Giving Thanks

I need to scribble  something  here to obliterate that image of a transorbital intubation in the previous post.  Jeez...that image gives me the willys. What was I thinking?  It's no wonder I got blacklisted by a couple of referral sites for being too grotesque. Blame it on poor judgment instilled by far too many years in the trenches. What comes to me, I suppose, not every time, but often enough, are the inelegant vignettes of trauma that have pitched a tent in my hippocampus.

So it's time to move on.  I'm wishing a festive Thanksgiving to all those who peruse my foolishness. I'm humbled by your readership and it simply  amazes me that someone is always viewing my foolishness-especially those who visit the middle of the night when all should be sound asleep.

I have so much to be thankful for, especially the patients I cared for in days gone past. They did more for me than I did for them. One thought that never escaped me was the notion that all those nasty ailments lurking out there in the world are equal opportunity afflictors. Anyone could be stricken down any time. It's really just a matter of chance accompanied by good fortune that I was fortunate to remain healthy and  vertical for so long.

Glioblastomas are out there in the world  and occur at the rate of about 4 per 100,000 people. I owe so much to those patients that suffered and ultimately succumbed to this terrible neoplasm. It could have just as likely been me with the glioma, but someone else took  all that pain and suffering to spare me of this terrible fate. I owe them a deep debt because it could have me.  I don't know how many times I uttered a silent thank you to these patients and tried to do something special for them. I am eternally grateful to these patients who took the hit for me.

This gratitude fills me with a sense of helpful sharing and a strong disdain for the greed and financial preoccupation of healthcare today. Oops... don't get me started on that one! The respect and peace that nursing has filled my soul with cannot be  derailed by dollar signs. It's what's left in your heart when the day is done that really matter, not your bank account.

Anyhow, for some genuine foolishness here is a link to a post I wrote some time ago https://oldfoolrn.blogspot.com/2015/11/how-do-you-cook-thanksgiving-turkey-in.html

Happy Thanksgiving! I treasure your loyal readership. It  means more to me  than you know!

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.

Fine Dining Hospital Nursing School Style

Oh..The tales that were told during mandatory dinner hour.

Vintage  hospital diploma schools were hybrid affairs: one part workhouse, one part charm school, and one part plantation. The charm school component made attendance mandatory  for the evening meal in the hospital cafeteria if you happened to be fortunate enough to work  on a clinical unit during the 3-11:30 shift. Sharing a meal together was probably  thought to have a positive  social impact on  hospital confined and culturally deprived nursing students

The nursing school had commandeered a long table in the very back of the chow hall. A sense of decorum was added to the ho hum environment by the use of genuine china dinner plates emblazoned with "IMMC School of Nursing  Dedicated to the Service of Mankind."  Another unique touch was the  disbursement of several bottles of Red Hot Sauce prominently displayed as a centerpiece.

Nursing students were undernourished in social experiences and overfed on shame and degradation  dished out by mean old coots masquerading as instructors. The fine china and special sauce adornment was a lame attempt to mitigate the harsh realities of life as a nursing student and spice things up a bit.

Working with the most challenging patients was difficult enough, but our tough minded, anal retentive instructors demanded strict self-regulation of our behavior. There was no crying, complaining, or lamentations of any sort permitted. We always answered to our hard core instructors in plantation speak, "Yes'um, No madame, and Right away," were stock replies.

So when we all sat down together for dinner, it felt as though a weight had been lifted off our shoulders. Typical dinner table conversation revolved around difficult nursing procedures and technical tips for their  successful completion. Occasionally the various foodstuffs were used as props. I will never forget the time my friend, Janess, demonstrated her prowess at removing fecal impactions by using a stale donut leftover from breakfast and an overcooked chunk of bratwurst. The key was to bury your finger well into the brat and the flex the distal phalanx into a hook like device before pulling it  through the donut.

Being the sole male at the dinner table had it's awkward moments when I was called to mediate arguments about boyfriends or menstrual cycles. Although I may have been a disinterested party my knowledge base was not up to snuff and led to lots of round about jibber jabber.

Our final dinner together as student nurses was held outside the hospital at a really nice nearby restaurant, The Ivanhoe, which was just down the street between Clark and Halsted.  The senior dinner held right before we were crowned GNs was memorable because or instructors were finally nice to us because we survived and were on our way to becoming peers. I made up my mind then and there that I was never going to treat anyone as we were treated as students.

Old School Automobile Lap Belts Engndered Bucket Handles and Fruit Loops

Cars from the 1960s were rolling deathtraps. Two  tone paint jobs, wide whitewall tires, and chrome bumpers looked snazzy, but in a motor vehicle accident (incident or crash in today's lingo) the passengers were propelled into rigid spear like steering columns or protruding cowl like hoods over the speedometer which, to say the least, were evisceration proficient. Any poor soul lucky enough to escape compression injury via steering column impalement or gutting by the speedometer was hurled head first through the windshield and wound up with spidery split open lacerations on their forehead and all too often, hopeless neurotrauma.

Initial efforts to restrain vehicle occupants and  transfer some of the destructive forces to crumpling sheet metal consisted of lap belts.  Curiously, lap belts were always referred to as "safety belts," instead of the current seat belt terminology. These girth gripping girdles prevented some of the unfixable neuro trauma at the expense of the abdominal organs which ,at least, were potentially fixable with timely surgical intervention. Typical abdominal trauma from car wrecks  involved banged up and bleeding hollow viscus organs, blood oozing spleens, and contused and bruised livers. Retro peritoneal renal injuries were less common. Maybe all that fat surrounding the kidneys protected them from some of  the trauma.

Typical stigmata of lap belt trauma consisted of a 2 inch wide ecchymotic banding across the lower breadbasket. This ominous finding almost always meant internal injuries and called for the immediate diagnostic peritoneal lavage. After cannulating the peritoneal cavity about half a liter of normal saline was infused. After  about 10 minutes the saline was allowed to drain back out by gravity. Any blood in the drainage meant a quick trip to the anxiously awaiting personnel in the OR.

Innovative lap belts caused a surge in a new kind of deceleration injury, bowel/mesenteric separations which were a good trade off for the neurotrauma sustained from crashing head first through the windshield. Most abdominal trauma was fixable if caught in time, while neuro trauma usually meant a grim prognosis.

The bowel is fixed at the flexures,the ligament of Treitz, and last but certainly not least, the rectum.  With the colon and small bowel moving forward at 60mph ( or whatever speed) the sudden traumatic stop of an accident pulls like a John Deere tractor on the intestine adjacent to these tack down areas dividng bowel from it's lifeline, the messentery. Without mesenteric connection, the section of isolated  bowel withers up and dies like a man in the desert without water.

Mesentery supplies vascular, nervous, and lymphatic connections to the bowel. It also holds our  intestines up out of our pelvis where there are enough problematic structures without dropping another player into the mix. Mesentery is one of the most underrated abdominal players.

Suspense reigned as the surgeon cautiously entered a traumatized abdomen and when the problem was finally delineated and deemed curable, a feeling of jubilation and relief was experienced by the team. Hearing Dr. Slambow, my general surgeon hero, deliver his diagnosis was always a musical treat. As the Airshields ventilator chugged out bass beats in the background there was proprietorial pride in his harmonius voice as he practically sung out "bucket handle," four notes, key of "C," ascending. The hootenanny proceeded as the intestinal resections marched along with needle drivers clicking away like castanets and heavy instruments adding dissonance clunking away in the lap tray on the back table. The finale was always the best part as we stepped down form the podium with a meticulously patched up patient that was sure to recover.

 How did this injury acquire it's strange moniker? The section of large bowel stripped from mesentery did indeed look like the handle of  a bucket so the name fit. Small bowel separations were more subtle and were named after the little cloth hanging loops on the back of men's shirts of the day. Even though they did not resemble the popular breakfast cereal, everyone knew what an intestinal fruit loop injury looked like.

A bucket handle injury of the transverse colon and 3 fruit loops down below 

where small bowel parted ways with mesentery. That lower separation
is beginning to show the effects of devascularization.

(Photo courtesy Dr. Michael McGonigal)

When the call room phone incessantly rang  at 2AM and the harried voice on the other end intoned "Motor vehicle accident ETA 10 minutes," my feeling was similar to one of those daredevils going over Niagara Falls in a barrel. Lots of mental anguish leading up to the case because the final landing outcome  was unknown. Bucket handles and fruit loops usually led to a successful plunge over the falls.

The Surgical Abdomen

While fresh, young  surgeons pour over detailed cross-sectional CT scans or overpriced, extravagant ultrasounds, old surgeons relied on the wisdom gained from a physical exam and meticulous history taking to delineate abdominal pathology. "Hot Bellys," in the vernacular of the day could be a real hornets nest to deal appropriately with, and the wily veterans had there own brand of diagnostic techniques which were crude, but effective.

Decisive clinical diagnosis was elusive, but a strange hodge-podge of clinical maneuvers (if you could call them that) were enlightening to the battle tested old surgeon. Observations were also key element  of the work up.  A "sweated brow" or "a hypovigilant countenance" suggested a septic process. Jaundice suggested some sort of hepatic dysfunction and a strange blue periumbilicular coloration signaled an internal bleed.

The exam of the acute abdomen consisted of, euphemistically, what would be termed palpitation, percussion, and auscultation, but was really poking, pushing, lifting, listening, and twisting limbs around with gusto, much like a pretzel.

The psoas test was performed by forcefully flexing the thigh while rotating the foot outward. The test was contraindicated with concaminant orthopedic injuries. A positive response elicited a vociferous verbal response from the hapless victim  patient and suggested a lower abdominal process.

A shake test was of great value when the patient had difficulty identifying the area of maximal belly pain. While in a supine position the patient's hips were slightly elevated off the bed while a vigorous to and fro shake was delivered. Dr. Slambo, my favorite general surgeon, had an interesting method of augmenting the shake delivery that only applied to ambulatory patients weighing less than 75 kg.

With the physician and patient standing back to back with arms interlocked together at the elbows a gentle elevation is initiated by the good doctor leaning forward. The optimal height was with the patient's feet about 6 inches off the floor. The abdomen is bowed such that the viscera are near  the surface while a side to side shimmy/shake elucidates the problematic quadrant. The technical name of this procedure (according to Dr. Slambow)  was the elevated, gyrating, gambol gambit and it was far better than one of those new fangled CT scans when it came to elucidating the exact focus of abdominal distress..

Dr. Slambow also knew how to augment just about any type of palpation technique with a miraculous gooey, slippery substance known as ordinary Surgilube. He began with a full tube, superior to the umbilical concavity and began squeezing until there was a generous pool of  goop.  He then began exploring the aching quadrant with his hand gliding across the abdomen like a shoe that stepped on a banana peal. The quantity of Surgilube used during the procedure also provided valuable insights when planning the surgical intervention. More than 1/2 a tube of the gelatinous goo signaled problematic obesity that called  for extra long instruments and a platform for Dr. Slambow to stand on while he looked down into the wound.

Fist percussion commonly known as a blow to the upper bread basket was performed along the anterior thoracic wall by placing one hand on the skin and beating it with a fist. Exquisite pain evidenced by vociferous howls indicated cholecystitis or hepatic issues.

Murphy's inspiratory sign can be demonstrated in acute cholecystitis  by asking the patient to take a deep breath while pressure is judiciously applied below the right rib cage. As the liver descends, the inflamed gall bladder is brought into contact with the abdominal wall causing immediate cessation of the inspiration.

I really liked scrubbing on acute abdomens because the offending problem was identifiable and fixable. There was no better feeling than seeing a seriously ill person stroll out of the hospital with a new appreciation of life. Viewing that so vulnerable  prepped abdomen supine on the table awaiting the surgeon's ministrations always put me in a contemplative mood with the realization that despite all our political and religious differences  we are all just meatsacks enjoying an undeserved period of wellness so no matter what or who, With this thought lurking in the back of my foolish mind, I tried to be nice to everyone and treat patients as though they were my mother, father, or child.

Hospital Signage

Yesterday's sign was a model of stark simplicity

Today a ridiculous hodge podge of word jugglery. What a mess!

Cyclopropane Anesthesia - A Blast From the Past

Inhalation anesthesia was dominated by ether until cyclopropane made it's debut in the late 1930s. This new agent was potent and did not induce the unpleasant nausea and vomiting associated with ether. Those operating room scenes from Ben Casey or Dr. Kildare where the patient is asked to count to 10 after the anesthesia mask hit their face were classic cyclopropane inductions. Most were sound asleep by the count of 3. Cyclopropane was like magic pixie dust in an orange steel cylinder;  inhale it and almost instant anesthesia, back on room air, and presto... near immediate emergence. There was only one problem, cyclopropane was explosive and had the potential to turn just about any cysto room into a wiener roast.

Every old time operating room suite  had a cyclo room that was heavily modified to avert cyclopropane detonation. I always liked the way cyclo room sounded when pronounced, it had an eerie Alfred Hitchcock feel to it because it sound so much like "psycho room." Indeed these were different sort of rooms where strange rituals and  happenings prevailed.

Cyclo rooms persisted until the early 1970s. Any new OR suite constructed post 1970 lacked an explosion proof room. The first line of defense against exposions was the elimination of statuc electricity discharge by grounding everything to a terrazzo floor which was interlaced  with conductive copper dividers. A gleaming terrazzo floor lined with glowing copper dividers was a beautiful sight.

Everything in the room was supposed to be grounded to the conductive floor. Operating room personnel wore shoes that were modified by a metallic plug smack dab in the middle of the sole and shoe covers had a conductive strip running from toe to sole. First order of business upon entering a cyclo room was testing shoe conductivity by stepping on a small bathroom scale like device. A green signal meant all was well and it was OK to proceed. The shoe testing requirement also served to exclude rubbernecking snoopers and busy body administrators. Only the personnel that really needed to be there were present. An anesthetist, 2 nurses, and a surgeon with an assistant could handle just about anything that came along.

Equipment in the OR was grounded to the floor by tiny metal chains that jingled  when the furniture was moved about. Old operating rooms were always furnished, never equipped. The anesthesia cart which was always a repurposed Sears Craftsman rolling tool chest  had double chains. Why take chances?

The other approach to explosion proofing the room was a bomb squad containment mentality. Potential sources of explosion were shrouded in a heavy steel housing. Operay overhead surgical lights had a particularly robust containment chamber that I thought resembled Russia's Sputnik satellite. I'm not so sure I would like to be laying on the table with that ominous black orb hovering  overhead. It looked spooky to me.

The electrical switch for the Operay was covered in a heavy leather boot that looked like the covering on a Mack truck gearshift. Every time I turned the overheads on, I imagined the carefree life of an open road trucker as opposed to facing up to the stressful work ahead. Oh well...at least I did not have to worry about unannounced visits from my favorite nemesis, Alice, the all knowing supervisor, always steered clear of the cyclo room.

Working in the cyclo room was always the best part of my day, and then later on, the best part of my night. On call, high risk emergency trauma surgery was the perfect venue for cyclopropane because it actually elevated blood pressure to improve perfusion. A good question was; If cyclopropane is so frequently selected for the high risk trauma patient, wouldn't it be good for the healthier patient? The limiting factor was the risk of catastrophic explosion.

I loved the peace and quiet in the cyclo room. There were no Bovies  buzzing or power tools whirring, just the quiet swish as the anesthetist went about  breathing for the patient. The brisk snip sound of straight Mayo scissors cutting ligature after ligature was almost hypnotic.  Occasionally while in the midst of a messy trauma surgery you could actually hear a vessel bleeding.

 Cyclo also had a very pleasant, gasoline like smell that always reminded me of one of my favorite high school courses, auto shop. No matter how carful the anesthetist was with holding the mask, a tiny bit of cyclo always seemed to pervade the room.

Attending anesthetists often told the residents that cyclo was to be   handled with the finesse of a violinist, not with the banging of a kettle drum. Anesthetists were also advised to keep in physical contact with the patient at all times to keep the electrical potential balanced.

Whenever I see a modern operating room furnished with enough electronics to land a 747 in a whiteout and multiple OR personnel milling about it shivers my timbers to the core. To heck about worrying about the finesse of a violinist, these rooms are the equivalent of a symphony orchestra complete with a grand piano. Cyclopropane R.I.P.