Corona Pandemic Hits the Nursing Culture Reset Button

A few days ago, I passed by a nearly empty hospital parking lot. The  ER entrance was backed up into the street with all sorts of emergency vehicles  so there was  no shortage of patients. Sirens screamed in the background and the place was hopping.

 The lonely vehicles present in the parking  lot were of the Ford Focus or Toyota Corolla permutation. It wasn't too hard to deduce where the BMWs and Infinitis  with  their nursing themed vanity license plates had gone. The self proclaimed  elite members of the nursing academic/administrative office sitter complex were holed up in their fancy abodes while a dedicated contingent of bedside nurses were slogging it out  in a challenging environment with a crude hodge-podge assemblage of personal protective equipment.

The righteousness of the busy body administrators at the top of the nursing administration pyramid looks especially iffy when lowly bedside nurses lack even the most basic equipment for safe patient care. Bedside nursing is a tough, often thankless undertaking and a lack of support from above for necessary equipment exacerbates the misery. Bedside nurses have a long history of facing insurmountable difficulties. Florence Nightengale lasted only 3 years at the bedside.

In years past, charity hospitals with no concern for personal financial gain were the  institutions that sanctioned and preserved nursing culture.  No patient was ever asked for an insurance card or copay. Everyone was welcome and eligible for care rendered out of kindness without a preoccupation with remuneration or the bottom line on a spread sheet. There was a strong feeling that we were all in it together for a greater good.

Money is the sand in the gearbox of healthcare today and the end result is a public health meltdown. Reimbursement for heroic, expensive  procedures without improvement in  patient outcomes grease the skids in hospitals of today. This one for all and all for one approach does not meet the needs of a population that  is threatened by a pandemic.

It's no wonder countries with readily available healthcare not dependent on an individual's wealth or yoked to employment  are doing so much better. You cannot buy your way out of a pandemic with profit centered care. In the land of the free and the home of the brave we do have the very best healthcare money can buy and it's proving to be lacking. Folks here are lucky if they can even get tested for corona virus.

Nursing is about to change and nobody is sure of the "how," but people in crisis help each other. Caring  for those near us begins widening the care net for others. Maybe the nurse office sitters will emerge from behind their computers and help others because it's the right thing to do. Experienced nurse "rockstars" will rejoin the band and help young nurses at the bedside instead of soaking   funds from a vulnerable group of nurslings for overpriced video courses. Nursing is not about being an Instagram influencer or money changing hands. It's about helping others without concern for self.

Just maybe the pandemic will  transform nurse entrepreneurialism  with it's  inner impulses geared for money grubbing and influencer prestige to more charitable  values delineating our nursing lives - duty and responsibility to our patients. Preoccupation with over indulgent, extravagant, nurse "self care" be damned. We were meant to suffer along with our patients. Oh..and  don't let me forget, sometimes at the hands of our patients.https://oldfoolrn.blogspot.com/2015/08/knock-out-punch.html

Smokeeters Cleared the Air at Downey VA Hospital

That coffin sized brown box hugging the ceiling of a Downey VA Hospital dayroom was one of the most indispensable elements of the therapeutic milleu; a Smokeeter. This machine droned on with an intestinal rumble as it digested hazy nicotine laden air and expelled a mountain fresh breeze from the opposing end. In with the bad-out with the good.

Downey VA Hospital dayrooms had a dismal aspect about them with bars on the windows and the walls reflecting a gloomy potatoe-y  noncolor with brown gravy like nicotine stains in just about every nook and cranny. Worst of all was the unbearable effluvium of cigarette smoke combined with the scent of men densely packed into a confined area. A palette rinse and sinus lavage was mandatory at the conclusion of a shift. The place just plain stunk.

 The lighting cast a yellowish pall over the entire unsavory mess reminding me of a Foley bag long overdue to be emptied. Smokeeters were an acknowledgement of the foul conditions and an inadequate intervention to remedy the situation, a microcosm of the mental health treatment system.

Serious mental illness does strange things to folks. Emotional channels become intricately wound together so they coagulate and strangle each other. Recreational chemicals like nicotine, alcohol, and caffeine are some how involved in the masking of the pain induced by nervous dysfunction. One of the mantras often heard on the ward was, "nicotine cuts thorazine." Patients truly believed in the therapeutic effects of smoking and would go to great lengths to ingest as much nicotine as possible.

Smokeeters worked by electrostatic precipitation and the nicotine that adhered to the electrodes in the device required daily flushing. In an addition to an electrical connection, Smokeeters required plumbing to provide a water supply for routine cleaning. This maintenance operation called for twisting open the supply valve and making sure the drainage line to a utility sink in the laundry room was patent for the final journey to the sanitary sewer system.. A kink in the drain resulted a most unpleasant blowback of the toxic brackish nicotine concentrated effluent.

Curiously, there was always a contingent of anxious, over eager patients volunteering to flush the Smokeeter. I soon discovered their strange motivation one evening  while making ward rounds. I was perplexed to see a patient whose entire upper torso was contorted into the depths of the utility sink where the foul liquid from the Smokeeter drained.

As I eased his head from the sink a syrupy brown exudate covered his lips. He had been guzzling  the foul drainage from the Smokeeter.  "What in the world are you doing?" I asked. With an ear to ear grin framed in the brown nicotine laden sludge he replied, "I'm drinking nectar from the nicotine gods courtesy of the Smokeeter.Try a swig-it's like smoking a whole carton of cigarettes in one drag. WOW..what a rush." I declined and made certain the laundry room was secure prior to flushing the Smokeeter.

Downey VA Hospital Presents the Communication Book

It's been quite some time since I've written anything about the long ago shuttered psychiatric facility known as Downey VA Hospital. I worked there 1974-76 and recently discovered an interesting old tome in my basement junk pile extensive nursing archives.

Every ward at Downey VA Hospital  maintained a communication book which consisted of random comments by just about anyone involved in direct patient care. Relevant notes of significant findings during multidisciplinary ward rounds were among the more important recordings. The book was also supposed to contain notes of meetings with nurse officesitters and assorted busybodies, but any staff member with an ounce of sense steered clear of these crazy conclaves as a matter of survival. There is very little in the way of notes about meetings.   When one volume was filled it was tossed in the trash and a new one started. It just so happened that I rescued one of these delightful digests  from the dumpster and will share a few choice entries with my loyal readers. The entries provide a brief snippet into the life on a Downey ward. Patient names are all pseudonyms.

Insulin shock therapy was one of the more barbaric treatments administered to inpatients at Downey VA. The patient was given a significant dose of regular insulin and allowed to descend into shock The following note by a resident offers a valuable tip to ward nurses.
.All ward nurses should carry a round or two of Lifsavers brand candy with them in the event they have a patient that is slow to respond from insulin shock therapy. Each piece of candy raises the blood sugar approximately 10mg/%.

Mason, Wm -  admitted to drinking a pint of vodka under the water tower. Return to locked ward.

Ayers, Bob - No longer feels homicidal. Was under the influence of drugs and alcohol when he attempted to assault a psychologist with a dagger. Intelligent with insight into problems.

Farna, Kyle - Attempted to break into father and step-mother's home while on pass. Family does not want him back.

Grounds crew workers are busy spreading used grease and oil from the motor pool over the barrier wall around the building in an attempt to deter elopements. If you see a patient covered in grease you know what he's been up to.

Night shift- Please see  that patients remove pajamas before dressing in the AM

The roofers were a bit overzealous with spreading hot tar above the "C" ward dayroom. A small amount leaked down and burned the head of  Ronald Alt. Patient sent to Bldg. 133 for medical evaluation.

Jack Ray caught guzzling from a bottle of William's 'Lectric Shave. speech slurred with unsteady gait.

Cockroaches the size of a small Shih Tzu are taking over the  "A" ward dorm. Please be more careful about screening patients for foodstuffs before retiring to bed. Several partially consumed HO HOs were found under Harry Vonsickel's bed.

Ressary, Jorveit- Eating from garbage cans again and Linda is missing a box of paper clips. Abdominal flat plate X-ray requested.

Note from a nurse detailed from the medical building to cover a last minute call out on night shift: Unsafe to be in attendance in this building at any time!

Glen Rimes bit Thomas Reynolds on the calf without provocation. Since this is his second serious bite will refer to dental service for full mouth extraction.

Carlton Searing needs an ENT consult. He has been impacting his ear canals with Thorazine 200mg. tablets in a futile attempt to "stop the voices."

There is more, but I suspect you have read enough. I hope this has been a brief distraction from the Corona virus horrors. This pandemic sure has me concerned for all the whippersnapperns out there in harms way. I think of you often and hope that you are staying safe.

April Fools

"Yikes..that's going to be a challenging intubation. Get her to a trauma bay!"

A pseudo zombie got a jump start on April fools day tomfoolery when she presented to a level one trauma center in Michigan. Professional dancer Jai Fears was in the process of having gruesome make- up applied for a grisly photo shoot and was overcome by an acute panic attack

Maybe the artisan who applied the cosmetics did such a good job that it scared the daylights out of  Jai or perhaps it was an allergic reaction. Over use of make-up is never a good idea.  At any rate, the autonomic storm it prompted was enough to send her to nearby Beaumont Hospital.

As she hit the entry doors to the ER the ever vigilant staff expedited her transfer to a nearby trauma bay. While rituals of ACLS alogorithims danced through their heads a cursory assessment left them flummoxed. Quickly pressing 2 fingers behind the mandible showed a nice regular pulse and an auscultation of her chest revealed the lovely muted swoosh of active gas exchange without rhonchi or rales.

As the apparent acuity of the victim rapidly vamoosed, the trauma team's unconsciously formed tableau dissipated  faster than a snowball on the 4th of July. The hollering that ensued from the trauma bay was not the typical shout out for life saving measures. A shriek more akin to that of an elderly matron who had just been scammed out of her monthly Social Security check reverberated about the trauma room. "My God," hollered the duped trauma surgeon. "It's all just make up."

In a public relations gambit the hospital released the following statement: The emergency room is not a place for fun and games. They see many patients with severe medical issues where lives are at stake. doctors and nurses need to be able to focus on those patients with true emergencies.

In a strange torque of therapeutics, I wonder if the young patient was cured of her panic attack by transferring her feelings to the trauma team.

Getting to the Bottom of the Tidal Wave Enema Story

The trinity of nursing care for big invasive abdominal surgeries included scultetus binders, Montgomery straps, and last, but certainly not least, tidal wave enemas. I briefly mentioned tidal wave enemas in a previous post and I received an email asking about the unsavory details of this backward procedure. I just love esoteric, little known nursing procedures and  nothing came up when I googled tidal wave colonics. So, an idea for this  post about this bowel ballooning buffoonery was born

Before the late 1960s enema administration apparatus consisted of a 2 liter metal can with a tapered spout at the bottom that mated with a 2-3 foot length of opaque rubber tubing. This tubing was connected to a nozzle that ranged  in size from a small straight length to a longer tapered instrument that resembled a bandicoot's snout. Small straight nozzles were useful in uncomplicated cases, but it was tough to beat a large tapered nozzle when retention problems caused unpleasant blow backs. Once a tapered nozzle was snugly ensconced within the leaky aperture, it tended to stay there, putting the brakes on the flustering back blow.

"The only tidal wave I wanna see better be in the ocean."

Rank had privilege in hospital  nursing and full fledged RNs had the benefit of an IV pole to suspend an enema can above their anxious patient awaiting the hydraulic highjinks. Student nurses were mandated to hand hold the enema can at the prescribed height; no easy feat with a fully loaded 2 liter can. That loaded can got heavy rather quickly unless you had the arm strength of Miss Bruiser, my favorite instructor.

 Enemas could be embarrassing for both patients and student nurses alike with Miss Bruiser's running commentary about our lack of arm strength. One of her favorite lines as we struggled with the heavy enema can was, "Is the responsibility of nursing care WEIGHING HEAVILY UPON YOU?" Of course it was and in more than one way.

The  transition to disposable enema sets with crystal clear tubing  illustrated  an interesting phenomenon. While struggling to hold the clear enema  bag airborne, an observant nurse noted the oscillation of the infused solution rising up and down with the patient's respirations. As the enema was nearing completion, expansion of the chest pressurized the colon causing the fluid level in the tubing to rise. Exhalation resulted in a marked descent of the fluid level.

Hand held enema bags and the graphic illustration of the  to and fro flow of the solution provided one of those rather profound "EUREKA" moments in nursing history. The tidal wave enema was born. Nurses soon discovered that any enema could be super charged, so to speak, by aggressively raising and lowering the enema bag while the solution was flowing in. Suddenly raising the enema bag to it's maximum height from a level which was sometimes below the patient produced dramatic results. Patients often complained bitterly of cramping during the peak of the tidal wave, but the end results were often impressive in restoring normal bowel function.

Peristalsis, the progressive wave like movement of the bowel was frequently brought to a halt by old school open abdominal surgeries. When the surgeon noted an absence of bowel sounds during the post -op period, action was required. An order for TWE was written. A plain old TWE order was for the run of the mill tap water enema. A TWE order  with wavy lines scribbled alongside was a directive to bring on the big guns of the tidal wave flush.

The proof was in the pudding with tidal wave enemas which worked wonders in restoring normal peristalsis. They really did the trick.

Wagensteen Suction - Elegantly Simple Without Electricity

. 
Wangensteen suction in action during the 1930s. The water level in the top bottle
drains by gravity into the lower bottle to the left generating negative pressure. 
A glass drinking straw inserted to the top of the top bottle conducts suction to the patient.

Whippersnapperns  don't give a second thought to the equipment  needed  to suction a patient. Intermittent Gomco, straight tracheal suction, or low pressure Wangensteen, just plug that suction  regulator into the handy dandy wall socket and go to town. Like everything else in today's high technology world, handy dandy wall suction is a convoluted, complex system masquerading as something  simple. Hospital  centralized suctions are anything but simple. Bright  young whippersnappern are  tapping into an over-engineered, overpriced  pipeline connected to hidden pumps, vacuum reservoirs, traps, filters, regulators, sensors, and alarms. I shudder to think of the resources required to maintain this complex hodge-podge of exorbitant  components.

There is an easier way to maintain GI  suction on  a post - op patient suffering from a paralytic ileus. I'm not talking about those plug in "portable" machines that weigh 1/2 as much as your patient. There are few pieces of medical equipment that generate a more annoying buzz saw  noise than portable suction machines. A bone saw in action might sound worse, but at least the patient does not hear it.

Electrified  suction machines in action remind  me of the time a yellow jacket flew inside my full coverage motorcycle helmet while cruising on Lake shore Drive. You can't turn off a buzzing suction machine when suction is necessary and you can't remove  a helmet in heavy traffic. Meanwhile that persistent  buzzing is driving  you  nuts.

In old diploma nursing schools, instructors like Miss Bruiser, my all time favorite, frequently said that we should learn how to do something "just in case."  Students were required to "learn" how to smoke cigarettes so we could better relate to psych patients. Other various hacks were part of the "just in case" curriculum like using sterile finger cots to perform procedures in the event we ran out of gloves.

We were also taught how to construct a do-it-yourself Wagensteen suction using 3 large glass bottles, rubber tubing and a glass drinking straw "just in case" of a power failure. Old hospitals had no backup power supplies.  The  principle underlying manual Wangensteen suction was Boyle's gas law which stated there was an inverse relationship between pressure and volume. As the water flowed out of the glass bottle on top, a negative pressure was created by the increase in size of the void within the bottle. A glass drinking straw inserted through a hole in the stopper served to harvest the vacuum created by the falling water

The clothesline pulley on top of 

the stand facilitated bottle exchange

There were a couple of ways to suspend one large glass water filled  bottle above another. The easiest way was to hang it  with a canvas sling suspended on the rail for the bedside curtain, but this required lifting the bottle on the floor when it had filled upon completion of a cycle. A big glass bottle filled with water requires the arm strength of Magilla Gorilla to heft back into position.

 A more elegant system involved a pole outfitted  with an ordinary clothesline pulley which according to my notes could be obtained at any hardware store. A length of rope about 7 feet long was attached to each bottle and threaded through the clothesline pulley  assembled at the top of the pole.When the bottles needed exchanged after draining, a nurse could swap their position  with a  not so gentle tug on the connecting rope. As the bottles made their up and down journey continuous suction was maintained as water continually drained from top to bottom. Dr. Owen Wangensteen, the inventor would have been most proud.

There is something to be said for simple devices cobbled together with a nurse's two hands. Wangensteen suction was a breakthrough discovery in the 1930s that reduced operative mortality from 44% to less than 20%. Owen Wagensteen should have received the Nobel Prize for medicine in 1931, but they gave it to someone who discovered an esoteric enzyme. Simple, silent devices like this suction engender those immersive, visceral feelings old nurses experienced from directly helping someone feel better even if the nurse  was too busy yanking on the clothesline to take a break for a Coke and a smoke.

The Disappearance of Needle Stylets

.

A thing of beauty is a joy forever. A stylet at home in the bevel of a needle

New fangled disposable injection needles with their cheap looking plastic syringes were just beginning to show up on wards at the beginning of my nursing journey. I just love that "journey" vernacular so common in today's healthcare lingo. See, I can talk just like a whippersnappern if I try really hard.  Anyhow, old school nurses had lots of laments about disposable equipment of any permutation because it  went against the grain. We were taught to reuse just about everything. Throwing away Monoject disposable syringes was bad, but the elimination of stylets was even worse.

Reusable injection needles always had a stylet running the length of the needle bore that terminated at the beveled business end of the needle. Whippersnapperns might start out their day by logging on to a computer, but their predecessors started out by sharpening injection needles. The stylet was a vital component to reusable needle maintenance and sharpening. Ramrodding a stylet through the needle served to clean the bore of any residual debris. When sharpening was completed the stylet served to clear the needle bore of any residual micro shards from the grinding process.

Stylets also served as a template to maintain the appropriate angle of the needle bevel during the sharpening operation. Minimalist minded nurses could sharpen a dulled needle on an ever present match book striker. Needle sharpening was one of those rare instances when a nurse was off her feet and the matchbook was a cue for a quick smoke. Smoking and sharpening needles went together like peanut butter and jelly. Mechanical devices for needle sharpening were most commonly hand cranked gizmos where the bevel of the needle was rocked back and forth by a cam while pressed against a rotating wheel all the while an indwelling stylet maintained the bevel angle.

Every nurse's station needs a needle sharpener

Biopsy needles with their very shallow bevel always have a stylet as a stiffening mechanism and as a control over the cored tissue sample. When sampling liver tissue from an obese patient the stylet is left fully engaged during it's journey (oops..here I go again with that "J" word) through the subcutaneous tissue. When the final liver destination is reached the stylus is withdrawn to snatch a core of tissue. Stylets are also needed to expel the cored tissue from the biopsy needle.

When performing spinal taps or removing fluid from a body cavity, the stylet is also necessary to control the flow of fluid. No stop cock can halt the flow of fluid through the lumen of a needle like a trusty stylet.

Inventive nurses discovered that stylets have  unintended uses that have loads of utility. When the hinge screw mysteriously disappeared  from my ever present eyeglasses a quick fix was needed. I discovered that a stylet from an 18 gauge needle was the perfect diameter to fit the void left by the missing screw. With the stylet in place, it was a simple matter to bend it in the shape of a horseshoe with a needle holder. A perfect fix. It was also common knowledge that a stylet was the perfect instrument to pierce ear lobes for those nurses that liked to decorate themselves with earrings.

It's nice to know that stylets have survived into the present age with spinal tap and biopsy needles, but once upon a time every needle worth it's jab had a stylet.