Successful Swallowing Secrets

It's one of those rare occasions when it's time to sequester my foolishness to the back burner as I offer some time worn proven measures to help patients experiencing difficulty swallowing.  Long term endotracheal intubation,  TPN,   and neuro problems all invite dysphagia.

Position the patient upright and check for a gag reflex or at least some indication of an intact airway protective response. The famous ramrodding a patients posterior pharynx with a tongue depressor is not what I had in mind. The gagging and retching elicited by this cruel trick does not necessarily indicate a protective response against aspiration. A kinder, gentler  method of assessment involves asking the patient to say "Ahhh"  and observing if the uvula and posterior pharynx retract. I have also been told that an intact blink reflex indicates an intact gag reflex because the same nerves are involved. Cross over of neural impulses makes me hesitant to trust eye blinks as an indicator of airway protection.

Caution is the key so don't even think about injecting fluids into a patient's mouth with an Asepto or using drinking straws. The suction applied to a straw to permit atmospheric pressure to propel the liquid into the mouth can compromise airway protective reflexes. The act of applying suction can impede the transition to an airway protecting response.

Drinking from a glass replicates a familiar experience for the patient, but hyperextending the neck by tilting the head back to drink opens up the airway. The epiglottis is repositioned from closing the trachea-something to be avoided at all cost.

The secret to keeping the epiglottis positioned over the trachea when swallowing from a glass is to keep the chin level or even slightly tucked down. How do you raise the glass to drink without tilting your head back? All it takes is a few snips of your trusty bandage scissors to create an aspiration resistant drinking device.

Cut a nose clearance notch in the side of a paper cup and you can drink without tilting your head back maintaining the airway. Just drink from the side opposite the open notch and as the cup is tilted up to take a sip the opening accommodates the protuberating nose. The mandible remains level and the epiglottis remains intact covering the trachea.

Smaller notch for more petite noses. This 

aspiration resistant cup works perfectly for 

Oldfoolrn's like me.

Fevers - Antiquated Defervescent Interventions

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

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

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

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

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

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

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

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

Finger Cots - Minimum Coverage Saves Vintge Hospitals from Bankruptcy

"Here is your daily allotment of gloves. Use them judiciously and I better not here about one shift hogging them - remember they have to last 24 hours."

Finger cots substitute for gloves in budget minded hospitals

This was the warning issued by one of those stern nursing supervisors as she reluctantly surrendered a box of one size fits all gloves. A box of 24 latex (nobody was allergic to this substance in the good old days) gloves was supposed to suffice for three busy wards inhabited to the gills with patients vomiting, excreting, and  oozing every bodily fluid known to mankind. At least these fluids were organic, the Cidex based cleaning solutions we used on hospital equipment would make unprotected skin boil and bubble up like a dousing with boiling water. We always tried to handle cleaning solution soaked rags with forceps, but sometimes the volatile fumes were enough to accelerate skin lesions. Nasty stuff indeed and don't dare get caught wearing a precious glove on an ordinary cleaning mission.

Old school nurses eschewed gloves for reasons other than the negative impact such extravagant expenditures had on hospital budgets. Nursing was a hands on affair and this meant bare hands  with skin to skin contact. Gloves imposed an unnatural barrier and were viewed as an offense to the patient.

I was conditioned like Pavlov's dogs when I had gloves on. This was just not right and my shoulders hunched over with a strong sense of self consciousness. Even when using gloves appropriately, I was anticipating that cranky old nursing supervisor in the background  hollering and belittling me.

Finger cots came from the supplier in boxes and were clean (hopefully) but unsterile. Sterile finger cots like Montgomery straps and scultetus binders were produced in house by cantankerous, past their prime nurses who toiled diligently in central supply. Three finger cots were oriented in the same direction and placed in a glassine finished envelope which was then autoclaved. A piece of autoclave tape sealed the envelope and verified sterility by proudly displaying diagonal black stripes.

You could do lots of fun tasks with sterile finger cots such as dressing changes or Foley catheter insertions without bankrupting the hospital on  exorbitant expenditures like sterile gloves. Donning sterile finger cots took lots  more practice than  sterile gloving. After carefully opening the sterile packaged fingercots with your ever present bandage  scissors, place them business end down on a bedside stand. Judiciously apply a very small dab of tincture of benzoin to the tips of your thumb, index, and second finger with an applicator  and blow dry with a couple of puffs. Smokers (which compromised 95% of all nurses) with their comprised tidal volume might need three puffs.  Press your thumb into the very center of the rolled finger cot and let the tincture of benzoin work it's adhesive magic. With the finger cot firmly stuck to your thumb slowly and carefully unroll it with your free hand while touching only the inside surface of the finger cot. Rinse and repeat for your index and second finger.

Now that you're all  gloved cotted up it's time to rock 'n roll. To maintain sterility it is essential that you curl up your bare naked  third and fourth fingers. For the time being just pretend they don't exist (I used to make believe  they were burned off in a Bovie mishap.) You do not want them flopping about contaminating the sterile field or the catheter.  You can now use your finger cot festooned fingers to make like a forceps and guide that Foley home to pay dirt. When you're in (urine) haha, its time to peal off those finger cots and hook up the drainage bag.

Finger cots have limited surface area compared to gloves and can be predisposed to slipping off your digit at inopportune times.  The no finger cot left behind doctrine incorporates several measures to prevent in vivo loss of cot custody. The tincture of benzoin trick helps ameliorate wandering finger cot issues when sterile technique is used. For the more common everyday uses of finger cots  the keyword is restraint. Discretion is definitely the better part of valor when exploring any internal orifice with a finger cot. Never ever inset the finger cot into anything past it's cuff. If you poke that finger cot in deeper past the cuff all it takes is a sphincter contraction to strip it off faster than  a chimp can peal a banana.  It's a real challenge to gain purchase on a retained finger cot and the best course of action is probably benign neglect while hoping that it works itself out.

A tenaculum  grasping cervix and a cot on
the index finger. Note the 3 exposed fingers
providing traction on the tenaculum. Gloves optional.

Spilling the Beans on Vintage Hospital Cafeterias

Lots of folks have bitter complaints about hospital cafeteria food.  Not me!  I actually enjoyed eating in the ultimate of institutional dining settings. Student  nurses had unlimited access to this crude, but very satisfying  sustenance  via  monthly issued meal ticket books. One day my clinical work was interrupted by that dreaded summons. "Report immediately to the nursing  director's office."  I was soon ushered into her inner sanctum by her assistant who was an authentic nurse with cap and pin; there were no nattily dressed executive assistants with perfectly coiffured  hairdos  for old school nurse executives.  I was somewhat  relieved by her cheerful demeanor, "Fool, the girls  (her generic term for all student nurses except for me. Male students threw her for a loop) have told me how much you enjoy the cafeteria meals and I wanted to give you extra meal ticket books." I stammered and stuttered a timid "thank-you," and slithered out dreaming of those perfectly round machine stamped salisbury steakette  patties. I was fascinated by the way grease gravy squirted out of them and glistened in the overhead florescent lights  when pressure was applied with a fork. Fine dining in all it's stomach gurgling  glory.

The Sisyphean task of tendering expeditious food service to intermittent parades of time pressured hospital personnel gave way to many unique innovations.  Fiberglass trays were easily propelled along shiny chrome runners that minimized friction as hungry diners made their selections. Just as ceramic tile was the defining element to the operating rooms, chrome was the underlying theme to old school hospital cafeterias. The shiny stuff was just about everywhere from the food displays to borders on any horizontal surface. Even the Sweeda cash register was chrome.

 A small army of colorful characters on the supply side of the chow line could cut a gigantic sheet cake into perfect 3 inch square pieces or whip up a massive vat of our favorite desert , Whip N' Chill in the blink of an eye. I don't recall the flavor of my favorite whipped desert but it was  red in color. That  food dye would leave a permanent stain so be careful with that white uniform.

Just about any standing kettle of soup or chili would acquire a 1 inch thick layer of gooey grease that rose to the top. These underpaid but well meaning food service workers had bulging forearms from the near constant stirring motion necessary to keep the grease in suspension.

In the OR all of our cases ended in an ectomy and in the cafeteria all the meat product entrees ended in the suffix ette. There was my favorite pork chopette, steakette,  hamcheesette, and last. but not least chicken croquette. None of today's  pretentious  light and fit, locally sourced artisanal food here. Artificial flavors and texture enhancers were embraced as a great space age wonder. Those clever scientists were hard at work making our food taste better. Great work and don't spare the MSG and nitrates.

The three horsemen of addictive, pathogenic food additives were proudly displayed as the centerpiece of each table. A gigantic cylindrical dispenser of good old fashioned sugar was always front and center, tempting nurses to drown their fatigue in a hyperglycemic rush. Pepper and salt were readily available. There was nothing like dousing highly processed foodstuffs in salt for a hypertensive boost. The artery clogging fat of a pork chopette could be supplemented by that insulated mini carafe of whole cream for your coffee. Some folks liked to add a spot of whole cream to their Whip 'N Chill to give it "extra body," but I preferred mine unadulterated.

Perhaps it's time to resurrect old school hospital cafeteria food. In the mindset of today's greedy hospital corporate types foods like this are an integral component of a dynamic profit circle. Consume these  high fat, high sugar, processed food and business is booming in the diabetic clinic and cardiovascular services. Besides, I have a decades long hankering for just  one more pork choppette

Major Operations and Thoughts and Prayers

A long, long time ago the mere mention of a major operation had genuine meaning for surgeons and nurses. It commonly referred to entering the peritoneum (abdominal cavity,) chest, or cranium. This was big time intervention and "major operation"  was a call to arms.  Hypervigilance and extra care were to be expected when it came to aseptic technique and surgical procedure.  Damp dust the overhead lights with alcohol soaked rags and be extra diligent with those hard to reach areas.  Buff those instruments to a nice shine with that trusty 4X4 during the case. Implement hypervigilance when it came time to count sponges.

"Major operation"  as a call to special action began to lose luster as more aggressive open procedures became commonplace. The term was tossed about casually and soon devolved into jocularity. Say, have you heard about Lansing Michigan? ...now that was a major operation.  As a nurse scraped that brown crud from a coffee percolator (remember those?) someone was bound to wise crack, "That looks like a major operation." At the end of my nursing life  in the OR, the term had fallen into extinction. That was the end of the blathering about major operations.

Lately I have been thinking about all those thoughts and prayers platitudes extended to the victims of mass violence. Mass killings have been occurring with the regularity of a Circadian Cycle and the predictable avalanche of thoughts and prayers has likewise crescendoed.  Mass killings...thoughts and prayers, rinse and repeat.

I betcha God has had a bellyful of these thoughts and prayers when they become a substitute for accepting responsibility and taking meaningful preventive action.

It makes my head spin when I consider the logistics of treating so many gunshot victims. In the good old days, which in reality, were not all that good, a couple of  Chicago style gunshot wounds would upset the apple cart. Rounding up appropriate staff  at all hours and disrupting OR schedules for the next day. Thoughts and prayers has become the linguistic equal to major operation.

A Slide Rule Life Lesson

As a quiet young high school student, I had all the personality traits of a nerd, but lacked the mental horsepower to lay claim to the moniker. Siting in a class room, I found myself staring in horror at a gigantic model of a slide rule. Keuffel and Ester was the intimidating logo plastered on the mysterious looking device. Numbers on scales that moved laterally as the thing was expanded. I could not make heads or tails of it.

"Looks like a warning not to take physics class," I muttered to myself  under my breath. Mr. Green, a beloved teacher overheard my mumblings and immediately disagreed. "You can learn how to do calculations with a slide rule if you put your mind to it. Anything worth while is worthy of your time and effort."

Mr.  Green was one of my very best teachers. The concept of being a life long learner had yet to be recognized, but whatever the notion was called back then came through clearly in his lessons. He really was interested in my answers to physics problems and made tests interesting with references to Red Ryder BB guns and bowling ball pendulums.

To study waveforms, Mr. Green constructed home made ripple tanks and I spent more time admiring the elegant simplicity of his creation than learning about waves. The time and effort he invested in making physics interesting communicated the importance of learning. It's amazing how much easier it is to learn when the importance of the subject matter is recognized.

Yes, I did learn how to use that intimidating looking slide rule and can still recall the "C" scale is on the slide and the "D" scale is on the body....I think. At least my long term memory is clear as a bell, now if I can only recall what I ate for lunch. That's a post for another day.

In nursing school calculating dosages and solutions required lots of multiplication and division. I resurrected my old trusty slide rule and even taught a few of my classmates how to use it. They were impressed with my lickety-split calculations, but the real thanks belonged to Mr. Green.

Working from multiple instrument trays as a scrub nurse could really get my dander up, but I always thought of Mr. Green and reminded myself that I could learn how to manage the task, after all, I was able to master that blasted slide rule. Thanks, Mr. Green

Cats vs. Dogs, ADNs. vs. BSNs, and the Ultimate O.R. Conflict: Burners vs. Knotters

These are certainly disunited times and there are many divisions among  nurses. The  endless ADN vs BSN debate has a life of it's own. Being an old time diploma graduate, I don't have a dog in this fight and will stick to conflicts I have direct experience with. When it comes to controlling bleeding in an operating room there are two very distinct and different types of nurses with profoundly diverging  ideas.  One group, the Burners,  just love to support surgeons using offensive, humming and smoking  electrocautery devices  or "Bovies." The  opposition composed of older, more  wise thoughtful nurses likes to cut ligatures for manual ties. I affectionately refer to them as the Knotters because nothing maintains hemostasis like a tightly secured and knotted ligature.


Opening an abdomen is done in sequence and when you are waiting for someone to fall asleep before you scar them for life, it's prudent to take a thoughtful, careful approach to minimize the inherent barbarism. Compassion is always best delivered person to person rather than nurse to patient so it's a good practice for the scrub nurse  to stop and think if this is how you would like to be treated lying on that cold, skinny table. Can you imagine your naked derriere  plastered against that gooey, mucilaginous, ice cold  Bovie  grounding plate smeared with conductive gel while the surgeon makes like Smokey the Bear and burns every bleeder in sight?  The alternative, silently tying off bleeders with ligatures is more appealing to the senses and exudes a kinder, gentler, more considerate approach.

 The buzzing behemoth  of a  Bovie  unit is the  Burners favorite piece of OR furniture (back in the day we had furniture, not equipment.) Bovies were an electrocautery device that looked like a Maytag and had connections for three electrical cords. One was plugged into the wall socket, the other connected to a large metal grounding plate the size of a cookie sheet which was smeared with conductive gel and unceremoniously scooted under the patient's buttocks right before they  fell asleep. the third cord was connected to the business end of this buzzing monstrosity of a machine and resembled a ball point pen.

Some of the Burners were frustrated artists and made the application of conductive goop to the Bovie grounding plate an exercise in self expression. That big metal plate was their canvass and the goop their medium. I noticed one of these Burners with her bouffant cap on sideways to mimic an artist's beret scribbling away with the goop and mentioned her sketch looked like it was part of a freight train. "Oh no...It's a caboose for the  patient's caboose," she haughtily replied. Never interrupt a burner at work on her art.


I always shuddered when I considered the last conscious thought  a patient had before anesthesia induction  was what it felt like to land their  keister on an ice cold, gooey piece of ice cold  metal. It reminded me of someone sitting in a giant tub of Jello. YUCH!

The Bovie generated a high frequency alternating current that was passed through the patient's body. There was minimal resistance at the grounding plate on the rear end, but lightening in a pen at the business end controlled by the surgeon operating a foot switch. There was big time electrical resistance at the Bovie tip: enough to occlude a vessel in a jiffy.

After the skin incision, venous bleeders begin to appear as little dark blue puffs of blood. The glistening white fat tissue forms a beautiful background for the little  pops of blood as the veins are cut. This part of the surgery always reminded me of those old 12 O'clock High TV shows with Robert Lansing. The puffs of blood resembled the bursts  of the anti-aircraft flack exploding near the vulnerable B-17s. "Hey doc we have a bleeder coming up fast at 12 o'clock," I sometimes felt like hollering out. The Bovie smoke further added to the flack resemblance. Members of the Greatest Generation made us Boomers look like slackers and surgeons from this vintage were very proficient Knotters.

Burners were very fond of simply snatching a bleeder in the jaws of a hemostat and then tapping the ringed handle with the Bovie. A puff of nostril bludgeoning smoke and that was that, no more bleeding.

For the knotters this was a time to pause and hand off meticulously cut strands of ligature. Back in the day I could take an endless spool of 3-0 silk and in the twinkle of an eye cut it into 18 inch lengths all exactly the same. These ligatures were held out like an offering to the surgical gods for the good doctor to  grasp and masterfully tie around a vein that had been lassoed by a hemostat. The scrub nurse then trimmed away the excess suture a millimeter distal to the knot with a straight Mayo scissors and it was time to move on to another bleeder. There was a reassuring rhythm to the process that was like meditation.

Hand tying did take longer than using a Bovie, but I always thought that tying off ligatures was a good way for the surgeon to limber up his fingers  before tackling the more serious stuff inside the abdomen. A time to reflect on the future course of action.

A knotter happily unwinding a tie from a ligature spool.

Ties and non-swaged  sutures were so revered they deserved

a dedicated table with 4 spools on the right and 4 on the left

Now for that burning question: Which of these tribes do I self identify?  I  survived long enough in the OR to beat those nasty Burner impulses into extinction and am an old foolish Knotter.