witnessing such an ordeal and it was a cause  for rejoicing when those slippery specimen cups were on their way to the lab for analysis..

When learning about the cause of peptic ulcers the "ulcer personality" was stressed and was described as a person experiencing resentment, anxiety, and anger. I never believed these traits were the cause of ulcers. I always suspected the ineffective medical interventions of the day and the sheer misery quotient of the diagnostic testing caused much of the ill will and bad feelings on behalf of the patients. It's amazing how long  such an inappropriate treatment can remain in place and become accepted practice. Of course such foolishness would never happen in the healthcare environment of today!

Infant Incubators - An Amusement Park NICU

"Step right up..for one thin nickel see pint sized preemies in their incubators"

Vulnerable patients seeking care and hucksters with remuneration on their minds are collisions of opposites. Contemporary hospitals have been corporatized and proud professionals have been turned into mere employees along for the ride. Balance sheets and office sitting bean counters rule the roost.

Health care  finance took an unusual course around the turn of the 20th  century.  Dr. Martin Courey, a pioneering OB physician  who was equal part showman had a brainstorm. "Incubator Baby Exhibits" were initiated at Coney Island Amusement Park adjacent to a roller coaster. This venture was so successful that it spread to many expositions including Luna Park here in Pittsburgh.

Dr. Courey was as adept at showmanship as he was in his medical endeavors. He dressed the premature infants in oversize gowns to emphasize their miniature size and preferred nurses with the stature of a football linebacker to minimize the size appearance of the babies. A hybrid physician and carnival showman.

The amusement park exhibit resembled a typical hospital ward with nurses providing care 24/7 behind a glassed partition. After paying their 5 cent admission (inflation later increased the price of admission to a dime) the public could position themselves so that the distance between them and the babies was the length that the wrist is distal to the elbow.

 At the time of the exhibits the babies were referred to as premature which had a different meaning than preterm. Medical literature of the day described the infants as "weaklings" and viewed them as lacking energy or vitality. There was much debate about the etiology being hereditary vs. immature development.

Most babies of this era were born at home and cared for by the mother. It was common practice to keep babies warm by placing them in a laundry basket warmed by hot bottles. The invention of the incubator involved a transition of care from the mother to an institutional setting. Low birth rate babies were soon transferred to the amusement park incubators for care. HIPPA regulations were many moons away in a distant future.

The amusement park shows were really a celebration of technology and the promises of hope for premature babies. Some things never change and today the publics' expectation of medical technology is stoked by images of robotic surgeries and laser beam miracles. You pay your money and take your chances.

New Year - New You Thanks to Tapeworms

A penny in the fuse box solution for weight loss. Maybe I can launch a new career in retirement as a tape worm sanitizer by training the little critters to jump into a bottle of Phisohex.

Trauma Blankets - A Macabre Masquerade

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

Bleeding? Get that trauma blanket STAT

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

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

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

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

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

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

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

Who You Gonna Call?

I certainly hope for this young man's sake, that the  tattoo is prophetic, but who are we going to page to extricate that foreign body. Many decades ago, all it would have required was a quick page for my general surgeon hero, Dr. Slambow.  In the days before surgical protocols were  dreamed up by busy body office sitters,  limiting the scope of a surgeons intervention, general surgeons did it all. Amputations, setting bones, circulatory grafting, repairing lacerated livers, kidneys was their stock and trade. There were few "specialists" and no subspecialties.

Dr. Slambows treatment plan would be to anesthetize and "succ" the above patient and then simply yank that nasty blade out. "Standby...if there is bleeding we will have to go in and find the bleeder, lets hope for the best." Dr. Slambow always called the standing around and waiting routine, "masterful inactivity."

I can't imagine the number of specialties that might be consulted today for a case like this. Here is the conversation between two residents considering the various consults that might be indicated.

"We better get an occuloplastic surgeon to see this tattooed knife target. That wound is pretty near the eye."

"No..I'm calling the ENT man, that toad sticker is obviously impacting his maxillary sinus. Maybe an oral surgeon too."

"What about that hospital directive advising a neurosurgery consult for any wound to the head?....That's not his head, that's his face I' calling the chief plastic surgery resident on call."


The straightforward approach would be a call to Dr. Slambow to quickly resolve the problem while the others are pontificating and checking the patients insurance coverage.

"

Bridles Are for Horses - Not Patients

This post is about nursing interventions with nasogastric tubes from  many decades ago and filtered through my aging nervous system so don't count on relevance. It's foolishness of the highest order for entertainment purposes only. With the advent of PEG tubes and a more enlightened attitude, hopefully bridlers are extinct.

Nasogastric tubes (NG tubes) were handy little devices. They were used post operatively and connected to low intermittent suction to decompress and keep the operative area clear after gastric surgery. Another use involved feeding patients that were unwilling or unable to take nourishment and this is where the problems showed up.

NG tubes were dangerous devices in the hands of an inexperienced practitioner and complications related to wrongful placement were sometimes devastating. The most common misplacement was in the lung via the right main stem bronchus  (It's more perpendicular and bigger than the left bronchus) We always added a dash of methylene blue dye to feedings  and if your patient coughed up blue mucous, it was a sign of trouble. The pleural regions are not known for their ability to assimilate nutrients and likewise there is little gas exchange across the stomach wall. It's best to respect these barriers and that's the understatement of all time!

Skull fractures involving the cribiform plate invited the disaster of  the NG tube winding up in the brain as shown on the right.  Old time physicians hated to come clean with mistakes and I can just hear an old blow hard doc from the1960s coming up with a clever explanation that the NG tube in the  X-ray  could be used as a ventricular shunt, "after all it did course straight up the ventricle. Now we don't have to worry about complications like  hydrocephalus."

Blogger, Skeptical Scalpel has a fascinating post about an internal jugular vein cannulation by a misplaced NG tube. I think the person that accomplished this amazing feat  blunder would have to fess up to the mistake. Who in the world ever heard of  gaining vascular access via the nose? That phony excuse is just plain unbelievable.

Nurses commonly inserted NG feeding tubes and were responsible for keeping them in place. Post op patients were usually very cooperative as a result of vitamin "D" (Demerol) and did not tamper with their NG tubes. Placement of these NG tubes was also a short term affair of just a couple of days. It's much easier for a patient  to put up with a short term nuisance than a long term festering aggravation.

Having an NG in place for a couple of weeks is a miserable experience that I have had personal experience with. Occluding a nostril for the tube results in forced mouth breathing that makes your throat dry as the Sahara dessert. Dried mucous referred to as snot in less formal arenas dries up around the tube and picking it off results in red sore nares.

Tubes like Foleys are out of the patient's view. NG tubes of yesteryear were a bright red in color and were like the matador's red cape to a bull - always annoying and always in sight. It's no surprise that patient's liked to remove their NG tubes. I always figured these poor  old souls were trying to communicate something to us - they did not want tube feedings and their feelings should be respected. Leave the NG tube out and place a glass of water within reach.

Old nurses from the greatest generation had other ideas and I learned never to argue with these gallant geezers. All too often their interventions reflected their  rigid, authoritarian personality and not the reality of the situation. They did not tolerate fools like me and their answer to patient self removal of NG tubes was a brutal but effective trick called NG tube bridling. Somehow these determined oldster nurses  always prevailed when imposing their idea of therapeutic intervention.

Bridling involved inserting the NG tube via the right nostril until the tip of it was visible just below the uvuala (that funny thing hanging down between your tonsils.) I've been criticized for not writing clearly for non-medical folks, so that crude explanation is one of my lame attempts to be more broad based.

The old battle axe of a nurse then grabbed the NG tube from the back of the throat with a Magill forceps and gracefully pulled  yanked  the tube out the mouth. Some of these old Marquise de Sade nurses had tiny hands which meant they could skip the forceps and yank that bad boy NG  tube out with their fingers. Once pulled all the way out via the mouth the NG tube was looped around and reinserted in the left nostril into the stomach.

The end result was the NG tube anatomically anchored because the loop went completely around the ethmoid bone and maxillary sinuses before it's descent back to the stomach. Pulling on the end of  the NG tube resulted in excruciating pain which was an effective deterrent to removal. From my perspective, bridling was the stuff of nightmares with the poor patient yanking his nose and maxillary sinuses loose along with the offending NG tube.

I always tried to empathize with the patient. Dying patients just wanted peace and quiet on their lonely journey and before the hospice concept arrived this was rare. I always found a way out of the bridling NG tube business and only wish I could have had more influence on bridlers.

You Gotta See This!!

I'm happily at work in the equipment room packaging delicate, specialty surgical instruments  for ethylene oxide gas sterilization. My grueling cases (hehe) for the day are finished and I'm just trying to make myself useful. Like a bolt out of the blue an excited colleague bursts in shouting, "Fool.. you won't believe what's going on in Room X. You just gotta see it to believe it." It takes quite an event to rile up an OR nurse to this level of excitement so here are some of my recollections of things you must see down the hall. Perhaps it would be better to unsee some of these sights, but memories have a very persistent nature.

Positioning patients for surgery was a true art form. Commercially made specialty positioning devices were not available back in the good old days. We used things like IV poles, sand bags, rolled towels, 2 inch adhesive tape, scraps of egg crate mattress and whatever else we could scrounge together. In my profile photo there is a length of friction tape draped around my neck. We used this stuff to tape just about anything to anything else - sounds nonsensical, but it's true.

You gotta see this positioning technique for a parietal crainiotomy. Patient's head is placed at the foot of OR table to avoid interference with table control devices. Left arm is allowed to dangle free to avoid pressure on ulnar nerve and allow for anesthesia access. Right arm liberally padded with eggcrate and flexed out of the way.  Pillow placed between legs making sure the Foley catheter is in a dependent position to drain and there is no scrotal entrapment (OUCH). There is an open area preserved laterally under left chest by a rectangle of folded towels to allow for pulmonary excursion and the finishing touch is added by tying this all together with 2 inch adhesive tape to confer stability.

It's a darn shame to cover this positioning capstone feat with drapes. I always tried to keep a snapshot in my mind of how the patient looked before draping. Yes, this is  someone's  mother or father and I better do my very best for him and his family.

Obese patients can require unusual positioning techniques that sometimes you just gotta see. I vividly recall one man with a massive pandus (the overhanging mass below the umbilicus) that required some out of the box thinking to position. It was necessary to elevate the pandus and there were no commercial pandus elevators available. We positioned 2 IV poles on either side of the table at the patient's waist. Next we used an IV pole top section as a crossbar. Three towel clips were placed equidistant at mid pandus. The loop handles of the towel clips were threaded over the section of IV pole that was secured in a horizontal position secured to the standing IV poles on either side of the patient.  VIOLA... a flying pandus. "You gotta see it to believe it."

Human parasitic illness is fodder for some genuine nightmares and luckily rare (for me anyway) in operating rooms. I vividly recall a "you gotta see this" episode that involved a  taeniasis or tapeworm induced appendicitis in a teenager. The worm apparently deposited eggs in the appendix occluding the lumen. As the nasty critter grew, intraluminal pressure was elevated within the appendix. I remember seeing  a spaghetti like creature wiggling out of the excised appendix. The surgeon was hollering, "Quick throw that thing in a specimen bag." The last thing I recall was hoping that the specimen bag contained the wiry little beast.

Some adventures in OR nursing seem like they would be a "You gotta see this!" episode, but sound much better than they see - if that makes sense we are probably both in trouble. I'm thinking of various objects inserted in assorted orifices for purely recreational or amusement purposes. These self-inserted intrusive objects are the fodder for a great urban legend tale such as the overtold ditty about the snake inserted to deal with the previously retained mouse. The RFBs or rectal foreign bodies might be worth a story, but not worth a look. Not much to see.

The one case of this nature that I attended to involved the surgeon gaining "purchase" on the foreign invader   - his terminology, not mine, by using suction. I bet this is the only case where a cigar was twice purchased, once in a smoke shop and once in the OR. Our most pressing dilemma was whether the cigar should be sent to pathology.

Uncontrolled hemorrhaging is something else I don't want to see. All that blood obliterates interesting anatomy and bleed-outs all look depressingly alike. One of the most pathetic, dispiriting sights seen at a bleed-out was an intervention by a nurse theoretician who happened to rotate through the OR. She was a big fan of "energy fields" whatever that is, to help patients. She aggressively made harp strumming motions around all the IVs and blood bags to impart this energy to the patient. It did not work and the patient died. I was mad as a wet hen because the nurse theoretician did not even help us in cleaning up the room. That's the least she could have done.

I always had the sneaking suspicion that some  nurses fled the clinical area and became theoreticians because they did not like to wallow in the big messes we frequently encountered. I always figured the bigger the mess, the more a patient needed my help. Diving into a big  mess and helping the patient recover was one of the most rewarding aspects of nursing. Nurse office-sitters don't know what they are missing.

Opps, I'm starting to ramble off task so it's probably time to wrap this up. As ever, I really do appreciate your readership of my overflowing font of foolishness.

From the Anals of Anesthesia History

This photo was snapped in 1909 and immediately piqued my curiosity. At first glance, I guessed that this must be an old school exercise device, perhaps an inversion table or tilt table, but further investigation revealed that it's a set up for the rectal administration of ether anesthetics. This sounds like a high risk technique bordering on medical misadventure based on the flammability and mucosal irritating nature of ether. Here is what some of the physicians of the time had to say about colonic ether.

"The fact that the intestinal mucosa is especially efficient in transfer of gases to and fro from the blood, prompted the colonic administration of ether. The head of the operating table is depressed after the patient is placed on the table. The afferent rectal tube is inserted past the bulb and efferent tube. The anesthetist then opens the efferent tube to allowing bowel contents, if any to escape. The etherization should then commence by forcing the ether mixture into the bowel by pressing on the bulb until an intracolonic pressure of 20 mm Hg is obtained. Every 15 minutes the efferent tube should be opened and the cycle repeated. The colon should be inflated with oxygen after venting the superfluous ether at the conclusion of the procedure."

The prep for this anesthesia was brutal. NPO for 24 hours prior to surgery. Cleansing enemas the evening before and again in the AM prior to surgery. I was trying to deduce the rationale for the Trendelenberg (head down position) of the OR table and came up with a couple of guesses. Ether was notorious for inducing cardiac arrhythmias. An old school trick for converting arrhythmias was to place the patient in Trendelenberg and tell them to hold their breath or possibly the position helped in the retention of the ether. Who knows?

I was curious as to the nature of the ether used and learned that an ether generator was used. This was a crude vaporizer that created etherization by passing room air or oxygen through the liquid ether. Who knows what they did with the ether vapor that was vented off via the "efferent tube" but somehow I suspect that it was just vented out a window. This was a common practice many years ago and one of the reasons ORs were always on the top floor of old  hospitals.

One of the early axioms in medicine was the more primitive the procedure, the more sophisticated the lingo describing the action. That must be how the "afferent" and "efferent" rectal tubes came about. The clever old docs hijacked a term describing the autonomic nervous system and applied it to their backside buffoonery.

I don't think their notion that the intestinal mucosa is an effective means of gas exchange is accurate. "The patient is desaturating...get that rectal tube hooked up to oxygen said no one!" There is very little gas exchange along the GI tract as anyone who has erroneously intubated the esophagus knows all too well.

Although butts and gas go together like tweedle dee and tweedle dumb this procedure was inherently dangerous because ether was so flammable. Another complication was (surprise) rectal bleeding. This procedure looks more like a colitis simulator than an anesthesia agent.

Anyhow, the next time I have surgery it's going to be a spinal or regional.

Not on My Back Table!!

Don't even think about lobbing that ovarian cystic teratoma on my back table.

Old school scrub nurses work from 2 horizontal surfaces, a Mayo stand which is positioned just South of the surgical site and a back table that sits at the patient's feet at a right angle to the patient. Every scrub nurse likes to keep an organized Mayo stand with a minimal amount of instruments. When it's time to close all I kept on the Mayo stand was a pick-ups, needle holder, suture  and straight Mayo scissors. This can lead to the back table assuming the role of a dumping ground which got me  angry as a surgeon with a non-functioning suction. Here are some things to keep away from my back table or I will pinch your keister  with a sponge ring forceps. I am experienced with doing this without breaking sterile technique, so beware! I know from personal experience that sponge ring forceps can leave one heck of  a mark and the pain can give you something to really think about.

I don't like basins of water or solutions sloshing around on my back table. This is an OR, not a trout farm. Whatever happened to ring stands for basins of water? When I see photos of contemporary ORs the ring stands have disappeared. Where does all that unused OR  equipment wind up? Probably in the same place as sponge racks and table-side light stands. Bring back the ring stands and get that aquarium sized basin of water of your back table. It's a hazard every time you move or bump the back table. A wet back table is a contaminated back table.

Another thing I hate on my back table is oversize specimens. Trying to land a huge pandus or teratoma on my back table is like landing a 747 jumbo jetliner on an aircraft carrier. Don't do it. Big hunks or globs of tissue should be handed off to the circulator. If the circulator is busy and the surgeon insists on lobbing that Big Tuna of a specimen your way, just drop it in the kick basin. The crash/splat noise it makes when it hits the target will remind everyone not to pull this trick again. Think of that sound as resembling a church bell ringing in a slaughter house as that big side of beef is placed on a cutting table. It's a  very memorable sound like a newborn's first cry or the rales and rhonchi of a patient on his death bed; an acoustic experience that really sticks with you.

Kudos to the person who invented sterile operating room light handles. Surgeons are like patients in that the more they can meet their own needs, the better for all parties concerned. Savvy scrub nurses do not keep sterile light handle adjusters on their back table. Before you set out an instrument, take a couple of seconds to thread those sterile light handles in place. Get them off the back table.  When a surgeon bellows to the circulator for a lighting adjustment you can curtly reply, "The adjustment handles for the lights are sterile, monkey around with them at your leisure." Multiple adjustments of lighting on the same surgical site can be indicative of a poor prognosis. I wrote a post about unusual signs of a bad prognosis, I think it could be located by typing "Prognosis" in the search box. In the new year, I promise to figure out links!

Anything that has the potential to dangle over the edge of the back table does not belong there. Only the very top of any table is considered sterile. Get rid of that suction tubing and potential dangler early in the game to be on the safe side.

Here is something that I have had some painful encounters with. Loaded needle holders on the back table are a real danger to hurried hands. They will stab you right through that glove.  Why do bright, young whippersnapperns wear gloves when handling needles? Gloves provide no defense when it comes to needle sticks and dull tactile sensations. It is hard for oldsters like myself to make sense of healthcare today.

Enough of my foolishness. Thanks so much for indulging in my silliness and I hope the New Year brings you peace and fulfillment in all that you do.

Venereal Disease Patient Enlightenment (Old School)

Old, hardened, and down right mean nurses were enough to stimulate the worst in terms of nightmares. Bad dreams that could bestir me from my deepest sleep were close at hand when thoughts of these brutal bats in white arose. They were as tough as they come and capable of smoking an unfiltered cigarette  in two deep puffs. It was an amazing experience watching a cigarette burn down 3/4 inch with a single puff. Their perpetually brown, nicotine  stained fingers always looked like they were involved in a messy code brown. At least one can hope that it was nicotine stains.

 Years of witnessing adverse and unfair outcomes in their patients while working for poverty wages was a catalyst for the formation of a bitter, righteous, and judgmental personality profile. If these tough, white starched gestapo nurses suspected a patient's behavior had a causative component to their health predicament; look out because someone is about to be taught a painful lesson by these old "That'll learn ya" nurses.

The hospital where I trained was a designated facility to treat referrals from the public school system for a variety of infectous diseases. Students that suffered from run of the mill  bacterial infections received very good care unless they had the misfortune to be diagnosed with either syphilis or gonorrhea.  These ailments  were termed venereal diseases before the current terminology of sexually transmitted diseases came about. Venereal disease was loaded with stigma and negative connotations which made it a perfect target for corrective actions at the hands of these painful practitioners with punishment on their agenda.

These old nurses had witnessed the gruesome complications of secondary syphilis with tertiary symptoms such as profound dementia from nervous system involvement.  Infected  students needed to be taught a lesson for their own good. The accepted  treatment for these venereal dieases consisted of a series of painful Bicillin injections administered over a two week course and these old nurses used to get involved in heated arguments over who had the pleasure of inflicting this painful punishment treatment. A stroll through the outpatient waiting room often revealed a trembling youngster curled up in a chair while in the background a couple of nurses would be heard claiming their next victim patient.

Bicillin given with care, is a painful experience. The medication is a thick gooey substance with the consistency of toothpaste that burns like fire when forced into a muscle. These old nurses had ways of making the injection even more memorable painful. As students, we passed through the outpatient area frequently. A common sight was a tearful youngster hobbling from one of  the treatment rooms while vigorously rubbing a wounded rump. The elderly, smirking nurse soon followed twirling the spent glimmering  Bicillin  Tubex  injector like a proud drum major with a baton. We always wondered what was going on here.


On our senior rotation some of these punishment minded ancient  nurses let us in on their  pain inducing trade secrets that were truly bone  chilling. In nursing school we learned tehniques to minimize injection pain, but these old bruisers had quite the opposite in mind for their hapless charges.

The sadistic, aged nurses  said one of the best techniques to enhance injection pain was to inject the viscous Bicillin into a tense muscle by having the victim patient bear weight on the hip being injected. Exposure to cold with open windows in winter enhanced shivering which induced even  more muscle tension. Cold was also an effective agent to make the Bicillin even more thick and irritating.  According to these old nurses, a tense shivering buttock was ripe for injecting with thick ice cold Bicillin. These punishment minded nurses also claimed to have Herculean hand strength that enabled them to inject the thick Bicillin with enough speed to actually tear the   gluteus  muscle. "If you can hear above the crying and screaming, you can actually listen to the muscle tearing," one of them related. Ouch, I envisioned the thick Bicillin acting like the business end of a hemostat being opened while buried in the muscle. That must really smart.

Luckily for the infected students, the Bicillin was made available in prefilled cartridges with a fixed, non-interchangeable 18 guage needle or I am certain these old nurses would be looking for a 16 gauge monster needle. Dulling of the needle did increase pain during skin penetration and this was done by deftly inserting it through the tough rubber on a multi-dose vial a couple of times prior to injection. These punishment minded nurses thought of everything. "If you can see the skin around the needle insertion site retract 1/2 an inch in or so before penetration, you have achieved an appropriate level of needle dullness. This should elicit an audible response from the patient," was the nurses explanation of the procedure.

The ubiquitous isopropyl alcohol foil wrapped pledgets so common today were not available for skin prep  40 years ago. These old nurses were fond of cotton balls soaked to the point of dripping for their prep. Wet alcohol that remains on the skin prior to the injection can be tracked deep into the tissue with the  injection which really stings. Most nurses carefully dry the skin before injecting, but not these punishers that dreamed of alcohol soaked and  quivering buttocks awaiting their painful ministrations.

Nurses were taught to carefully rotate injection sites and make a note of this in the medical record. Punishment nurses followed the same principle as WWII pilots that "bombed on the leader." They carefully administered subsequent injections in the exact same tender site as the previous "leader"  nurse. Recipients of this type of treatment often carried lumps the size of golf balls in their hips from the painful repeated injections.

As a youngster, old nurses could really creep me out. I could see where their mean spiritedness came from but doubt that it benefitted anyone. I guess the most kind way to describe their actions would be to say they were misguided. I sometimes wondered if these aging nurses faced consequences for their self -induced lung cancer from heavy smoking. What's good for the goose is good for the gander.

 I'm thinking about a future post explaining overdose  enlightenment protocols that these punishment minded nurses used.

Sacral Perirenal Oxygen Insufflation - An Embarassing Gas Problem

A uroseptic patient positioned  with his derriere kissing the ceiling. A 3 inch spinal needle. Gas under pressure injected to the tune of over a liter. A young resident with the reassuring words, "Don't worry I've done this once before..."  What could go wrong?

I cannot imagine a more unpleasant imaging experience than this one from the 1960's. Just imagine feeling as sick as a dog and having someone position you with your buttocks as the highest point of your body and then ram rodding a 3 inch spinal needle into your coccyx. The best is yet to come as over a liter of oxygen is pumped into a place that it certainly does not belong. If you think expelling air post-colonoscopy is uncomfortable, you aint seen nothing yet. The only way to get rid of gas from this procedure is to hope that it absorbs before you suffer a fatal emboli.

All this for an X-ray that might define the morphology of a diseased kidney.

Thank god for CT scans.

Look Out Below

Florence Nightingale  envisioned hospitals as one story structures that had large windows for both lighting and ventilation. The fresh air was thought to have a healing benefit. Old hospitals had windows that easily opened and closed. There was no mechanical ventilation with a HVAC system and positive pressure rooms were in the distant future. Rooms were heated with radiators and windows were usually wide open in the Spring and Summer.

There were no high altitude flying insects in Chicago, so the windows above about the 4th floor lacked screens. There was nothing between the hospital interior and the good old outdoors.

This direct connection to the outside world presented a temptation too great for some nurses to resist. After working a harried evening shift with normal inhibitions dulled by being too tired and seeing too much misery the unthinkable suddenly seemed like a good idea.

The thought process went like this; "Hmm.... there are 8 Foley bags on this ward that need emptied.. I'm already behind schedule and it's 10:50PM...Over in the corner is a janitorial bucket with impressive capacity...Now lickety split I'll drain the urine bags into the bucket.. Now for the real stepsaver, DUMP THE BUCKET OUT THE WINDOW."

Now, I'm not saying that I've ever done this, but I know for a fact that it was practiced. One old nurse said the hospital planners even allowed for this practice. "Why do you think the sidewalks are located a good 40 feet from the building?" she asked. I don't know if this was true, but I made a mental note to keep a safe distance from any hospital building.

I noticed another tell-tale sign of the window urine dumping syndrome; the grass below selected ward windows was a dead brown color. The high nitrogen content of the urine had effectively killed the turf. I also noticed that upon venturing off the sidewalk (not a prudent thing to do without a raincoat) the unmistakable odor of urine was present. This smell could have wafted out the open windows, but it seemed to always be there which was further testimony of urine dumping.

Miss Bruiser, my favorite nursing school instructor, once asked the class for an explanation of gastric dumping syndrome which often occurred after a gastrectomy. One eager student quickly replied, "The dumping syndrome occurs on the detox wards when a patient vomits out a window." Miss Bruiser seemed puzzled by the student's response, but vomiting out an open window did indeed occur on the 6 bed detox ward.

I think it was a conditioned response with seasoned alcoholics to hurl their gastric contents out a window. The detox ward had that peculiar blend of olfactory insults as a result of the paraldehyde, stool, and emesis coexisting in a small area, so the windows were always open.

It is much easier to vomit out an open window than

trying to hit one of those tiny emesis basins. "When I

open the window, let it rip."

To a detoxing alcoholic the window looked like a perfect place to vomit.  The bed placement also encouraged this tactic. Two of the beds had the head of the bed aligned perfectly with the open windows.    As one old booze hound explained, "I've pucked out my car window many times, it's a lot easier to drive drunk, than clean vomit off the interior." I guess it's called projectile vomiting for a reason. This provided an added incentive to keep your distance from the hospital exterior. I don't know which would be worse to have dumped on someone, urine or emesis. They were both nasty.

There was no positive pressure ventilation in our old operating rooms and with our positioning on the 7th floor the windows were frequently open. Old time anesthesia machines were rather crude and sometimes leaked anesthetic agents. Even on cold days, Dr. Oddo would start hollering, "I'm getting sleepy, open the window."

Not much refuse was ever thrown out the OR windows as there were plenty of witnesses. Hospital window tossing of garbage or effluent  was usually a solitary act. The one exception would be an orthopedic case done in a regular general surgery room. This occasionally happened with a trauma patient and left the circulating nurse with a cleanup dilemma. The only sanctioned disposal location for casting plaster was way down the hall in the ortho room. The stuff could not be poured down a sink as it totally gummed up the plumbing.  After a long trauma case, the window could be a tempting place for plaster dumping. I always wondered what that stalagmite looking mass was on the ground below the general surgery OR. Now I knew, it was casting plaster, that stuff lasts forever.

With Lady Bird Johnson's keep America beautiful campaign in the late 1960's littering and dumping really had a pejorative connotation attached to it. I think most of this unsavory activity ceased. Of course if a nurse was working late at the close of a stressful shift, who knows what might happen. It's always prudent to maintain a safe distance from open hospital windows.