The Doctors' Dining Room

 

Old school hospitals offered lots of special treatment to their esteemed  medical staff. Free front row parking with valet service on demand and an ornate dining oasis which was far removed from drab, utilitarian hospital environs were the more obvious perks. Physicians were the alpha predators in the hospital food chain, far removed from nurses and ancillary staff. There were no "mid level providers" in days gone by. It was just the doctors and everyone else.

Doctors' dining rooms were entered through a solid wood door conspicuously marked PRIVATE. Inside the door was a room paneled in dark mahogany with fancy brass grills covering the radiators. Maroon Karastan carpeting covered the floor. Pictures of the institutions hallowed great healers from the ages adorned the walls with an occasional pretentious bronze  bust tossed in for good measure.  Genuine white table cloths with a fresh floral arrangement salvaged from one of the many bouquets  left behind by departing patients added to the ambience. Fancy light fixtures illuminated these deluxe digs and sculpted plaster potentiated the high brow ambience of these over stated  eateries. A two year old with a plate of spaghetti could do more damage to an over adorned room like this  than a hurricane 

General practitioners and internists served the role of personal physicians and  asserted complete control over the care of their patients spending  many long hours in the hospital.  A readily available source of nourishment was essential.  These dining areas were a feeding lot open 24/7, serving snacks like Good Humor ice cream bars, bagels, donuts, and crackers laden with cold cuts or liver pate' during off hours. Normal operating hours featured  food from the hospital cafeteria embellished with little sprigs of parsley, ripe olives or whatever else the colorful characters known as hospital cooks could whip up. A distinctive touch to our hospital dining room were  bottles of hot sauce smack dab in the middle of every table.

Doctors'  dining rooms were the consummate private place for the boys to raise questions about care and explore  solutions to ethical dilemmas. Operating rooms were fertile ground for  mishaps and screw ups when  minimally trained general practitioners were  granted surgical privileges. Thankfully, they were prudent in restricting their services to simple procedures like vein strippings, tonsillectomies, and D&Cs. 

A ham fisted G.P. might ask an ENT specialist if it was OK to with hold information about a patent's uvula  that had the nerve to get tangled up in an errant tonsil snare. The ENT doc usually advised it was best to be truthful since the first time a patient looked in the mirror he would notice that little thingee hanging down in the back of his pharynx was AWOL. It's best to be honest when your mistakes are obvious.

Wrong site surgery was an egregious error but could be easily explained away by claiming that the errant surgery was necessary and not a simple minded mistake. Circulating and scrub nurses would likely be fired for wrong site surgery or  foreign body oversights, but the surgeons remained unscathed except, perhaps, for an admonishment to be more careful next time.

Doctor's private dining rooms were doomed by hierarchy busting youngsters and the welcome influx of women to the medical field. Most women did not take kindly to putting their own needs ahead of patient welfare when covering up mistakes, an issue frequently addressed in all male forums like doctor's dining rooms.. Corporate healthcare had a significant role in shuttering doctors' dining rooms because of their negative cash flow. Any use of space that failed to contribute to cash flow was history.

What Was the Most Viewed Post of 2020?

This has been a really strange year, just when I thought that I'd seen just about every thing, the Corona Virus pops up and attacks some of the most vulnerable members of our population. Dr. Slambow, my surgeon hero of yesteryear, always said it was the things you cannot see that should cause you the most worry. I suspect he was talking about lesions hiding out somewhere in the small bowel, weird anatomical variations, latent coagulopathies  or breaks in sterile technique. Viruses were not on the radar back then, but I thought of Dr. S. many times while the COVID19 mortality and morbidity numbers were flashed across my computer screen. He was right about hidden danger being the ultimate source of worry.

There has been a flight of ideas coursing  through the remnants of my nervous system about subjects to post;  the long tenure of ether screens (anything that lasts for over a century grabs my attention), questionable adjuncts to ventilator therapy (proning, the latest and greatest of these interventions prompted this idea), the demise of doctor's dining rooms, the disappearance of ortho beds with traction frames and a personal tale of TPN addiction.

It's sometimes a long road from an idea to typing up a new post. Declining eyesight and gnarly fingers from IP joint arthritic changes have put the brakes on my once upon a time nimble fingers. My latest status post encephalomyelitis MRI showed a loss of brain volume, so I best get cracking before my vintage memories evaporate in that looming cognitive abyss. Oh well there is always next year and I will strive to post more than once a month which was my 2020 goal.

The most viewed post of 2020 by a swarming plethora of views  was...drum roll please:oldfoolrn: March 2020. I was really taken off guard by the popularity of a post about such an unsavory topic. I think there is a post languishing in my unpublished drafts about every old nurse's favorite colonic, the 1...2...3... enema. Maybe some day I'll hold my nose and publish it, although I was never one for over rated enemas and their associated backside buffonery.

 My personal favorite was about the crude, but effective Wagensteen suction oldfoolrn: Wagensteen Suction - Elegantly Simple Without Electricity In this electonically complex world filled with flat screen monitors and assorted doodads, it's a delight to see a simple mechanical device do it's work. Just because we were ludites doesn't mean we were stupid or lacked creativity.

Happy New year and I appreciate your loyal readership of my never ending  foolishness. You give an old man a sense of deep rooted purpose.

Christmas Arrives at Downey VA Hospital With a Gift for Warren

 

 

Warren was a big, tall man with a complexion that reminded me of custard pudding, forty-one years old, with half a lifetime spent on the back wards of Downey VA Hospital, a warehouse for the mentally ill. Like most all the patients here he was branded with the diagnosis of schizophrenia, chronic, undifferentiated. By the 1970s psychiatrists had given up on the idea of delineating the various subtypes of the illness; catatonic, hebrephrenic, paranoid, or schizoaffective,  all permutations were treated the same at Downey. Determining the underpinnings and concocting efficacious treatments for complex mental disorders like schizophrenia made nuclear physics look like a game show.The brain was a complex organ with very complex disorders.

Warren's most visible problem was that he was literally lost in space and required constant contact with a wall to do just about anything that required movement. Staff members regarded this as a behavioral manifestation of his psychosis and dealt with it  accordingly by initiating harsh measures like restrictions on privileges such as smoking and moving his bed to a dark, grim, windowless  area for special observation with threats of physical restraint if he persisted in his wall rubbing routine.

Watching Warren navigate the subterranean world of Downey's interconnected tunnel system was like following a bumper car at the state fair. He repeatedly bumped or bounced his right shoulder off the rough red brick walls leaving a trail of textile shards in his wake, similar to the sparks trailed by the bumper car contact wire on the electrified ceiling. His posture resembled the letter "J" upside down with the end of the letter in constant contact with the wall as he gallivanted along his way.

Just about any staff  reprimand, which was nearly constant,  to cease this shirt/coat shredding behavior was meant with a look from Warren that could smelt lead. Out of pure frustration, Warren developed a unique skill that involved tapping on the few panes of glass windows that had not replaced by plexiglass, skillfully he increased the force of the impact until the glass shattered, leaving his hand virtually without injury.

I talked to Warren about his need for wall rubbing and came away with an assessment much different from my esteemed colleagues. I thought the  incessant wall rubbing was not a direct manifestation of his psychosis or voluntary acting out. Warren had a proprioceptive disorder where he really could not tell the position of his body in space. He felt that without contact with the walls while moving he  would follow a circuitous path and never arrive at his destination or fall injuring himself.

That evening while pouring medications my eye was drawn to the heavy plasticized bottle the pharmacy provided for a solution we mixed with Thorazine concentrate liquid to make it palatable. The side and bottom portion of the bottle had a contour that was a near perfect match to Warren's right shoulder where it interfaced with the brick walls.

I took an empty bottle home that evening and went to work on a garment that could slide along those rough Downey walls and remain intact. Warren loved football, having played receiver  in high school, but while his team mates soared to the stars with their lives. he burned up as he plunged back through the atmosphere like the space shuttle Columbia.

After fashioning an appropriate skid plate from the pharmacy bottle, I drilled a series of tiny holes around the periphery of the plastic armor  and carefully sutured sewed the protective armor to the right sleeve of a Chicago Bears jacket  ala a craniotomy bone flap. A test drag across the outside wall of my apartment building proved successful. Warren was an avid Bears fan and I had a feeling he would really enjoy the jacket, especially if he could rub the brick walls without worry.

I carefully wrapped Warren's special Christmas gift complete with the  abrasion tested shoulder armor in a box that was emblazoned with the corporate jingle, "Tarreyton  100's for smokers who would rather fight than switch." He eagerly unwrapped the present half expecting a mother lode of cigarettes, but as he eyed the special jacket, his eyes gleamed. The look was priceless. He quickly donned the jacket with a renewed sense of purpose. When he spotted the shoulder guard, he couldn't wait to try it out with a quick mosey down along the hall walls. It doesn't take much to make some folks happy - one of the special rewards of working at a place like Downey VA Hospital.

Egyptian Fun in The Nursing Dorm

 Hospital diploma nursing schools mandated that all students reside in the dorm which was conveniently located within the hospital complex. Individuality was nipped in the bud with all student nurses sharing the misery while at the same time maintaining a pseudo happy face. A monastic-like existence was thought to enhance the nursing educational training experience. Older nurses viewed nursing as a cult and eschewed an outside life for the good of nursing.

These dorms were not fun places and novice nurses slept, woke, ate, slaved for 8 hours on the wards, ate again and studied under the watchful eyes of house mothers before sleeping again. As the bewitching hour of 9 PM rolled around it was time for some fun. House mothers, affectionately known as house hags, completed their last rounds before mandatory lights out at 10PM. The end result was one hour of time for which there was no accounting. Between 9 and 10PM was the bewitching hour.

Student nurses had to make their own fun in this  stark environment that was devoid of  televisions or any form of recreation that cost real money. Of course the sewing room was open, but who felt like mending aprons or fussing with uniforms after working or studying all day. Novice nurses were pretty much left to their own devices when it came to recreational pursuits.

Water fights were popular diversions with an enema can rigged above transoms to dump a deluge on anyone answering a knock on the door. The downside to water sports was the clean up and the screaming frequently attracted uninvited attention from nosy house mothers.

Water fights were fun, but messy

Human pyramid building was the activity of choice in many diploma nursing school dorms. The base of the structure was formed by 4 girls kneeling on the hall floor and gradually built up until the tiniest girl was perched at the apex. Pyramids were fun because there was an immediate sense of accomplishment. This was something novice student nurses could do on their own without being harangued by overbearing instructors or busy body housemothers.

Pyramid diagrams were often used in nursing school to explain the nursing hierarchy or illustrate the priority of patient needs. There was an inherent sense of satisfaction in having fun with something that was not fun.  Human pyramids in the hall were good, clean fun.

 I looked forward to our pre-clinical cafeteria breakfast at 6:30 AM where the first topic  of discussion was frequently the last night's  pyramid building adventures. Early one morning there was an unusual buzz in the air and the discussion was preceded by a "you are not going to believe this disclaimer." The girls had constructed an inverse human pyramid with the most petite girls at the base and "Big Betty" who tipped the scales at about 100kgs as the top. I wondered why so many of the more diminutive students were hobbling about!

Nursing Was a Great Sanctuary from the Forlorn Politics of the 1960's

Chicago Police vs. Demonstrators 1968

 On this election day, my thoughts turn to the days of old school political tomfoolery. Some things never change. The day to day political process in Chicago during the late 1960's was a mine field of toxic emotional response fueled by the unending Viet Nam War. There was the police riot just outside the doors of the Democratic National  Convention in 1968, followed by the mayhem  so freely sewed by Jerry Rubin's YIPPIES.

Richard Nixon's  election and subsequent inability to bring the war in Viet Nam to a conclusion, incited a renewed rift of student demonstrations. SDS or Students for a Democratic Society was the mover and shaker on college campuses and had divided over the issue of violence as a means to end the war.

In the fall of 1969, the Weathermen contingent of the SDS staged the Chicago Days of Rage. Stores were ransacked and police cars overturned. Lengths of chain, slinging case hardened padlocks were one of the weapons of choice. The police countered with batons and tear gas, bringing many of their more seriously injured customers to the ER. Some of the victims arrived at the ER strapped to the back of Harley-Davidson Servicars which were unique 3 wheeled motorcycles. A rough ride on the back of one of these contraptions was one of the social engineering experiments by law enforcement. A ride on these bucking broncos was enough to deter further bad behavior.

I was a 19 year old student nurse at the time and often came in contact with some of the hapless student demonstrators as they were triaged. These well intentioned youngsters sometimes asked me if I was going to attend the next demonstration on Halsted Street in the morning. "No, I have clinical all day on 3B tomorrow. There is no time for any of that if you are a student nurse."

Nursing was a wonderful shield from the political tumult of the day. Being present to my patients in their time of need felt so good compared to the emotional cauldron stewing within the tear gassed and beaten demonstrators. Diploma nursing schools, with instructors like Miss Bruiser on your back all the time, could be trying, but  the monastic life did have it's peaceful moments-some of which I would like to call to mind on this strained election day.

All Nighters in The O.R. Were Real Stinkers

 

Bovie smoke carried olfactory nightmares into every 
nook and cranny

As lengthy night time trauma surgeries came to a close, nurses were often presented with a cafeteria-like  assortment  of wounds to dress. The deep stab wound on the medial thigh called out for iodoform packing which had a nice, sweet, iodine like scent. After the thigh wound was ram rodded  packed to the hilt with ribbons of iodoform, it was time to dress that monstrous midline abdominal wound. Tincture of benzoin would be applied to secure Montgomery strips in anticipation of frequent dressing changes. Montgomery strips spared the patient the pain of abrupt removal of adhesive tape; just loosen the ties to swap out ABDs.

This juxtapositioning of one scent (iodoform) on top of another (tincture of benzoin) often led to the creation of a completely new and frequently unsavory smell that I thought of as the third effect. Under this principle, when two smells are brought together, their individual effects are irreparably  altered  and potentiated into a novel, foul, lingering witch's brew completely  unlike that of the initial contributors. I think the technical name of this newly created stink fest was compound smells.

 The addition of residual  Bovie  smoke made  the foul smell penetrate every nook and cranny of  just about any object or person in it's path. Just as a syringe and needle transported medication to a site, the Bovie smoke delivered the stink as reliably as a  mailman.

Underlying scrub attire reeked of the compound smell when our impermeable surgical gowns were removed. I always thought of this as the diaper principle, because as long as the gown was intact the smell was relatively contained. Removing the diaper...OOPS...I meant surgical gown was another story as the foul odor homed in on awaiting olfactory senses like a cobra strike.

The best part of a  long night  in the O.R. was the beautiful sunrise over Lake Michigan as this usually signaled an end to the mayhem and the arrival of reinforcements in the form of day shift nurses. Fresh, kindly arriving nurses always stopped to help the  worn out, bone tired trauma victims and I'm referring to personnel-not patients.

One July morning, my friend Janess, bounced into the room as a case came to a conclusion to act as cheerleader and help us off with our gowns. I noticed her eyes and jaw roll as her eyebrows popped toward the top of her head as she assisted. She looked distressed - to say the least.

 The next day I thanked her for the moral support adding, "We must have looked pretty bad, Dr. Salmbow and I felt like we had been beaten to a pulp after that doozy of a case."  I'll never forget her immediate response, "It wasn't how you looked. It was how you both smelled."

Lights Out in The O.R.

 

Late night trauma surgeries were performed in  a parallel universe diametrically opposed to run of the mill, day-to-day, elective surgery. In place of the measured orderliness, gowned and gloved players were often blinkered by an all consuming bone tired, sense of fatigue that descended on the room like a choking mist. The emergent condition of the patient spurred a driving sense of expedience among the weary staff. Fatigue and the hurry-up nature of trauma surgery can have bad consequences no matter how well intentioned the staff, a lesson I was about to learn the hard way.

Delusional thinking, fueled by the infinite wisdom of youth, falsely told me that fatigue was a nonissue.  I sometimes played make believe, telling myself  that fatigue actually made me perform better by focusing on the things that really mattered.  I often felt like the grand wizard from the land of OZ. Hidden behind the curtain of mask and gown, I was just pulling on the strings and manipulating the levers to quickly load needle drivers and collect bloody sponge sticks.

My delusion of being fatigue proof was about to be shattered when the phone in the call room awakened me with an 0200 hour  emergency one early Sunday morning. The trauma gods always got restless on Saturday nights in Chicago. It was a harried nurse from the ER advising me that a hot trauma was being loaded unto the elevator for a nonstop flight to the 7th floor OR. A teen aged stabbing victim with volume depleting abdominal bleeding was our patient and the ER nurses had applied a scultetus abdominal binder in hopes of slowing things down. Not an encouraging prognostic sign.

The Lakeview  neighborhood was home to the Aristoctats, a youth gang that often meted out punishment with the blade of a knife. Firearms were thought to be unmacho and eschewed with youthful vigor. Not a bad concept in my book, as knife  wounds were more amenable to surgical repair. 

Although these kids looked menacing on the street, on the OR table they looked like the vulnerable little children they were. Their vicious behavior was often mixed with the typical adolescent sense of humor and more than one of them smiled as they related, "It's not how deep you stab your knife, it's how you wiggle it around."

I had just finished setting up my back table as the bleeding youngster crashed through the doors accompanied by the usual cast of lifesavers, pushing the gurney like it was a guided missile. Dr. Slambow had gowned and gloved himself while I quickly tossed  together a basic laparotomy setup. I was loaded for bear, complete with a boatload of Satinsky vascular clamps. My heart always did those little flip flops when an attending surgeon volunteered to gown and glove independently without the help of a nurse. Something unsettling was usually close at hand.

Dr. Slambow urgently announced that this was going to be a "Whoop-dee-doo" case. (His unique vernacular for an O.R. free-for-all.)  He  was going to start cutting  immediately without the anesthetist present. The patient was unconscious with a secured airway, but cases like this always hit me with  a feeling of raw, primal panic. Obeisance to sterile technique was tossed to that void behind the vacant ether screen and  questions like, ""What if he wakes up while we're inside his belly?; Can we stop the bleeding in time?;  Do I have all the instruments and supplies?;  What happens if that fenestrated sheet that I hastily tossed over the patient for a crude drape falls off?" I don't think there is anything more pathetic  when a drape falls to the floor exposing an unfortunate  little kid with a big hole chopped down the middle of his puny, little bread basket. Truly the stuff of nightmares, at least for me.

Things went better than expected. After Dr. Slambow carved a midline incision and  sucked out the blood things began to slow down. The inferior vena cave was intact along  with all of the other major vessels. The bleeding was brisk but confined to lots of superficial venous circuits and the spleen. After a quick splenectomy, the bleeding was pretty much under control. Dr. Slambow would clamp off a group of bleeders together and give the command to "meatball it" so the resident would tie the mess off in the shape of a little sphere. After making a few meatballs we were done cooking and the patient was doing well.

The O.R. room for trauma  was one of the oldest on the floor, selected because of its proximity to the elevator and nearby autoclave which although vintage, worked great for flashing a last minute instrument or preparing Thanksgiving dinner. We even nicknamed the old autoclave Mr. Yell N' Cuss because that's what we did when the door was unbolted and we got hit with a burst of steam due to a constipated venting mechanism.

During  the emergency trauma  surgery  I noticed, Clarence, our diligent housekeeper, peering through the porthole-like window in the door. I thought  that he was admiring our lifesaving surgery, but when the case was over, Clarence wheeled his mop bucket in with a perplexed  expression. "You folks 'spear- menting again?" he asked. "What do you mean by that Clarence?" I asked.  "You done that whole operation without the great big overhead lights tuned on!" Oh my gosh, I could not believe what we had done. I ran to the surgeon's locker room and updated Dr. Slambow on our oversight. In a tired voice he wearily explained, "Well the ambient lighting was pretty darn good and we weren't deep within a body cavity. Sometimes things work out in spite of our screw-ups."