The Daring Ortho Patient on The Flying Trapeze

 

"Get that needle outta my leg or that doc on  my right with
the glasses gets clobbered by a flying trapeze!"

                           

  Modern hospitals have become disquieting places without the time worn cues to orient folks to the  type of services available on a particular ward unit.  The ortho wards look naked without beds fully encased by unwieldy traction frames and their sundry attachments. 

Respiratory floors were easy to spot with their huge "U" tanks of oxygen wheeled about by tired looking nurses and orderlies. Now everything looks the same and  the appointments are more expensive than can be easily afforded by the common man.

Fancy in the wall pipes did away with the huge oxygen tanks scattered wily nily about the ward, but lack of orthopedic framework and their ever present trapeze was a move in the wrong direction. Living (if you could call it that) tethered to weighty  traction inside the confines of  an orthopedic bed was an unpleasant patient  experience to say the least,  while outside, in the untethered world, the healthy danced the tune of their small delights. In todays vernacular, orthopedic traction and it's accompanying long term confinement was a huge patient dissatisfier.

The underbelly of the miserable world subsisting below the  ortho trapeze always reminded me of a steaming jungle  teeming with rank smells that bubbled with hot gasses vented from inside an overheated, sweat infused hospital mattress. Patients confined in nasty conditions like this clamored for attention and soon learned a trapeze was better than a call bell for eliciting attention from nursing staff.

It's a sad truth,  most of our nursing forebears had seen way too much suffering to be easily moved by a patient's plight. Patients strung up in restricting traction soon learned that like the porcupine's belly, the weak spot for just about any hardened nurse was a struggling patient.

 So struggle they did. The key to attracting a friendly nurse to the bedside was timing, as the target nurse passed by the always open door, the hapless patient wildly swung by one extremity from the dangling trapeze as if he were about to crash back down to the stench laden  mattress in a fatigue induced heap.   Who in the world could turn their back on a struggling patient?  The "helpless dangler, about to crash gambit," worked on just about every nurse. It was a sure fire way to garner some attention, if even, for a brief moment.     

Wily traction bound patients had the luxury of lots of time on their bedridden hands to come up with more sinister uses for a trapeze. It didn't take much ingenious thought to weaponize an overhead trapeze. Aside from a direct assault by swinging the trapeze at a victims cranium like the poor soul in the illustration above, the pull and shriek strategem was equally painful, but more subtle. 

Nurses tending to orthopedic patients frequently had to work below the dangling trapeze when performing painful procedures like cleaning indwelling  traction pins  with hydrogen peroxide  pins or administering stinging  injections. The ortho patient's  golden hour of returning the painful favor to the nurse was when her cap and/or hair brushed against the chain securing the trapeze bar. A quick downward thrust on the horizontal trapeze would lock the nurse's hair in the trapeze suspension chain. The end result was a hair pulling event upon the nurse's pained departure. I think this is one of the reasons that orthopedic nurses were the pioneers when it came to abandoning the traditional nursing cap. A clump of scalp hair suspended from a trapeze bar was a chilling sight.

Most everything encountered in the nursing world has a yin/yang aspect to it, and trapezes were no different. Trapezes could do good things as well as cause trouble. Orthopedic patients were ordered to wear TED compression hose at all times as a clot prevention measure. Most all life threatening clots formed in deep veins and compression hose only worked on superficial vessels. I could never figure out how such an ineffective intervention could gain widespread use, but that's fodder for a future post.

Patients soon discovered the trapeze was an ideal suspension device for drying newly laundered hose. Just hang the TED hose over the horizontal bar and PRESTO they dried in nothing flat in the steamy hospital environment. Enterprising patients also discovered the trapeze was a great place to suspend photos of loved ones. Having a treasured family member in line of sight worked wonders for patient morale.

The pendulum like back and forth movement of a trapeze was also great for inducing a calming effect. The rhythmic swing tended to induce a peaceful hypnotic sort of state that helped counteract some of the misery induced by immobility.

I recall one patient who discovered a truly novel use for a trapeze. The ends of a trapeze were open and the void made a convenient place to ramrod cigarette butts. Old hospitals were chock full of smokers on both sides of the bedside, patients used the trapeze ends for an ash tray and nurses were known to use the traction support holes in the footboard for cigarette disposal. 

Head Nurse Annie confronted one of the nurses about finding KOOL cigarette butts in the traction receptacle and was countered with a good defensive point, "But I smoke Winstons," the wizened nurse replied.

Happy Easter

 

I can't believe how many folks are perusing my foolishness on such a Holy Day. I hate to go Dean 
Wormer on you, but life is so very short, go spend some time with your family and Happy Easter from OFRN!

Nursing Performance Evaluations

 

And furthermore, those black bobby pins securing 
your cap are most unprofessional. Use white pins!

Nothing exploits the fault lines of professional nursing quite like the annual performance evaluation. The assorted dynamics are varied, but always divisive; the young vs. the old,  BSN vs. diploma,  'Mericans vs. foreign born, neat fanatics vs. free spirits, and at the root of all conflict, the nurse office sitter academic/administrative complex vs. the lowly bedside nurse.  

The rigid, authoritarian nurse administrator doing the evaluation was once a member of the bedside nurse cohort but ascended the administrative ladder as a result of being totally unfit for direct patient care and also holding anyone who is good with patient care in contempt. Basically, it's a cabal of malcontented  busy bodies whose primary mission in the nursing world is proving their power and mettle at the expense of the lowly bedside nurse.

I love the optimism of  naive, young whippersnapperns who think it's possible to come out of performance  evaluations with an honest assessment of how they are  doing on the floor. Nurse Buff even has a blog post titled, " 8 Ways to Knock Your Performance Evaluation Out of The Park." Maybe things are different today, but in my experience, the nurse is far more likely to get knocked out of the park in this  nursing administration world of bureaucratic incompetence and legendary bullspin. It's a no win ballgame.

 The fur licking, scratching and hissing so common in nursing office settings is  like a magnet for administrative minded  folks. I once received an evaluation that noted I had zero potential for administrative advancement and considered that a high complement. Sitting in an office with these other worldly creatures  would have been like a prison sentence for me. Not everyone wants to climb the so called ladder of success when it involves joining the ranks of administrators.

One of the inherent problems with nursing evaluations is that good patient care is simply not narratable. Long time bedside practitioners develop a 6th sense based on pure instinct. I've worked with nurses who could smell impending death and could assess blood pressure without a syphgmomanometer by applying variable pressure to the radial artery. Long time neuro nurses can actually visualize that pre seizure aura and take appropriate action to nip the convulsion in the bud.  A good bedside nurse is indescribable, but you know one when you see one in action.

The philosophical bifurcation between administrative nurse and bedside care giver is enhanced by the use of lexicon hijacked from the business world. Office sitters have loads of time on their hands for the black art of word play.  In the age of corporate driven medicine the use of high minded sounding goobledegook has flourished. We have phrases like poor time management, customer service, inappropriate consolidation of resources, best practices, building consensus, core competency, paradigm shift, mission critical, or matrix structure. Wow, talk about a tower of Babel.

Here are few of my time proven strategies for dealing with nursing performance evaluations. The first rule is to simply avoid any specialty or area that has a high density of nursing offices. The operating room was a perfect refuge from office sitting navel gazers and misfits. There were no nursing offices in the OR suite and supervisors, like my long time nemesis, Alice, rarely sat down. Her evaluations carried supreme weight and her theory was "If  you don't hear from me, you are doing a great job."

 It's also good job security to excel technically so that your services are valued by the surgeons. That way you have an advocate from the top of the hospital food chain to back you up when the inevitable hits the fan. My favorite general surgeon, Dr. Slambow would body slam just about anyone giving me the business. I had earned his respect through our late night meetings over some gosh awful trauma that we usually  managed to turn the tide on.

Demeanor counts big when on the receiving end of evaluations, so  never, ever, back someone into a corner who is meaner than you, and that accounts for 95% of nurse administrators. Practice this one in front of a mirror. Your facial expression should assume a beacon of baptismal innocence when the dreaded document is being reviewed. Take some measure of control over the situation by signing the blasted thing and making a hasty exit with a broad smile plastered all over your countenance. This is a game you cannot win. Simply grin and bear it then rapidly forget all about it.

If nursing abomination administration genuinely wanted to improve patient care they would provide units with adequate staffing, pay nurses a livable wage, acknowledge circadian rhythms when scheduling, and maintain supplies of equipment to get the job done. Evaluations are small potatoes when striving for better direct patient care.

Although, I've tried to limit my tales of personal woe, there is one evaluation experience that will always haunt me. I was hospitalized with the mother of all Crohn's disease exacerbations and had not been able to eat for weeks. Thankfully,  hyperalimentation was initiated and as I was surrounded by beeping monitors and several infusion pumps a cheery, young nurse popped up at my bedside with news that there was a piece of mail for me.

How nice I thought, some kindly person from work was sending me get well wishes. Upon opening the envelope, I was dumbfounded, it was my annual nursing performance evaluation sent by Helene, my head nurse. I guess she figured that I was never going to recover and return to work so she might as well get it over with. Nursing can be a cold business and, yes, I did return to work just to spite her.

LABELS

 This blog has always been filled with foolishness, it's the underlying theme and glue that holds everything together. Lately, much to my amazement, posts about my experiences at Downey VA Hospital have been the most widely read. Although my tenure at this long term psychiatric warehouse was but a brief snippet of my work as a nurse, it left me with some of the most profound memories of human suffering. The men from Downey were a memorable bunch and will always occupy a special place in my heart.

I felt it was unfair to those with an interest in life at Downey to peruse through a quagmire of other posts completely unrelated to Downey so I set up labels on blogger to categorize my ramblings. I started by categorizing the Downey posts and then got carried away and added some other groupings.  So if you want to see my 1970s paystubs documenting my meager nurse's  salary just view the label "remuneration." If you are curious about the demise of sluice rooms just call up hospital design. You can also learn why old school operating rooms were always on the top floor of the hospital.

I hope this labeling makes things easier for my treasured readers. The labels begin in the right column just below my profile.

Downey V.A. Hospital Was The Home of Polypharmacy and Megadoses

 

Desperate situations often produce less than optimum results. The patient population at Downey V.A. Hospital was an intractable bunch, tortured by some of the most severe psychopathology known to man. My first time passing medications was a real shocker as one pour soul was ordered 2000mg. of the potent major tranquilizer, Thorazine. Nursing school pharmacology taught me that a usual dose was 75-200mg of Thorazine. A ten fold dosage of 2 gms. was out of the ball park.

Another disturbing trend involved patients dosed with more than one major tranquilizer with some dispensed as many as four. When the V.A. administration discouraged megadoses, polyharmacy was haphazardly substituted. I don't know which practice was worse in fueling disabling side effects like tardive dyskinesia, polypharmacy or megadoses.

When I brought this up to our ward physician, Elihu Howland MD, he agreed that it was a less than desirable situation  and suggested that I do a study enumerating the problem and he would see what he could do. Good luck were his parting words which were uttered in a less than sincere manner.

I eagerly went to work and came up with the following.

There are a significant number of patients at Downey receiving  more than one antipsychotic drug or a witch's brew combination of these neuroleptics. Here on Building 66AB I found a patient receiving three different antipsychotic drugs with a PRN order for a fourth neuroleptic agent. This much chemical restraint could be as disabling as the underlying illness.

Many studies evaluating  polypharmacy under controlled conditions demonstrate that there is no effectiveness over monotherapy. There really is no basis in fact for the existence of polypharmacy as a treatment method nor empirical evidence for its continued use as an effective treatment modality. Additionally, polypharmacy creates an added risk, even a fatal outcome, from a combination of drugs with mutually additive effects. With polypharmacy it is nearly impossible to delineate which specific drug is the culprit inducing untoward side  effects.  Many articles conclude that single drugs are the treatment of choice over polypharmacy.

Furthurmore, a recent review clearly shows that  we have a number of patients on extremely high dosages of antipsychotics. Megadoses   seem related to poly pharmacy in that one poor option is often substituted for the other. When megadoses are discouraged, polypharmacy soon fills the void.

Megadoses indicate  we have a large group of chronic patients who have been receiving a very high dose for a long period of time and whose mental status has stabilized, yet no attempt has been made to reduce their dosage to the lowest effective maintenance level. This maintenance dosage should be as low as suitable for retaining therapeutic progress. Dosage should be gradually titrated down to avoid a sudden emergence of symptoms.

The notion of lowering doses is especially important when megadoses or high doses are ordered. The patient's symptoms , drug history, and general physical condition should be considered when the risk of megadoses is evaluated. The occurrence of side effects must be balanced the benefits in the chronic patient who continues to present psychotic symptoms endangering himself or nursing personnel.

Once control of target symptoms has achieved, the dosage must be be adjusted downward as most all patients could be maintained on a lower dosage level.

Perhaps we should start by eliminating polypharmacy and then carefully titrating down on some of the megadoses.

I submitted this report to Dr. Howland with a listing of the patients receiving polypharmacy and megadoses. While there was some success with reducing polypharmacy, there was much resistance to decreasing megadoses. The main argument was the patient was on these doses for a very long time so there was no rationale to decrease doses.

My frustrations working at Downey reached a boiling point a few months later when my head nurse recommended me for a grade promotion, but  it was rejected by the personnel office because I was 4 days shy of the time required in grade for promotion, but never fear, I could apply again next year.

I resigned from Downey V.A. on May 21, 1976 after working there 1 year, 5 months, and 28 days. It was a very long year and a half and made working in the OR seem like a walk in the park. I happily returned to my favorite stomping grounds in the O.R

Informed Consent Would Have Annulled This Vow!

 

                                                             A diploma school promise

Time Worn Adjuncts to Mechanical Ventilation - The Good, The Bad, The Ugly

 

Proning is the latest modality for augmenting ventilator 
therapy.  Some vintage measures were not so effective

Recognition of acute respiratory distress syndrome (ARDS) in the early 1970s and treatment with Engstrom ventilators was a game changer, with  mortality plunging from 100% to about 40%. As more experience was gained mortality plunged even further. Deducing what worked and what didn't with ventilators was a rocky road.

It's human nature that clinicians faced with an unstable, critically ill patient want to do everything possible to rescue the person. We referred to situations like this as kitchen sink medicine when just about anything and everything was added to the armamentarium. Sometimes, desperation in medicine results in untoward  outcomes. I'm thinking about radical mastectomies for all breast cancers and surgeries like hemipelvectomies. Some pioneering accompaniments to mechanical ventilation bore little fruit, and did little to avert a vegetative outcome, but just about anything seemed worth a try when the clinical situation seemed so bleak.

Early practitioners in the art of mechanical ventilation were not like the experienced critical care medicine experts of today, but surgeons and anesthetists who saw the benefit ventilators made with ARDS treatment. They were drafted into the new role of managing ventilators and much of what ensued was on the job training..  Science was sometimes, in short supply when empirically based notions were applied as we shall soon see.

Everyone takes in a deep breath from time to time, so why not try this with ventilated patients? It was fairly easy to adapt those ancient, chugging, Engstroms to deliver an occasional deep ventilation, all it took was some monkeying around with that gizmo on top of the Engstrom that looked like an expresso machine, and PRESTO, the "sigh" was invented. A sigh was an occasional cycle with increased tidal volume and the frequency was highly variable.

 Intermittent sighs were a source of dread for sedation deprived ventilator patients, imagine having a hurricane force of air, unpredictably, blasted into your chest via a skinny little tube.  A United airlines pilot recovering from pneumonia said, "Now I know what it's like to suck on an engine of a 747." Unpleasant does not begin to describe the patient experience when the sigh cycle kicked in.

Ventilator driven sighs never really caught on in the hospital where I worked.  Surgeons blamed the sigh cycle for putting undue stress on suture lines and in the event of a rare evisceration, the sigh was always blamed. The elevated intra thoracic pressure was also blamed for barotrauma to vulnerable alveoli. 

Positive end expiratory pressure or PEEP evolved to be the replacement for sighs. PEEP entailed maintaining a low steady pressure (5cm/H20) in the lungs just slightly above ambient atmospheric pressure. Some overzealous physicians figured that if a little bit of PEEP was good, then more is even better. Super PEEP was born with pressure of 25 cm and above which was like blowing an automotive tire up to 100psi. Talk about a rough ride!

Super PEEP worked for a time until complications surfaced. High intra thoracic pressure compromised blood flow in the great vessels which caused big problems. A hemodynamically unstable critically ill patient is not a good thing. Renal problems often developed as a result of compromised circulation. Super PEEP was not such a good idea, but did persist when technology for cardiac output monitoring was developed which enabled fine tuning to allay complications. The father of super PEEP at Montefiore Hospital in Pittsburgh was Arnold Sladen MD. He was either a hero or a scoundrel depending on who you talked to.

Endotracheal tubes exert a seal by an inflatable cuff which contacts and forms a seal with the trachea. Sustained pressure exerted by the cuff can limit the amount of time a patient can be maintained on the ventilator before an invasive tracheotomy must  be done. Long term unremitting pressure from the cuff can cause problems.   Intermittent endotracheal tube cuff inflation was thought to be a way a kinder gentler way of sealing an airway. The cuff was inflated only on inspiration.

Intermittent endotracheal cuff inflation required some complex additional equipment and lengthening the inflation tubing  increased dead space and exacerbated the  potential for  leaks. There was also the ever present risk of aspiration when the cuff was deflated. This overly complicated  modality was usually abandoned with much haste as it just didn't work very well.

There is that old joke about anesthetists passing gas, but in reality, they are passing gases. Fiddling around with the inspired mix of gases was second nature when novice anesthesia folks began overseeing ventilator therapy. Traces of helium mixed with the FiO2 were thought to aid in alveolar dispersion, but in the long run seemed to make little difference. 

Life on a ventilator was unpleasant at best. Before propofol came along, anesthetists would sometimes  "trace an agent," or install an in line vaporizer to sneak in a whiff of halothane to settle things like "bucking" down. Progress in IV sedation put a halt to anesthesia  vaporizers on ventilators except, of course, in the OR.

Ventilators are an unforgiving entity and that ominous click...hiss...pause  always overshadowed the cheerful cacophony of melodious alarm tones, quickly becoming  the dominant noxious noise in the ICU. Ventilators really strummed a different sort of tune that frequently foreshadowed impending doom.

In the rapidly gathering storm leading up to intubation and subsequent ventilation, impending consequences were often conveniently overlooked. Rendering someone mute with an endotracheal tube and lashing them to a machine forcefully converting air into breathe has all the grace of getting clobbered by a linebacker on steroids.

Late at night, numbed by fatigue induced hopelessness, strange thoughts percolated through my mind when caring for a poor soul on a ventilator. We all want a nice linear, progressive, and predictable path from illness to health. Sometimes, though, ventilator patients are too far along on their journey to the other side. If  I'm ever in this predicament, I hope my caregivers reconsider my path and don't interfere with my final journey.

When I'm on that peaceful river journey to the other side, I better not come across a ventilator masquerading as a life boat!