The Smoking Finger

No, I don't have one of those fancy new fangled phones

that take photos, so I put what's left of my index finger in the scanner.

Surgeons and nurses toiling in an operating room become habituated to a very controlled environment where everything from lighting to air quality is subject to rigid regimentation. Unpredictable events throw a monkey wrench in the midst of this enforced order, often times, leading to a cascade of adverse events  which can result in personal  injury to staff.

Voice modulation morphs into a surgeons unduly harsh verbal  admonishment of the offending party. Harried nurses, desperate for a resolution to the problem throw caution to the wind and find themselves in a precarious situation while attempting to solve the problem. Desperation seldom leads to reasoned thinking. The ensuing pandemonium is enough to flummox a pope.

Operating rooms can be dangerous places. Surgeons waiting for someone to fall asleep before cutting them might, at face value, seem unsavory, but the notion of live by the sword; die by the sword holds true in the OR.  Those sharpened chunks of stainless steel do not discriminate when inflicting their trauma and Bovies don't care what  tissue they roast.

 As a circulating nurse I was known for constructing elaborate platforms for height challenged scrub nurses. My colleague, Janess, loved my elevation tactics and was so enamored with one of my creations she failed to notice an unusually low hanging overhead light. As she emergently  ascended my stairway to operating room heaven for an urgent trauma case,  the crown of her head struck the low hanging illuminary with a sickening THUD..CRASH. After finishing the case, a close inspection of her cranial vertex revealed a hematoma the size of the distal end of a Babcock. After a quick neuro check and 15 minutes with an ice pack she was back on duty. I've witnessed several intraoperative injuries to staff and not a single nurse or surgeon broke scrub, no matter the extent of the injury.

Karma can be a cruel mistress and I soon received my payback for contributing to Janess's unfortunate mishap. I was finishing up a case with Dr. Oddo that entailed resecting a menengioma. These tumors are outside the brain and with removal have an excellent prognosis. I was in a great mood thinking about how we were actually being  of some service to the poor soul suffering from this nasty,  neoplastic malady. One thing I've learned over the years is to be wary of those euphoric Kumbaya moments when everything seems to fall in place because a true shitstorm is often in the works.

Dr. Oddo had been using a foot pedal actuated Mallis bipolar cautery during the case. This nifty little device looks like a pair of tweezers with an electric cord attached to a high voltage generator. When Dr. Oddo tramped on his foot pedal electricity flowed between the tips of the tweezer like device cauterizing anything in between. It was a great little gadget for controlling bleeding in small vessels.

Dr. Oddo loved to instruct the anesthetist to lighten the anesthesia near the end of a case. One  of his favorite phrases in the post-op report was, "The patient was able to transfer from the OR table to the awaiting carriage independently." This sometimes made for exciting moments near the end of surgeries when the patient took ambulatory surgery to a new level and decided to bail out before the final skin sutures were in place.

Sure enough, just as Dr. Oddo started closing the skin flap the patient began to emerge from general anesthesia. As he came to, his right leg spasmed into a mighty lateral kicking motion impacting Dr. Oddo's leg poised with his foot just above the Bovie actuating pedal. I was tidying up by clearing off the operative field and was preparing to wipe down the distal, business end of the Bovie forceps. The patients kick to the good doctor's leg turned the Bovie forceps ON and as the juice flowed a sickening burnt flesh/charred rubber glove malodorous scent filled the air.

The Bovie had cooked my right index finger on the distal phalange. As the smoke cleared I requested a new glove and plunged  what was left of  my smoking finger into a fresh sterile barrier. There must be some truth to the notion the body releases pain killers when traumatized because initially I was pain free. Upon finishing the case and pealing off the second glove the extent of the injury became apparent. The end of my finger had extensive "remodeling" with the distal aspect about 1/3 AWOL.

Dr. Oddo helped me remove the melted latex glove from the wound and suggested wrapping the finger with iodoform gauze. Dr. Slambow was consulted and said "welcome to the club" while showing off a massive scar on his right palm. After about 4 weeks, it was time for the unveiling. Dr. Oddo involved himself in a spirited debate with Dr. Slambow questioning whether  the nasty blackish tissue around the wound was eschar or scar tissue.

After the unveiling and the scar/eschar mess was pealed off I had a functional but rather disfigured index finger with a square tip and missing 1/2 the nail. I never missed a day of work and today I regard what's left of the end of that finger as a badge of honor. It's better than thinking of it as a living monument to my foolishness.

What if Pathologists Performed Surgery?

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

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

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

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

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

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

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

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

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

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!

The Most Popular Post of 2018

For the life of me, I can never predict which one of my foolish posts makes for a good read. I tend to favor outright goofiness and venturesome tales that lend themselves to entertainment purposes. Imagine my surprise when a dull, uninspiring fact laden account of the disappearance of genuine glass IV bottles was the most viewed post. Go figure! I got that last bit of lingo from listening to whippesnapperns. Who says you can't teach an Oldfoolrn  new tricks

https://oldfoolrn.blogspot.com/2018/04/when-and-why-glass-iv-bottles.html

One of my favorite posts received less than 10% of my boorish IV bottle post. Operating room  nurses tended to have somewhat of a twisted sense of humor. I guess it went with the territory. It was all business in the midst of a case but at the end of the day buffoonery showed it's prankish  face. Arguments are for the surgeons so nurses had special little ways of settling disputes. One of my favorites forms of arbitration was the ring stand race. This contest was used to determine clean-up duties and delegate unpleasant duties like clearing out floor drains or troubleshooting clogged suction machines. Maybe I favored ring stand races because I could slither myself through that hooped demon with as much speed as poop flows through a goose. Here's the link in one of my cheesy attempts to solicit readers.

https://oldfoolrn.blogspot.com/2018/09/ring-stand-challenge-racing.html

Is Surgery A Spectator Sport?

Observers in a sanctioned overhead viewing site 

advancing their surgical acumen. Serendipitous 

snoopers were another story.

Vintage hospitals went to great lengths to provide surgeon and/or nurse wannabes the opportunity to observe surgeries. European hospitals even referred to their operating rooms as "theaters."  I once worked with a charming British surgeon that affectionately  referred to  us "theater nurses." This soft spoken man actually  thanked  us personally after a case was finished even if our performance was not up to snuff.  A different breed of surgeon compared to his American colleagues.

Surgical spectators were all different and the most interesting  involved the serendipitous observer who happened to be in the right wrong place at the time of the surgical experience.  Don't get me started on those whippersnapperrns who freely use that confounded "experience" word to describe a planned operative  anatomical alteration, but I figure if you can't beat 'em, join 'em. Who says you can't teach an old dog new tricks?

The operating rooms where I toiled were on the very top floor of the hospital and offered a beautiful view of Lake Michigan which was 8 blocks due East. Large picture windows offered surgeons and nurses the opportunity to feast their  weary eyeballs on a  tranquil visual treat of sailboats and sparkling blue water far off in the distance. A welcome reprieve from eyeball stinging Bovie smoke and squnting to thread fine needles with 8-0 white silk while a surgeon hollered at you in the background for being too slow for his speedy needle plunges.

Everything was fine and dandy until the esteemed members of the hospital board decided to erect a high rise employee housing palace  next to the hospital. Nurses were agitated because these were luxury apartments and unaffordable for all but the most privleged office sitters. We were stuck in our 3rd floor walk ups where heat was a rarity even on the coldest winter nights.

Various members of Chicago's building trades toiled on the construction crews erecting this palace for the medical center moguls. They were a cast of colorful characters to say the least. Ironworkers in particular were a flamboyant, in your face sort of personality. I think it had something to do with their performing hazardous work at elevations where one false move meant falling many stories to a colorful  death.

As the building began to rise, we eagerly watched the progress while standing at the scrub sink which was probably less than 50 feet away from the ascending steel I-beams. You  could hear the ironworkers incessant babble before you could see them.   We joked with the surgeons that the ironworkers must be afficionados of expensive German automobiles just like them because they bantered constantly about "beamers" while guiding the gigantic steel beams into place.

The merriment came to an abrupt halt when the ironworkers ascended to the level of the operating room windows. This rag tag bunch of haggard workers acted as though they found a visual paradise. They glared and made contorted expressions as they avidly observed the goings on in the operating rooms. If they found the proceedings in one room not to their liking a short stroll along the steel beam provided a different procedure to observe. Legitimate surgical observers were limited to viewing the proceedings in just one room while the ironworkers enjoyed a virtual cafeteria of surgical sightseeing.

Their ringleader with his distinctive orange striped  hardhat led his merry men along a steel beam parallel to the OR windows until they found a procedure to their liking. The cysto room was the least popular after a worker nearly stumbled off a beam while observing a meatotomy. That procedure shivered my timbers too, so I could empathize with their revulsion.

The most popular room for these happenstance journeymen observers was the orthopedic room. A hammer is a hammer whether the one doing the hammering is a surgeon or an ironworker. The orthopedic surgeons were kept busy reducing and stabilizing bones just as the tradesmen were with steel beams. Both used lag screws and plates in their work. A brotherhood of sorts was established.

The surgeons took little notice of these nosey nitwits, but nurses thought the activities bordered on voyeurism and should be halted. Plan "A" was to scare them off. Sponge racks were crude, nasty looking devices ostensibly designed to facilitate counts, but really served to provide the surgeon of a visual reminder of blood loss. These morbid contraptions were wheeled, so positioning loaded sponge racks dripping with blood  in front of the windows worked to frighten off the men of steel. Some nurses took to displaying suction bottles full of blood on the window sills, but gradually the men of steel acclimated to our repulsive displays.

Alice, our beloved supervisor came up with the ultimate solution to the problem. Being an ultimate Killjoy, she used autoclave tape to suspend surgical drapes over the windows. some problems work themselves out with benign neglect. The observation opportunity ended with our move to the new operating rooms in the Stone Pavilion. Windowless operating rooms were very popular in the mid 1970s and put an abrupt halt to all the fun.

Retention Sutrures

Old school surgeons had a tendency to overdo just about everything from meticulously double tying simple bleeders to throwing in heavy duty retention sutures for added insurance against impending complications. A patient with wound dehiscence or more bluntly a burst abdomen was like a graphic, negative advertisement of surgical ineptitude. Something  to be avoided at all cost.  The  illustration above shows a wound that is beginning to "dehis" on the right side, but the retention sutures are averting a catastrophic blow out.

There was little science in deciding when to deploy torturous retention sutures and empirical notions ruled the roost. The end result was almost every obese surgical patient suffered the excruciation of miserable retention sutures which were applied in wide suture bites through skin, abdominal fat pad, and firmly anchored in the muscular abdominal wall. The dimpling of the  delicate skin before it yielded to the vicious thrust of a gigantic cutting needle pulling heavy suture was a chilling sight. A surgeon strafing a delicate abdomen with retention sutures shivered my timbers like nothing else. Orthopedic surgery with all it's bone crunching sawing and drilling was small potatoes compared to the forcible  application of retention sutures.

These gargantuan  sutures were usually left in place for about 2 weeks of abdominal throbbing madness for the hapless patient. Removal  was the most painful part of the surgical experience. ( I just love that new fangled vernacular where just about everything in modern healthcare is an experience or journey.) How about that, I can write like a whippersnapper if I try really hard!

The suture extraction process was very painful as a result of tissue adherence during the healing process. Sutures were practically cemented in place.  The fact that the abdominal wall was richly innervated exacerbated the situation. Considerable traction was necessary to pull the unyielding suture free from it's tenacious cementation in the underlying tissue. The sordid suture removal   affair reminded me of pulling cold taffy accompanied by loud screams and anguished howls. The task was almost always relegated to the least senior resident. Thank heaven, nurses never removed retention sutures.

One aspect of retention sutures always reminded me of an executioner applying a hood to the condemned before the act final was completed. This action was ostensibly done to make it easier on the prisoner, but the only real beneficiary was the executioner who could not see condemned man's suffering. For patient "comfort" the retention sutures were cushioned with short lengths of latex tubing where they contacted the skin. These bolsters or bumpers as they were called were custom made by the scrub nurse trimming a length of tubing as the sutures were placed. Any "comfort" from these little gems existed solely in the mind of the surgeon.  Retention sutures fueled post-op pain like pouring gasoline on a fire whether bolsters were in place or not.

More recent knowledge suggests that alteration  in the integrity of connective tissue is responsible for wound dehiscence and not necessarily obesity. The retention suture for all obese patients was not appropriate. Hopefully laproscopic procedures and improved techniques have made retention sutures extinct.

Giving Thanks

Maybe it's my advanced age or the Sinemet I'm taking  for uncontrolled spasms, but I have this recurring dream. I'm called in to scrub on a messy trauma case. When I show up in the tiled temple with overhead lights ablaze, everyone is glad to see me. Dr. Slambow greets me with that subtle grin and says, "Boy am I glad to see you,  we have a real doozy here. Open up a thoracotomy set with your usual general surgery  paraphernalia. I suspect we're going to need it." Trouble was always around the corner with this request because Dr. Slambow was a general surgeon and the administration determined that he did not have privileges for chest procedures. I always thought that my job was to do what's best for the poor soul lying there bleeding out on the cold table. Office sitters be damned.

About this time I wake up and realize it's all a dream. I'm just an oldster huddling under the covers with knees aching so bad that I would be lucky to crawl out of bed, much less stand at a Mayo stand for hours on end.

OR nursing was difficult to say the least, but I had people who really appreciated my efforts and made me feel important. Maybe a bit too important for my own good.  The difficulties made everything seem more worthwhile. At least I was trying to help someone and was grateful for the opportunity. I don't know what I would have done without it.

I'm grateful for a different sort of life now. I never thought I would outlive so many of my contemporaries who were more fit and much healthier than my foolish self. I was marveling at my longevity with my internist and he summed it up by saying, "Well you never know when your time is up." How true, and I'm  thankful for all these years whether I deserved them or not.

Thankfulness has opened up my soul to humility and the realization that it's not necessary to work in the OR to have a purpose-driven life. I'm grateful for a day unburdened by obligations with freedom from time constraints. The ability to reflect on all my foibles and foolishness. It's difficult for me to believe so many folks read my foolhardy reflections and memories. I am especially thankful that so many of you read my blogging foolishness. Gratitude brings about an all encompassing feeling of peace and satisfaction and I will always be thankful to those who indulge in my foolishness by perusing this blog.

HAPPY  THANKSGIVING.