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 Official Cigarette of Your Diploma Nursing School?

There were so many diploma schools of nursing in the 1960s that each class adopted their own unique motto, school colors, and slogans. There was no formal mention of the fact that each class had their own preferred brand of cigarette. Brand loyalty was the byword and everyone wanted to feel part of the same "club," so there was minimal deviation from the standard brand of smokes.

I dug out my old nursing yearbook from my basement  junkpile archives and refreshed my memory. Our class colors were light blue and navy blue, class flower was a white rose, class moto was A journey of a thousand miles begins with a single step, and the class philosophy was "I have no yesterdays ,tomorrow may not be--but I have today." Last, but not least the class cigarette was KENT. Student nurses tended to mark their territory and Kent cigarette butts were virtually everywhere. Favorite ashtrays included the orthopedic beds with big gaping holes for attaching traction bars and even unused suction bottles on the Gomcos used for demonstration.

Cook County School of Nursing students lived up to their hardcore image by smoking disgusting unfiltered Phillip Morris Commanders. You could always identify a Cook County Nurse by her nicotine stained brown fingers.

Ravenswood hospital was bicultural when it came to cigarette usage. Both Kools and Winstons were in vogue here. I guess the nurses could not come up with a consensus which was a frequent problem in nursing when critical decision making was required.

When I relocated to Pittsburgh the official cigatrette custom was in full force. At Montefiore Hospital all the nurses smoked Salem Light 100s. I think the 100mm length was a thoughtful choice because it served as a break extender.

I betcha Nurse Bonnies classmates were Red

Apple Smokers. An apple a day keeps the Dr. Away??

"Don't Worry, I Was an ARMY Ranger"

My obsession with surgical instruments and fondness of  esoteric operating room tales are not appreciated by everyone, so it's time for something completely different - a true story from that long term VA  psychiatric hospital, Downey.

It was nearing time for my annual proficiency review and I was beginning to feel nervous with an impending sense of doom. One of the key metrics in the evaluation other than restraint hours was avoiding patient elopements. The restraint hours could be managed with some clever slight of hand when filing reports and records. Maybe that's why all the nurses winked and called records of locked restraint hours the "funny papers." The favorite maneuver was to apply locked restraints and leave one of the locks open.  They were just as effective but technically not full locked leathers.

Mr. Dunkfeather who had been recently upgraded from head attendant to nursing assistant looked grim as he approached the nursing station. He had just completed the 2200 hour  patient count and came up one man short. "Fool, Hughes is not on the ward for patient count," he related. My first reaction was denial,  reasoning that it was impossible to elope from a locked ward. There were 3 sets of locked doors between patients and the outside world. Things like this never happened.

I quickly did a search of all the hiding places; shower curtains, under beds, and even inside lockers. Hughes had simply vanished. Next on the agenda was a review of the records. Whew..at least he was a voluntary patient. If a committed patient was lost, the notification process was quite onerous and time consuming and involved official notification to administration and law enforcement personnel. All that was required of a voluntary elopement was the completion of a 10-2633 form which was reviewed the next day at a treatment team meeting.

When I unlocked the heavily grated main entrance door to leave at the end of my shift a surprise greeted me. It was Hughes bounding up the front steps with an ear to ear grin. I must have looked like I had seen a ghost. "How in the world did you get out of there?" I stammered in disbelief.

"Don't worry, I was an ARMY Ranger and was trained how to jump. There is a gap in the bars covering the back bathroom window so I squeezed out and jumped. I was just repeating an old Ranger training exercise. Now that I know my skills are intact everything is going to be OK."

Hughes was obviously uninjured but the window he jumped from was on the second floor  of Building 66 which was the equivalent to a 3rd floor level because the basement was elevated on that side of the building. He showed me the gap between the iron bars  and further explained some of the techniques used when landing from a jump. He seemed amused by my interest and added that he would be happy to teach me some of his jumping skills. Not tonight I muttered before stopping at the nurse's station and discarding my elopement reports. No harm..No foul.

The Grooved Director Surgical Instrument Mystery Explained

The function of a surgical instrument is usually obvious; retractors retract, clamps clamp, cutting instruments cut and forceps hold things. I made a comment about a lovely grooved director instrument on Instagram and was asked, "What is that thing used for?"  When I was a novice scrub nurse grooved directors were widely called for and  used for a hodge-podge of probing, directing of suture and guides for  cutting tasks. As I approached retirement they  remained in the instrument tray on the back table and finally disappeared forever.

Grooved directors always reminded me of Mickey Mouse. The end of the instrument with the ears was called the spoon or saddle. Dr. Slambow, my favorite general surgeon liked to sing Home on the Range while working so I took a  liking to the "saddle" reference. The curved shaft extending from the saddle was called the shank.

 Surgeons are big fans of devices that restrict their view to the work at hand and use drapes and devices like grooved directors to frame their field just like a movie director with  a view finder.  The tiny, circular opening in the saddle was often centered over the opening of a duct or anything else that might require exploring with a probe. The grooved director was positioned at a right angle to the wound or duct and served as a fulcrum for manipulating the probing. Imaging techniques were few and far between in days past. Probes  were a crude but effective tool for exploring. When ducts and wound tracts could be evaluated without probes grooved directors fell out of use as guides for probes.

Grooved directors could also be used as protective shielding tools. The shaft had a horseshoe or curved profile and could be placed over nerves, arteries or anything else that should not be cut. The rare illustration of a grooved director in action shows it placed over a tendon while cutting from above. The surgeon must be an early specialist as general surgeons almost never hold a scalpel like a pencil. He must really be an old-timer. Is he actually performing surgery bare handed? That lovely scalpel is way before my time. BD disposable scalpel blades have been in use since the 1950s.

Surgical residents are very familiar with 3 rules of survival:  eat when you can, sleep when you can, and don't monkey with the pancreas. Grooved directors were frequently used to guide suture away from the pancreas when working on the duodenum. They functioned much like a clothes line prop with the suture strand guided by the groove in the spoon away from the friable pancreas. If left alone, suture assumes a caternary  curve and the grooved director straightened things out.

I managed to put my blowhard nature on the back burner and seek outside input for grooved director information. When I Googled the instrument  I discovered uses like a pediatric tongue depressor or elevator during surgery on the frenulum. That's a new one on me.

I emailed Dr. Sid Schwab from Surgeonsblog fame and he exclaimed, "That's a trip down memory lane!" He used the instrument once or twice on pancreatic duct procedures. Dr. Skeptical Scalpel (on my blog roll) almost never used a grooved director.

Grooved directors fell from disuse like open drop ether anesthesia and Operay lighting systems. Almost everything has a shelf life and I often what modern devices will be extinct in 30 years. Maybe the grossly overpriced, unproven surgical robots?

A Dubious Award for Bovie Smoke Control

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!

Hospitals Before Air Conditioning

Vintage Hospitals had very little in the way of mechanical climate control and patient care areas on the wards often became sweltering brick ovens. High ceilings and transoms over the door of each room helped some, but hot is hot and working in an overheated enviroment was accepted as part of the deal of being a nurse. Wide open  wooden double hung windows helped a bit and as an added thrill there were no screens above the third floor. The theory that there are few high flying insects might have been true but pidgeons did not follow this rule. We used to coral them in a corner with a draw cloth and send them back on their merry way via the open window.
 

We all agree. It's too hot in here.

Staff nurses frequently draped towels  soaked in ice water around their necks, but such luxuries were not permitted for student nurses. Misery and suffering were vital elements in the quasi-religious initiation into the nursing world and belly achers soon found themselves on the outside.
I had it much easier than the female students who wore a heavy apron over their blue dresses. A common problem was sweat running down legs and pooling in fluid containment  vessels like Clinic shoes. A memorable sight was a student in the break room removing her shoes to drain the sweat. I had a different problem because my primary sweat generator was my back. The perspiration would slide down my back and soak my underwear and seat of my pants. I stopped one day to purchase a Chicago Tribune from the corner news stand and after producing a dollar from my hip pocket the vendor commented, "Hey..This dollar bill is soaking wet." I kept my mouth shut and just smiled rather than explaining the embarrassing source of the moisture.

Patients were the ones who really suffered in the heat. Working on the ortho floor meant dealing with a particularly uncomfortable bunch of patients. The casts often exacerbated the sweating which almost always produced itching in remote areas of the casted extremity. Clever nurses produced under cast scratching devices by taking an ordinary coat hanger and straightening it out. The business end of the scratching device was twisted into a tight loop which could be threaded down to the area of itch. They were crude but effective anti-itch devices.

The hospital director's office and operating rooms were air conditioned and clever nursing personnel learned to take advantage of an occasional whoosh of cold air. The ORs were accessed by a manually operated elevator that moved cold air down the shaft like a giant piston. An oasis of cool air greeted anyone standing near the old elevator doors when the device was on a downward plunge. We concocted a variety of excuses to linger by those doors. My favorite excuse was awaiting the arrival of a fresh post-op patient.

Hospitals were not early adopters of air conditioning. For the first couple of hundred years after it's invention, the wheel was only used for making pottery. Nobody could figure out how to make wheeled carts as effective as sleds on runners. The same situation applied to hospitals and AC. The roof of a hospital was not designed to support refrigeration units and there were no ducts in radiator heated hospitals, besides nurses and patients were meant to suffer. It was just the way the world worked.

Axillary Fallout a Pitfall in the Operating room

Axillary fallout abatement in action.

Tucked scrub top and containment 

garment under scrub top.

One of my most popular posts is from a couple of years ago and it was about the perils of perineal fallout and measures used to control such a menace in the OR. So as a sequel, I would like to present an equally dangerous infection generating body part, the armpits of OR personnel full of hair, sweat, and bacteria. They smell funny for a reason and attempts to camouflage the odor with topical deodorant only exacerbate  the situation.

Asepsis is one of the foundations of successful surgery and begins with the aggressive scrubbing of the operative site. This "prep" is usually conducted by the circulating nurse or a resident. The rub-a-dub-dub of scrubing  the patient's skin produces a copious (we always got brownee points for using that "c"  word in our care plans-old habits are tough to break) amount of to and fro arm movement. Some preppers even resembled marathon runners with their violent herkey-jerkey arm movements. This violent arm oscillation from a fixed point creates lots of friction in one of the most bacteria infested parts of the body, the armpit, second only to the aforementioned disease producing perineums.

My favorite OR supervisor, Alice, paid special notice to the arm swinging preppers and developed one of her famous theories. Hard scientific theory can become boring, but applied sciences like nursing is where the fun begins. Alice believed the armpits shed micrococci and who knows what else when the friction of the arm swinging liberated them from their hairy denizens in the armpit. The patient was especially vulnerable during the prepping procedure because the drapes were yet to be applied.

Alice just love finding fault with men especially those of a lower caste. Male  nurses were the perfect fodder for her "interventions." Alice had been verbally abused by an assortment of surgeons over the years and this created a revenge oriented mind set. Someone had the temerity to ask Alice why she singled out men for her perineal and axillary fallout ministrations and she knowingly replied, "because that's where all the hair is. It's the friction from rubbing two hairy skin planes together that unleashes bacteria."

Putting the brakes on axillary fallout begins with tucked in scrub tops and as I mentioned in my last post, Alice was an aggressive scrub top tucker inner. After ramrodding the top into the pants, Alice always administered a rough skyward yank of the pants which often changed the timbre of the victims voice and marked the laundry of those with poor hygiene.

When disposable gowns came on the scene in the early 1970s a large cache of cloth gowns was dedicated to the pre-operative skin prep. The old cloth gown served as a perfect containment vessel for corralling free falling axillary micrococci thus averting one of the pitfalls of skin preps.