Happy New Year

May the absolute delight, joy, and sense of accomplishment we experienced at our capping ceremony be with all those toiling at the patient's bedside in the New Year.  I hope you receive rewards that far exceed any monetary consideration. As an aging scrub nurse, I would give up anything I own just to scrub with Dr. Oddo one more time. It would be an added bonus to receive one of his tongue lashings even if the precipitating event was not my fault.  At the end of a difficult case we were always the best of friends and I miss him often.     Happy New Year and may your memories be pleasant.

Santa Brings Dr. Oddo a Polavision Outfit

Edwin Land, CEO of Polaroid Corporation with his most technologically advanced product, the Polavision film movie camera and processor/viewer which looks like a small TV. circa1976

Dr. Oddo, Chicago's internationally known neurosurgeon and my favorite person to scrub with bounced into the operating room a couple of days after Christmas ecstatically announcing his latest Christmas present. It was a Polavision film movie camera with a viewer that processed the film immediately after it was shot. This enabled someone to view the movie shortly after it was shot. A filmed based substitute for digital recording.  It was his notion that the circulating nurse could document the key elements of some of his procedures to show off educate the neuro residents.

Shortly after  Polavision was introduced, Sony came out with the Betamax. Polavision was less expensive and more compact than the bulky Betamax. The Betamax held some key advantages, Polavision film ran for 3 minutes, the digital Betamax went for an hour. Betamax had sound while Polavision was silent. Initially, it looked like there would be decent competition between the two products. Dr. Oddo always liked to be on the cutting edge of technology, but over time digital killed film.  Polavison was a really advanced technology for the times and Polaroid spent a small fortune in R&D cost.

Polaroid then spent millions on advertising even enlisting famed photographer Ansel Adams to shoot movies with Polavision, Yoko Ono and John Lennon shot home movies of their son with Polavision. In the end not enough of the product was sold to cover development cost. Polavision was sold only a couple of years at a retail cost of about $700. The price might have been affordable to a neurosurgeon but that amount of money represented my monthly take home pay. I was not about to run out and buy one. This product was the beginning of a long downward spiral for Polaroid.

Polavision may have succeeded if it had been introduced decades earlier. It was introduced too close to the emergence of digital recording. Kodak came out with digital 8mm cameras later and the Polavision era had ended. Film for the Polavision system was even discontinued. Dr. Oddo cajoled us into filming some aspects of his surgeries for a couple of months and then lost interest with the arrival of a Betamax system. The hospital even hired an audiovisual aide to run the machine. That was the end of film.

The whole Polavision got me to thinking about technologies that were regarded as high tech, but now appear very crude. The first procedure that came to mind was the pneumoencephlogram which was invented by the famous neurosurgeon, Walter Dandy at Johns Hopkins. The patient underwent a spinal tap where CSF was withdrawn and air injected. The patient was the secured to a chair that moved 360 degress in a vertical and horizontal axis. Film X-rays were made as the chair was rotated and the air bubble moved around between skull and brain. This was a brutal diagnostic test bordering on torture and about the only thing it did well was diagnose menengiomas. Thank god for CT and MRI scans.

I think another contemporary diagnostic measure where the technology got ahead of the knowledge is with PSA testing. The sensitive test was very good at identifying prostate lesions that were best left alone and not so great at identifying appropriate candidates for surgery. Add the Davinci robotic surgery device to the mix and you really have to question if this is a triumph of technology. I am sure their are great anecdotal accounts of miraculous robotic surgeries, but are their any studies that support robotic surgery? I think this robotic surgery thing is another example of the marketing hype exceeding the benefit. I'm certain hospitals must recruit a good number of patients just to cover maintenance cost.

I wonder if electronic medical records are another Polavision in the making. The development cost had to be huge and the system cannot even communicate between different healthcare systems. When I visit my MD he has been converted into a data entry clerk. Heck even proud bedside nurses now have their heads buried in a computer screen and there is even an animal called a nurse infomaniac or is it infomatics. These people will be the Polavisions of the future. If you are not a physician or nurse directly caring for a patient it will someday be time to get off the bus. When the healthcare bubble pops those doing indirect care will be the first to go. The administrative cost in today's healthcare is obscene.

I better stop this nonsense before I get carried away. For people caring for patients, I hope the New Year rewards you with a true sense of personal fulfilment and peace. The only thing that makes me feel good about healthcare is the notion that I might have helped a few people over the years. Don't let the business of corporate healthcare rob you of that personal satisfaction of helping others during their most vulnerable time. When you get old that's all that really matters.

A Christmas Trauma Tale

In the early 1970's, Chicago's Lakeview neighborhood was home to a couple of
rival teen gangs, the Aristocrats and  Latin Kings. Luckily, for local residents, their gang culture viewed firearms as not cool or macho. Gang fights usually resulted in knife inflicted trauma of varying levels of acuity. If a gang member could walk away from a knife fight, they would often go home and attempt to sleep it off as one would do with a hangover. The end result was an emergency room visit the next day when the sleeping it off routine failed. I was always mystified by the thought process behind the "sleeping it off routine."

Stab wounds were a fairly common trauma at our hospital. These wounds could really be deceptive because once the blade of the knife was withdrawn, the skin retracted and something minor in appearance could hide serious injury. Single edged knives caused the least trauma because they would push bowel and organs  away from the blade as they were inserted. Double edged blades caused more trauma because they perforated rather than pushed structures out of the way.

When these young gang members were anesthetized and on the OR table they presented a sad picture. It was then that it sunk in. These were just children, little kids caught up in an urban nightmare. They looked so menacing on the street and so vulnerable lying on the table. I used to feel really bad for them.

I was on call, Christmas Day 1974 when the phone rang in the call room. We were getting a case. It was a 15 year old gang member, Sam that had been stabbed in the abdomen on Christmas Eve. He tried sleeping it off, but by Christmas morning the pain was so severe he reported to the ER. After a cursory exam in the ER, it was off to the OR to patch  up Sam's abdomen.

I would be working with Dr. Slambow one of my favorite surgeons. He liked to make scrub nurses feel important by asking them what kind of suture to use and really getting them engaged. He opened up Sam's abdomen and began exploring, everything was pretty much intact and without major organ or vascular damage. He meticulously sutured several stab wounds in the small bowel and then engaged the scrub nurse by asking me to return the section of small bowel to the abdomen. He even taught us how to follow along the small bowel to find the cecum. I was always amazed at how slippery and difficult it was to handle bowel.  The abdominal organs always felt so fragile like a glob of jello and pushing the bowel back into the wound always reminded me of when I worked as a grocery bagger as a teen. When I thought of the abdomen as a paper bag filled with gobs of Jello, it made me realize how fragile we all are. We did one final irrigation of Sam's abdomen and Dr. Slambow closed. It was an uneventful and straightforward case which ended well.

A few days after Sam's surgery Dr. Slambow approached me and suggested I visit Sam on the ward because he was such a pleasant youngster. I had never visited a post-op patient and was hesitant, but Dr. Slambow was insistent.

Sam was in a 4 bed ward and sitting up in bed when I approached. I explained who I was and he was profoundly grateful. He thanked me profusely for helping him and we began chatting. I mentioned to him that I was sometimes fearful walking the 1/2 block distance to the hospital from my apartment. There was an area under the elevated tracks that had an abandoned old station wagon which was overturned. It was heavily tagged with the Aristocrats circled  "A" symbol. Sam told me the station wagon was on of the Aristocrats favorite haunts, but that I had nothing to worry about.

Months went by and my thoughts of Sam had subsided. One Spring evening I was walking to the hospital at about 11:00PM. As I approached the junk car under the elevated tracks a shadowy figure poked his head out from behind the rear fender of the rusted hulk and offered a friendly salute. It was Sam guarding my way on the walk to the hospital late at night. Keeping me safe.

Christmas tales like this reflect something meaningful about the season. Two people helping each other with whatever resources they had available.  Merry Christmas and if you are working in a hospital this holiday season, I think you are doing something very special.

In Cold Blood - The GE Monitor Top Refrigerator

The monitor top - just look at it - scarcely bigger than a hat box - yet one of the most amazing - one of the most revolutionary triumphs of modern engineering.  (From a GE magazine ad)

We had one of these old classic refrigerators that met all the refrigeration needs of our suite of operating rooms. It was centrally located in an alcove in the middle of the hall just past the ENT room. I vividly remember the label on the front that proudly proclaimed "General Electric Refrigerating Machine."  The door made a solid click - clunk when the spring loaded latch engaged. When the compressor ran it purred like a kitten.

We kept surgical specimens in the bottom section of the monitor top. It did not have crisper doors like a modern refrigerator, just a wire shelf. The two shelves above the specimens held our lunches and the blood products for the scheduled cases. If  there was a big case in the afternoon that required blood, someone made a trip to the blood bank after lunch.

When I first started working in the operating room, it kind of creeped me out, eating my lunch after sorting through a bunch of blood bags. It seemed like something a vampire might enjoy. The older nurses did not give the comingling of blood and lunch a second thought, so I soon learned to ignore the uncomfortable feelings.

A second advantage of using a monitor top refrigerator for a blood storage unit is the availability of a blood warmer. You can say goodbye to those messy warm water baths. Just stack the blood bags on the condenser monitor top. It takes about 40 minutes to warm up to the right temperature.

One of the unique things about the combined blood storage and lunchbox refrigerator was that you never had to worry about someone stealing your lunch. I think that the time it took to sort through the blood bags to find your lunch reduced the temptation to steal. The presence of a diseased gall bladder lying on the bottom shelf of the refrigerator probably served to spoil the appetite of a would be thief.

I don't know where our old blood storage unit/lunch refrigerator is today, but I suspect it might still be in operation. They built these things to last. I doubt that with all the regulatory oversight, you could get away with using a GE monitor top refrigerator for blood storage. It's probably also frowned on to comingle a ham sandwich with banked blood.

Old school rules for patient care

Never ever give ice water to a cardiac patient. This triggers a vagal response resulting in life threatening arrhythmias.

Never allow a patient on Coumadin to use a standard razor. An electric shaver must be used to prevent exsanguination.

The open end of all pillow cases must face away from the entry door to the room. On wards, the open end of pillow cases must face away from the window.

A patient could not get out of bed (OOB) to use the bathroom without a BRP (Bathroom privilege order.) This one really bothered me. Since when is going to the bathroom a privilege?

If the patient vomited on a dietary tray, nursing service must clean it up. This rule was especially unfair since it was probably the food that triggered the emesis.

Our neuro OR had  big notice on the door: "NO TALKING OR LAUGHING  NEUROSURGERY IN PROGRESS."  I guess I will have to stroll down to the heart room before busting a gut.

Patients with abcesses or infections were in a special classification - Contaminated Case which had all sorts of special rules such as being scheduled at night after all other cases were done, everything that exited  the room except the patient double bagged, and scrubbing the tile walls upon conclusion of the case with some sort of toxic witches brew of disinfectant.

After finishing a case in the OR all instruments must be returned to Central Supply unratcheted. If you really wanted to get a rise out of the old geezers in Central Supply, return a knife handle with the blade attached. Witnessing an old battle hardened nurse moving toward you at the speed of light with a knife in her hand is very frightening.

The grounding plate for the Bovie must be placed exactly in the center of a patient's buttocks. This rule caused much animated discussion and and arguing about gluteal anatomy. The grounding plate was the size of a cookie sheet and the best strategy was to place it on the table prior to the patient's transfer from the Gurney. I always thought this must be a really bad pre-induction experience for the patient. Imagine being frightened by the strange environment complete with scary, sharp metal objects and then being plopped onto a cold metal plate all gooey with conducting gel. YIKES and OOW that's cold.

The circulating nurse must be at the patient's side during induction even if there is nothing for her to do.

Use only a glass syringe to administer that Paraldehyde and make sure the  number on the syringe barrel matches the number on the syringe because  old syringes were not interchangeable. Don't you just love that Paraldehyde-Paregoric-coffee ground emesis smell on the alcohol detox ward. It was a great deterrent  when the urge to imbibe struck. "I think I'd just like a Coke tonight. That  Paraldehyde smell is imbedded in my nostrils."

I am certain there are many more, but I seem to be having one of my brain freezes. Don't forget to hold that cold water when caring for a cardiac patient!

How do you cook a Thanksgiving turkey in an autoclave?

Wow! one of those high end double ovens autoclaves and check out the size of that roasting pan.

Sometimes a confluence of events come together  (How is that for some foolish double talk?)  and the end result is both unexpected and spectacular. We were on call Thanksgiving Day and just received a hot tip from the medical center  switchboard  operator. The hospital administration was giving out free turkeys as a good will offering to all on duty nurses. I suspect they had incorrectly estimated the low holiday census and were just trying to get rid of them.

Dr. Clobber, the on call anesthesia  resident ordered me to head on down to the hospital dietary department and collect on our free turkey. "Don't ever look a gift turkey in the beak," he replied with his typical smug, all-knowing  expression whenever he had an epiphany. "We're going to have turkey for dinner tonight!" Thanksgiving was usually a good holiday to be in the hospital for call as there was not as much surgical trauma  or  mayhem as say New Years Eve.  There were always 2 nurses and an anesthesia and surgical resident in the OR suite for call. If we were not busy, foolishness was frequently forthcoming if we were not busy.

Back in the day we did not have a lot of regulatory agencies breathing down our necks telling us do this or don't do that. I do not know how you whippersnapperns function with preceptors, infection controllers, nurse infomaniacs, and assorted clinical whiz kids breathing down your neck all the time. I could never be a nurse today. We had much more latitude with what we could get away with clinical practice back in the day. The point is, I doubt you could get away with foolishness like this today, so unless you have an old unused autoclave and some time away from regulatory snoopers, don't try it.

We had an old operating room that dated to the 1930's at the very end of the corridor. We never used it and it was more or less a museum (there was an actual observation deck) and it basically functioned as a store room. It did have a vintage functioning autoclave permanently built into the wall. This  steamy  hissing beast was one massive piece of equipment that was one of the more impressive products of the Industrial Revolution. The bankvault-like door was anchored by 8 massive spokes that reminded me of the configuration of a radial airplane engine with the giant wheel to open it, the propellor.

There were no electronics to control or monitor this hulking steam fired behemoth. You had to eyeball the pressure gauge to make sure it read "0" before cranking open the door with that massive wheel. There were no safety interlocks and if you wanted to be the first scrub nurse on the moon, just open that door up under full pressure. Look out Neal Armstrong here I come!

When I returned to the OR suite with my prized gobbler, Dr. Clobber  whipped out his ever present slide rule (no calculators) and asked me the weight of the turkey (about 9  kg.)  and some other data about the autoclave in the old OR room. We test fired the old autoclave and it fired right up with that impressive belch of steam. No bothersome preheating with this baby!  It worked like new. We just had to be careful to remember the correct autoclave door opening sequence. Our newer ones were all equipped with safety interlocks and modern safety devices like pressure relief valves.

After some frenzied slide rule calculations, Dr. Clobber said to fetch an instrument tray and place the turkey in the roaster instrument tray.  Next, proceed to the old  autoclave and run it for a 20 minute cycle. We tied the gobblers legs together with autoclave tape more or less out of force of habit.  We figured it would function as well as one of those pop-up gizmos. After the 20 minute cycle we popped the autoclave door open to the most delightful aroma of turkey I have ever experienced. Betty Crocker would have been impressed.  The turkey was moist and delightful and made for a most memorable on-call experience.

The only improvement to the cooking procedure would be to stuff  turkey's cavity with some ABD pads to prevent the bird from collapsing under all that pressure. It kind of resembled road kill after the autoclave pressure smashed the bird's thorax into it's spine. The squishing of the bird was only an aesthetic issue and it in no way impaired the delicious, tender meat that we all enjoyed. I don't know if  using actual bread stuffing would work with this cooking method, but we did not have any, so it's a moot point. I would be concerned  with the collapse of the bird, bread stuffing might get squirted out into the autoclave making a big mess.

They say imitation is the most sincere form of flattery and I was astounded during a recent outing to Kohls. There in the kitchen department was a Wolfgang Puck pressurized oven. They copied our autoclave cooking technique  cooking technique to a "T." Although much smaller in scale, the basic formula  looks to be the same.  Heat + pressure = delicious turkey.

In an upcoming post, I am going to investigate the feasibility of sterilizing a minor surgical instrument set-up in the Wolfgang Puck pressure oven. Just like our old autoclave, I suspect it could be a dual purpose machine. Just what the busy surgical center of the new millennium needs, sterilize instruments in the morning and cook your lunch between cases later on.

I am very thankful for all of you who indulge me in  these foolish ramblings. Happy Thanksgiving.  I know as I enjoy the holiday, I will reflect back on those old days when we autoclaved that turkey. It was an unexpected treat and really was delicious.

What makes a scrub nurse cough?

As a youngster I was troubled by a serious dental problem having  teeth twisted this way and that way. Two teeth were extracted to make more room, and then braces worked well to straighten things up. As a young adult, I still had orthodontic bands on my back molars to pull them back into position with small rubber bands. The bands were attached by small hooks on the buccal  (I learned that cool term for cheek from an oral surgery fellow)  aspect of the molar. The only time I removed the rubber bands was for eating.

I was scrubbed on a long case with my favorite neurosurgeon, Dr. Oddo, and was getting distracted by a full bladder. I really needed to pee. As visions of a beautiful white toilet danced in my head, I must have opened my mouth in a weird way and one of the orthodontic bands popped off.

Before I could even process what was happening, it ricocheted off a tonsil and sailed down my trachea. My concern with having to void was overshadowed by a string of violent coughs. Dr. Oddo asked with  concern, "Are you OK."  "Yes,"  I lied in a feeble restrained voice as I tried to  stifle the cough.  I managed to hold it together until the end of the case. I was coughing like a TB patient as I ran to the bathroom.

Dr. Oddo was there when I exited from the bathroom and showing genuine concern, wanted to know what was wrong. I explained to him what happened and he immediately consulted a nearby thoracic surgeon.  After a cursory look he suggested a quick bronchoscopy.  Any time a neurosurgeon is concerned about your health, you are probably in deep trouble.

Dr. Clobber, an anesthesia resident, I knew well from being on call with wanted to have a go at the rubber band with a laryngoscope and a Magill forceps. That sounded better than a bronch  and he had a bottle of Cetacaine on the ready to numb up my throat. I was skeptical  of this and asked him, "What if you blast that rubber band further down the trachea with the Cetacaine spray? "Good point, I never thought of that," he replied.

By this time a crowd with expertise in just about every surgical specialty had gathered. I was really more nervous about the gathering gang of surgeons than the stray rubber band. Somewhere from the back of the gaggle of surgeons came the voice of reason. "Have that fool suspend his upper torso over the table for some postural drainage."

I suspended myself upside down over the side of a table and after several minutes the rubber band slid out by gravity. I came away from this experience with  two lessons. The simple, staightforward,  approach to a problem is best and never wear orthodontic rubber bands in the OR, especially when you really have to pee.