Downey VA Hospital in the News

I was really surprised by the number of people that read my post about "Downey VA Hospital a Lost Empire." I thought that Downey had probably disappeared for good and that there would be little interest. I was going through my collection of old nursing junk memorabilia and lo and behold I came across some yellowed newspaper clippings about assorted trials and tribulations at Downey. As you can see bad press about the VA is not just a recent phenomenon.

From the Suburban Trib May 12, 1975:
The FBI has begin an investigation into the operation of Downey Veterans Hospital. The Suburban Trib learned of the FBI investigation on the heels of an announcement that the General accounting Office was studying the administration of the hospital at Buckley and Green Bay Roads.

Sources will nor specify what FBI agents are studying, except to say the probe is in the initial stages.

F.E. Gathmann, acting Downey Director, said Tuesday that he was not aware of any FBI investigation other than into the murder last month of a 45 year old patient found stabbed at the hospital. A 17 year old Waukeegan IL youth was charged with the murder.

The hospital has recently been embroiled in controversy. John Reeves, a cook at the hospital and president of Local 2017 of  The American Federation of Government Employees, recently charged that former Downey director was transferred because he stepped o too many toes trying to convince the VA to fire incompetent employees.

Reeves has also charged that:
There has been mismanagement of funds at the hospital.
Drugs used in treatment programs are missing.
More attention is being paid to the needs of the Chicago Medical School  formerly  at 2020 Ogden Ave., Chicago than to patients.
Hospital employees have been threatened with reprisals for making public concerns about patient care.


I am not sure of the exact date of the next one, but I think it was from a local newspaper, the Independent Register. Perhaps a bit later than the previous article

Downey Veterans Hospital in North Chicago has launched an investigation into why 7 psychiatric patients took their own lives during the last 11 months.

Hospital administrators told the Independent Register the "suicide rate at Downey is no greater than at like institutions around the country, but what disturbs me is what we can do to spot the potential suicide and stop him before it is too late."

Administrators, who promised a report in two weeks, took action following Lake County Coroner Oscar Lind's charge of lax security at the hospital. Those who died were:

Robert King, 51 a patient who leaped from a 3rd floor window.
Thomas Azzano, 26 a patient who stepped in front of a Northwestern train in North Chicago.
Robert Horwitz, 40, a VA patient who stepped in front of of a train.
Michael O'Mera, 37, a resident patient who jumped in front of a train.
Allen Hamburg,37, a resident patient who committed suicide on the same spot he saw O'Mera die.
James Caba 57, who leaped to his death from atop the hospital water tower.
James Zvala,27, who committed suicide by a medication overdose.

Lind expressed his concern for increased security at the hospital and with the number of pills some of the patients had in their possession at the time of their deaths. "From our investigation...and results we believe this must be negligence," Lind said.


This is from a Chicago Tribune Column from October 29, 1976 by Jeff Lyon called: "The Law on Insanity-Time for its own Trial?"

There is a paradox here.
Wednesday night, security guard Sam Valenti,66 was killed in his cargo-gate guardhouse at O'Hare Airport. He was beaten and stomped so much that his face was caved in. His nose was nearly cut off with a pocket knife.

Police arrested a man outside the guardhouse. they said he was singing when they found him. He told them Valenti had refused to page an airport employee for him and explained his own gashes by saying  he had slipped on Valenti's blood and fell thorough a window.

The man was a former Chicago fireman and Golden Gloves boxing champion James O'Malley, 55. He was indicted for murder before in 1972.

On New Years Day that year, James O'Malley walked into a pizzeria and shot a stranger to death. Moments before he had pistol whipped another man who offered to help move his stalled car. shortly afterwards, O'Malley was found incompetent to stand trial. He would not understand the charges or cooperate with his attorney. He was remanded to the Illinois Department of Mental Health for treatment. Last year he was at last pronounced able to face trial.

During the trial psychiatric testimony was brought before Circuit Judge Romiti: O'Malley had been "schizophrenic," "delusional" at the time of the murder. He had been hearing voices. judge Romiti did what he had to do. He found O'Malley not guilty by reason of insanity. But he also found him in need of further treatment and sent him back to the DMH, apparently confident that mental health authorities would do what they had to do. And that simply, would be to keep n mind O'Malley's past violence and make sure he was well before he was released. That is where Judge Romiti was wrong.

O'Malley spent 22 days at Manteno State Hospital before he was sent to Downey Veterans Administration Hospital on April 21. Downey discharged him on May 26 ruling he could function in society. For nearly five months he did. Until the explosion in Sam Valenti's  guardhouse.

Valenti did not have much time to think much about the aw before being fatally beaten. The law says that if a man is unfit to stand trial, the courts retain jurisdiction. Once he comes to trial, after treatment, he is likely to be found innocent by reason of insanity. That means he is not guilty. It does not mean he is sane. but that's when the courts lose jurisdiction over him; psychiatrists not judges can decide when he returns to society.

The judge can scream as loud as he wants. If Downey VA says he goes out, he goes out.

I had n interesting chat with Marjorie Quant, Administrator at the Downey VA Hospital. Miss Quant said a treatment team of doctors, nurses, social workers, and the like deemed O'Malley ready to be set free. She said she could not reveal what  their reasons were, because of the Federal Privacy Act.

But she said, "I think we followed our normal procedure here. If  you're assuming there was an error here, that would not be correct." When they released O'Malley, did they take into account that he had committed a murder?  "I'm assuming something to that effect would have appeared in the medical history," she said.

Wouldn't that have made a difference? "What made a difference was his medical condition at the time...A patient is discharged only if it is determined he is well enough to live in society. If he is well enough to go home, he has the same rights as anyone else."

Judge Romiti declared Thursday that "you don't just put a bombshell back on the street." DA Bernard Carey called O'Malley's release "outrageous."  There are those who might even call releasing O'Malley from Downey something else. They might call it insane.

Downey VA Hospital Implements the One Bite Rule

As  you age, events from the past that seemed like an acceptable practice when viewed through the eyes of a youngster come back to haunt you. The event I will be describing seemed like an unusual but acceptable practice when I was a young nurse. Now it just creeps me out and seems cruel and indefensible..

At Downey VA Hospital in the early 1970's there was an expression that said; "The right way...The wrong way...The Downey way."  Downey was an 1800 bed long term psychiatric facility that was the lifelong home for people with serious mental illness.

One of the problems encountered at Downey was patient assaults. Patient to patient - Patient to staff- and patient to civilian (usually innocent visitors.) These assaults were so common that the administration had a form letter prepared for the victims. I don't have a copy, but the essence of it was that Downey was unpredictable, the assault was not a deliberate action, preventive actions are not always successful (no kidding), and we hope you have a speedy recovery. It also went on to state that only a small minority of Downey patients were assaultive which was true.

There were 2 categories of special observation at Downey, Suicidal and Homicidal. For suicidal observation, the patient was always within eyesight and never more than 8 feet distant. You never turned your back on a homicidal patient and tried to keep a physical object like a desk or dresser between you and the patient. A good pair of running shoes was a prudent choice.

We used to have practice  drills using a mattress as a type of shield to corner an assaultive patient and then upon utterance of a previously  agreed code word, have 4 people grab an extremity and transport the patient to a seclusion room where leather restraints were used.


The variety of weapons used in these assaults was unimaginable. I have seen pool balls hurled at such a velocity that they actually chipped brick walls and pool cues used as bats and skewers. The triangular device for racking the pool balls could be forced over a hapless  victims head and used as a collar.

 Ping pong was supposed to be a safe replacement for pool, but I never thought that an ENT consult would be required to remove a ping pong ball from some poor soul's sinuses. What ping pong paddles lacked in mass could be made up by swinging them at a velocity that was probably greater than the speed of sound. I swear, sometimes you could hear the victim scream before the smack of the paddle striking their head.

Another type of assault at Downey was biting. Ears, fingers, arms were all areas prone to receiving human bites. One psychopath actually sharpened his front incisors with a fingernail file and then strutted around smiling menacingly at potential victims. This type of assault was aggressively dealt with at Downey VA.

CAUTION: The one bite rule is being aggressively enforced.

It was widely known that there was a one bite rule in effect at Downey. Whenever anyone received a bite the assaultive patient was told that if this occurred again, all of his teeth would be extracted. There were no appeals or consent, the second bite triggered a full mouth extraction.  This crude, but effective strategy did work. Pulling the teeth worked like removing the bullet from a gun. Not only were the sharp injury producing teeth absent, but the distance the mandible had to move to inflict  a bite  was increased. The increased mandibular travel greatly decreased the pressure of the bite.  I heard one edentulous, assaultive, biting  patient threaten to "gum the hell out of you," but was never able to seriously hurt anyone by gumming.

The patients teeth were extracted in the operating room under general anesthesia. A naso-tracheal intubation was done  which provided anesthesia residents a chance to use Magill forceps. The throat was packed and all teeth were removed. It seemed like a reasonable idea at the time, but now seems barbaric to me.

There was one patient named, "Alfred" who must have been very difficult to deal with. He had both a lobotomy and full mouth extraction done. His hands were in constant pill-rolling motions caused by the Parkinson's induced antipsychotics. I can still visualize his toothless mask like face as he walked up to my med cart for his 2000mg. Thorazine  HS  dose. When I questioned the dose, I was told he had been on it for many years so don't skimp on it. Senior nurses always advised to add a little extra of the Thorazine Concentrate because, "Some of it always sticks to the medicine cup."  I declined.

The treatment of mentally ill patients always bothered me. It would be nice to think that mental health care has improved, but when you consider prisons and jails have become the default provider of mental health services, it's questionable.

Any thoughts?




One Flew Over the Cuckoo's Nest comes to Roost at Downey VA Hospital

Cuckoo's Nest Nurse Ratched on the silver screen at Downey VA

Downey VA Hospital, the 1600 bed psychiatric warehouse hospital in North Chicago, Illinois had it's very own movie theater showing first run movies that had been carefully screened by an assortment of know-it-all, busy body administrators. Disney Movies, feel-good musicals  and an assortment of cartoons were the typical fodder. Someone must have been asleep at the switch in the movie review detail  because one afternoon the head nurse approached me with an agitated look about her. "Can you believe it..One Flew Over the Cuckoo's Nest is being shown this afternoon at the theater on base." Hmm..I began thinking it might be an adventure to escort a group of our locked ward patients over to view this movie.

One Flew Over the Cuckoo's Nest, based on a Ken Kesey novel, was a movie filmed on the back wards of an Oregon State  Hospital for the Insane.  It featured a down right despicable Nurse Ratched character that was domineering and abusive to her patients. She controlled everything on the ward from the TV to determining candidates for lobotomy. The scenes of the patients' on the ward was a spitting image of Building 66AB at Downey where I was working. Downey nurses, for the most part, were too burned out to dominate anyone. The modus operandi was just getting by until that Civil Service Retirement kicked in. There were no Nurse Ratcheds at Downey.

Downey had a rule that any closed ward group of  patients must be accompanied by an RN on outings. I made it my personal mission to get these guys off that smoke filled, depressing  ward as much as possible and organized walks, picnics, and even ball games. So when I heard about Cuckoos Nest  being shown on movie night, I figured, what the heck? These guys are just about living the movie and I was curious how they would respond. I strolled onto the ward after supper and called out, "Movie night, who wants to go?"

Two dozen or so of the patients stepped up and we walked over to the theater. Sometime movies elicited shouting and bouts of unrestrained laughter, but during Cuckoo's Nest there was a strange silence from the crowd. The experience of sitting in a long term psychiatric hospital watching a movie filmed in such a location reminded me of watching a war movie in the middle of an active battlefield. Today one of the most overused words that pops up in contemporary banter is surreal.

Watching Cuckoo's nest at Downey VA with a group of schizophrenics was way beyond surreal. It was one of the most unusual experiences I've had as a nurse except perhaps for the time a patient filled his prosthetic leg with urine and asked for help putting it on. When I placed his stump in the prosthesis urine splashed everywhere to the delight of the young amputee.

After the movie ended, about half of the patients had no reaction what so ever, because the long term use of drugs like Thorazine had wiped out any trace of individual personality. A chemical lobotomy of sorts. Another group of patients had trouble separating reality from the movie characters and asked me to speak with Nurse Ratched to "straighten her out."  The other small group identified with the characters and  was delighted that someone had made a movie about them.

On the commute home, I kept thinking that I'm going to write about  that Downey VA movie night experience down some day. I knew my lackluster writing skills would fail to communicate the bizarre nature of watching a movie imitating a mental hospital in a genuine metal hospital. At least I tried.

Institutional Misogynism: The Women of Downey VA Hospital

At the height of the Viet Nam War, Buddhist Monks doused themselves with gasoline and immolated themselves near U.S. facilities to protest America's involvement in the conflict. Two Army nurses rushed to the aid of a monk who set himself ablaze near a remote Army field hospital. A Viet Cong sniper fired on one nurse, killing her instantly. The second nurse, for obscure reasons, was ignored by the sniper and survived. Screaming hysterically and subsequently lapsing into a mute state, the sole survivor eventually found her way to a long-term ward at Downey VA Hospital, a warehouse for the mentally ill. The slain nurse was hailed as a heroine and awarded several posthumous medals and an honorary promotion to Major. A street at Fort Sheridan Army Base was named after her.

(A snippet of Downey V.A. Hospital folklore)

I  worked as a nurse at Downey V.A. Hospital for several months before I was aware there were women veterans confined amidst the 1600+ men. One evening I received a frantic phone call from a nurse in Building 135 asking if I could come to their ward and start an IV on a patient who was seizing. My recent medical background was an anomaly among Downey nurses. Most nurses employed there had worked on the back wards for decades, allowing their med-surg skills to atrophy. Eager to be accepted in this strange new land, I let it be known if there was an emergent medical problem, I was available to do what I could.

I furiously jammed my bit key into the worn slot on the heavy solid steel door on ward 3A, Building 135 and the portal opened briefly and ominously clicked shut. I was shocked to see an emaciated young lady seizing away on the dayroom floor. I should have suspected that any women patients at Downey VA were sequestered in gender segregated silos. At the time, womens' roles in the military were restricted by gender. It was a male dominated world with tentacles that extended to the V.A. psych wards.

I learned there were two locked female wards at Downey in Building 135 and they were the only ones available in the entire health system. Everyone here was seriously mentally ill and a danger to themselves or others. This arrangement concentrated the most acute patients in one facility while separating them from family and community resources. 

The wards at Downey VA were touted for their therapeutic  milieu, but it's a real strain to deduce what could be gained by such profound isolation. There was an on-ward dining room where meals were served to avoid comingling with the young bucks in the communal chow hall. Washers and dryers were also available to reinforce that matronly obligation of wash day duties. The place was a tour de force of isolation  and womanly perspicacity.

Surfacing from my IV start and a hastily administered bolus of Valium, it was readily apparent that the wards in building 135 were much newer than my native Building 66 which was constructed in the 1920s. These contemporary quarters were straight out of the aseptic construction of medical surgical units. The gleaming terrazo floors and ceramic tile walls were more appropriate to an operating room than a place of comfortable lodging and recovery.

I had the notion that psychiatric units ought to be constructed in the architecture of theaters; not operating rooms. There was no shortage of high drama at Downey V.A.  In lieu of a stage, the television assumed the focal point  with the viewers numbly looking on like a brace of zombies. The TV came on at seven AM and droned on until bedtime.

I heard rumors that pregnant women gave birth on the unit and indeed there was an exam room eqipped with a table that sprouted stirrups from it's distal end. Hopefully mothers were carefully screened to delineate complicated deliveries, but you can never assume when it comes to VA care. The facility was loathe to having patients treated in community hospitals and had medical surgical units on site so the men did not have to venture off base for care. Pregnant patients flayed by desperate life circumstances giving birth on a psychiatric unit made me wonder what chance the infant had for a normal life.

As I eyeballed and wondered what a lone mattress was doing  on the dayroom floor, an attendant enlightened me. "We do takedowns differently here. I know you guys over in Building 66 like to countdown and have everyone grab an extremity to apply full leather restraints, but here we just force the unruly patient into a corner using the mattress as a shield and hold them there until they calm down. Visions of a mattress held vertically and used to pin down a patient reminded me of the Chicago Police in their riot gear and shields at the 1968 Democratic Convention riots.

Walking back to the hallowed halls of building 66 I thought of a cat driven high in a tree by a pack of dogs. Safe at last, but completely isolated like the women in Building 135. Maybe it's time to call the fire department.

Downey VA Hospital..... A Lost Empire

Decades ago VA Hospitals were divided in 2 camps, General Medicine and Surgery or GMS and
Neuropsychiatric or NP. Downey was an NP  faciltity  and the countries largest VA Hospital at 1800 beds. It was located about 35 miles north of Chicago adjacent to Great Lakes naval training center. It was constructed right after WWII and designed to provide a lifetime of care via institutionalization for people with chronic mental illness. There was even a full scale medical hospital with ORs and critical care units with strange names (critical care units were called GPUs or General Purpose Units)  The OR was always called EOR or emergency OR. God forbid anyone should mistake them for a "real" medical surgical hospital. That is the only rationale I could deduce for the funny names.

It was really a self contained city with it's own zip code, 60064. There was a movie theater, bowling alley, golf course, swimming pool, and various work areas for the patients such as the spoon factory where patients spent the day tossing plastic spoons into plastic bags. There was a greenhouse where the most common activity seemed to be digging compost and also a metal and wood shop. All the buildings were connected by underground tunnels which always reminded me of catacombs, with poor lighting and spooky dead ends. Staff moved from building to building topside whenever possible.

Patients were housed in multiple 2 story brick buildings with 2 wards on the first floor and 2 on the second with  total census of 104 patients n each building. Windows were covered with vertical iron bars. There were no elevators and the stairwells had imposing walls of cyclone fencing through the middle core to prevent patients from jumping. Radiators provided heat and there was no air conditioning. The buildings were like brick ovens in the summer. Open windows had no screens and various birds and flying insects entered the buildings. Electricity was delivered by underground lines which were not very reliable. Building 66 where I worked was once without power for 3 days. We used flashlights and battery operated lanterns as a backup. The patients barely noticed, but there was definitely a Halloween atmosphere with bizarre shadows and spookiness throughout. The souls of over 100 schizophrenics all in one poorly lit area.  Yikes, get me out of here!

Almost every patient had the same diagnosis (SCU) or schizophrenia, chronic undifferentiated. About 2% of the population was bipolar and added some spice to the mix. All patients smoked constantly while in the dayroom producing a dense ever present haze. Smoke Eater machines mounted on the ceiling did little to clear the air. A typical ward included the day room with connecting hallway to the dorm which was just a huge open room with beds. Just off the hallway was a restraint room with four heavy beds bolted to the floor. The beds were usually all occupied. My claim to fame at Downey was teaching a couple of very violent patients a self restraint technique. I got them to the point when they felt like slugging someone to come to me and ask to be put in restraints. I readily complied with their request and let them decide when they should be released. It worked like a charm for a couple of patients and I always thought I should have received some kind of performance bonus for my idea. The VA was always handing out bone head awards of one type or another, but I got passed over.

In the mid 1970's things began to change at Downey. When liberals and conservatives have common objectives, things happen in a hurry. I really hate political labels and politics in general, but the liberals thought chronic psych patients needed to be freed from the chains of custodial care and some thinkers like R. D. Laing even questioned the whole concept of mental illness. According to R.D. "Insanity was a rational adjustment to an insane world." The conservatives did not like to spend tons of tax dollars on what seemed like a lost cause. Downey began to change. Long term patients were discharged with terrible end results. Patients wreaked havoc in the community by strolling into restaurants and failing to pay. Camping in city parks and the homelessness we still witness today.

The "Downey" name was first changed to "North Chicago VA" then "Great Lakes VA."  The Chicago Medical School built a huge campus smack dab in the middle of the golf course. Today Downey is gone for good replaced by the James Lovell Federal Health Center. Real medical stuff without EORs or GPUs.  I tried Googling Downey and nothing even came up. I guess some things really are best forgotten.

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.

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 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.

Downey V.A. Hospital Signage

Dr. Scott Mastores is  a graduate of  Chicago Medical School which was constructed on the Downey VA Hospital grounds shortly after I quit working there. Thankfully, he rescued this sign from the trash and was kind enough to Email it to me to share with all those interested in Downey VA hospital.

There were lots of interesting signs at Downey and this one was on prominent display in the lobby of most of the buildings. I don't think many of the patients bothered to read them and enforcement was lax. Most of the nurses at Downey would much rather have patients lying on the floor than fighting on the wards.

Just about every ward had a pool table and a sign that stated throwing pool balls was prohibited. I broke up an unusually nasty altercation where two patients were bayonetting each other with pool cues and was promptly advised there was no signage prohibiting this activity. "If we can't throw poll balls at one another, what are we supposed to do?" was their response.
 

Yep...I'm Still Vertical, Part 2

 I encountered a tsunami of post-op complications following my total knee replacement surgery in August, but am starting to feel a return to my foolish baseline.  I received a fascinating email from Anna Pivoras, Executive Director of the Boone County Museum of History in Belvidere, Ill that got me back to thinking about this much neglected blog.

Anna read my posts about Downey VA Hospital because she has an amazing collection of journals from a woman who was a patient at this facility. Janet L. was a college graduate who played the organ for several churches and was very ambitious and active in her community. She joined the Army from 1942-1945 and taught kindergarten after leaving the service. She gave the appearance of being highly functional as she was engaged, had a nice car, and apartment.

After the death of her parents Janet decompensated and was sent to Downey for 3 months in 1967, where "they just wore her out." She became physically ill and was treated and sent back to her ward while still suffering from bouts of nausea. Unfortunately, this was fairly common at Downey. One of my saddest memories is of an elderly man suffering from psychosis as a result of an extended period of time on cardiopulmnary bypass placed in with young psychotic Viet Nam veterans.

The journals from 1971-1974 document a sad and troubled life with paranoid ideation, She chain smokes, a habit of just about every Downey patient because "GI" cigarettes were free and if you had funds, sold for 27 cents in the canteen. She has constant nightmares about shots, needles, hospitals, and psychiatrists. 

This sad story awakened my memory of the 2 womens' wards at Downey VA Hospital which were pretty much isolated from the rest of the facility. As soon as I can organize my thoughts, (HA...HA) not an easy task in my shape, I hope to get a post together on this forlorn topic.

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

Portraiture A'la Downey V.A. Style

Neuro was not one of my favorite courses in nursing school, but one lesson stayed with me throughout my approach to unresponsive patients and that was to talk with them. It didn't matter if they were comatose, obtunded, catatonic, or my favorite term, hypovigilant. If the auditory cortex found within the temporal lobe was intact patients could at least hear to some degree. Even if they could not understand the speech, a nurse's rhythm and timbre could still be detected and communicate caring and concern.

There were quite a few nonresponsive patients I encountered while working at Downey V.A. hospital, a long-ago shuttered facility devoted to the long-term care or in more pejorative vernacular, warehousing of schizophrenics. Crude treatments of the day including lobotomies, insulin shock, and massive doses of major tranquilizers were enough to silence just about anyone including a gentle old soul named Ireno who rarely spoke.

Ireno was a massive bull of a man who had been confined to the forlorn pastures of Downey VA hospital for decades. Standing in line for medications he towered over the other patients, despite his threatening size a HumpteyDumpteyish aura surrounded him. He was mute and acted as if the slightest action could break him apart.

Ireno had been on massive doses of Thorazine which works by blocking dopamine receptors in the brain and as a result more dopamine is released systemically in the synaptic clefts. There is more dopamine around the peripheral nerves and more receptors to respond to it resulting in uncontrolled tremors and movement disorders.

One evening I noticed Ireno reclined on the floor of the day room which was his usual habitat before the dorms were opened. I frequently opened the dorms early, but had to wait until the nursing coordinator made her rounds. The VA had many rigid rules and one dictum stated the dorms were to be locked until 10PM.

I noticed Ireno busy at work with a pencil and paper while wearing heavy winter gloves to attenuate his shaking hands. He also was applying counter traction to his tremoring arm by attaching a sleeve of an old tee shirt to a valve on the radiator with the other sleeve wrapped around his elbow. Whatever endeavor he was up to required great effort and concentration When I walked over to him, he quickly covered his paper, but looked up at me with kindness in his eyes. I told him the dorms would soon be open so he could hit the sack and rest in comfort.

About an hour later, Ireno shuffled up to me and proudly presented me with this portrait he had laboriously sketched out for me. I was stunned by his effort and thanked him profusely and was rewarded with an extremely rare vocalization. "You're welcome" Ireno clearly stated.

I keep a nurse's treasure box for all the little notes and trinkets that grateful patients so kindly provided me. Ireno's artistry is one of my very best treasures and proof to me that every day life on the back wards of downey VA could be miraculous if you knew what to look for. It took a combination of a miracle and sheer willpower that Ireno could sketch this out with his severe tardive dyskinesia induced severe tremors. Michaelangelo likely had an easier time painting the ceiling of the Sistine chapel. 

I Had The Stew Beat Out Of Me at Downey VA Hospital and All I Got Was This Lousy Letter!

                                                              

         Veterans Administration Hospital

                 Downey, Illinois 60064

              December 4, 1974                                  

Mr. Old Fool R.N.

Nursing Service  118

Dear Mr. Fool:

I am sorry to learn of the injury you sustained from a patient's assault. It is regrettable this incident occurred and I am hopeful you have recovered by this time.

I am aware that working in a hospital such as ours must be conditioned with a recognized possibility of occasional physical and verbal acting out by patients. Due to the nature of some illnesses, certain patients periodically lose control of their emotions. It is only through the contribution of such as you that the hospital is able to help these patients through their difficult periods and eventually restore them to a fulfilling life in the community.

Although you have a positive responsibility to protect and conserve all Federal property, including equipment, supplies, and other equipment entrusted to you, personal remuneration for the broken window you were thrown through will be waived,

I want to personally thank you for your assistance as part of the hospital team in carrying out out mission of service to veterans under our care.

                                                                                     Sincerely yours,

                                                                                      Paul K. Kennedy

                                                                                       Hospital Director

Post script: The VA system has changed quite a bit since this letter was delivered to my mailbox in Building 66 at Downey VA. The official VA seal was updated to replace the anchor and rifle scene with a hodgepodge of images including flags, an eagle, gold cord, and five stars. I think I like the old school seal lots better. There is something to be said for simplicity.

Patient assaults on staff were so common at Downey that a slew of these letters were written. The VA has subsequently ceased apologizing for assaults to limit their liability. In the 1970s, not a soul would even think about litigation, especially against one's employer. Times have changed.

If you're interested in the gory details of the assault here is the link; https://oldfoolrn.blogspot.com/2015/08/knock-out-punch.html 

Downey VA Hospital Slang

SUITCASE  - This referred to a patient with multiple complex psychiatric and medical problems . probably derived  from the expression, "This guy has every case but a suitcase"

SATELLITE 5 - This was a reference to the administration building inferring that the workers there were in a different orbit and out of touch with what was actually transpiring on the back  wards.

NAVEL GAZERS - This referred to outside consultants sent in by SATELLITE 5 personnel to provide theoretical solutions to problems of daily life on the back wards. Psychodrama where patients acted out their feelings instead of beating the stew out of someone was an example of an activity a navel gazer came up with. Worked like a charm until the psychodrama leader suffered a broken nose form a dramatic punch.

FUNNY PAPERS - This referred to records or notes made on the ward and not charted.

SLEEPER - This referred to a non committed  patient that suffered a neurosis or drug addiction problem and was sent to one of the chronic wards. They usually only stayed one night and left abruptly the next morning.

G.I. CIGARETTES - Non taxed smokes that were used as a reward system.

BOZO - An inept staff member

HARDCORE - Referred to patient or staff that had been in attendance for > 10 years. It was a toss up as to which group was the most difficult to deal with.

TOPSIDE - Referred to avoidance of the dimly illuminated  inter connecting tunnel system. "I know it's only 15 degrees out there, but I'm going topside."

ACCORDING TO HOYLE - Doing something carefully and by the book regardless of consequences.

TUNE UP - When an interesting patient from the medical component was sent to the psychiatric ward for adjustment of psychotropic medications it was often called referral for a  tune up. I once heard the Chief of Medical Service at Downey bitterly complain to our ward psychiatrist, " I sent that patient to your ward for a tune up and you blew his engine."

ANTISCREAM - A "Downeyism" for any major tranquilizer, usually Thorazine concentrate.

S&S - Short hand for stab and sprint. This was a unique Downey-way of administering an Intramuscular injection to a violent and/or agitated patient. When I was being taught this technique, I was told, "forget everything you know about injection technique." The nurses hand formed a fist with the syringe in the middle and needle pointing down, the thumb was always on the plunger. Whenever a suitable site became available, the syringe was quickly delivered with a stabbing motion and the thumb immediately jammed the plunger home. Whatever became of aspirating and capping the needle? I will have to take the 5th. A crude but effective method that was not according to Hoyle.

PIT - Referred to the restraint room which had 3 bed frames bolted to the floor. I tried playing relaxing music on the radio here and the hardcore nurses made fun of me!

SNAFU - One of my favorites, an old military term for Situation Normal All Foweled Up.

FUBAR - Another military term, Foweled  Up Beyond All Repair. Some people like to substitute another "F" word for fowled but I thought it was nice to maintain a little civility.

PAPER TIGER - A rather loosely applied term for any administrator or outside consultant that came up with rigid authoritarian solutions to everyday backward  back ward  problems. Frequently with impressive academic credentials but no clinical experience. Downey was a haven for these characters. Exhibit "A" would be the employee parking lots which were packed with high-end vehicles any weekday between the hours of 8AM to 4PM.  On weekends and off hours the parking lots were practically deserted  with the exception of a few jalopies belonging to aides and ward nurses like me.  Unlike most of the Panchera Genus, this particular species (paper tiger) is in no danger of extinction. Today I see a plethora of non-clinical nurse geniuses like computer nurses, utilization nurses and nurse infomaniacs with no shortage of grand ideas and schemes to rule the bedside nurse.

I better cease this foolishness before I get carried away. Whenever we were in over our heads in the OR, Dr. Slambow used to always say, "Discretion is the better part of valor." As I quickly loaded Hemoclip  Appliers, I muttered, "To bad you didn't say this 15 minutes ago, before the hepatic bed started bleeding like a stuck pig."  Actually, I never really said that, but the thought did cross my mind.

When I started this foolish blog, I wondered if anyone would read it. My only intent was to write some memories down before my mind topples into that great cognitive abyss that probably is not far off. I never dreamed that I would write 100 posts (this is #100) or that so many people would read my foolishness. Thanks for reading and I am always shocked by the number of people reading this in the middle of the night. A special thanks and I hope that I am not keeping you up.           O.F.

Downey VA Introduces the Shoe Shine Nurse

 Downey VA Hospital, the agencies largest psychiatric facility, had an aloof contingent of highly

educated,  office-sitting nurses dedicated  to grinding  out an assortment of directives, memos, and program notes to lowly staff nurses for implementation.. These administrative hot shots even had their own building complete with plush Karastan carpeting, air conditioning and fancy  pictures on the walls. A far cry from the dingy, smoke filled  wards with cyclone fencing and bars on all  the windows where staff nurses practiced. These office bound nurses never ventured far from their comfortable habitats, but their word became law out on the wards.

Here is a real gem of a memorandum  from one of those office sitters with ample, well padded backsides that I recently  discovered in my basement junk pile  archives of old nursing paraphernalia, "Adjunctive therapy is utilized for phenomenologically promoting a patient's  self actualization when neutrality and anomia of traditional therapy are compromised. An  additional tool to augment the psychotherapeutic milieu." That one's a real head scratcher, but I guess, the general idea is to engage the patient in an activity program so he can find something to do.

Examples of adjunctive therapy include: psychodrama where the patient acts out a scripted scenario under  staff direction, token economy where the patient earns rewards and privliges as outlined by the staff, exercise group involving that old 1..2..bend and grunt routine, and work details such as the "spoon factory" where listless patients dutifully inserted plastic spoons in plastic bags for 8 hours at a stretch.

These adjunctive therapy all share a common thread and that's top/down delivery. A group leader instructed patients in a rigid, authoritarian manner.This did little to establish trust or facilitate communication.

Something different was needed here to demonstrate trust and caring. As I surveyed the ward, I noticed most of the patients were wearing scuffed and dull leather shoes. The ubiquitous athletic shoe was decades in the future. Low and behold, off in a distant corner, a little used and neglected  shoe shine bench sat gathering dust.

Suddenly an epiphany popped into my head. The next day on the way to work, I stopped by the local Ben Franklin store (remember those?) and purchased a few tins of Florshiem paste shoe polish. After gathering  a few worn out T-shirts, I was in the shoe shine business.  That evening after the head nurse departed I initiated my shoe shine therapy program. I pulled that old relic of a shoe shine bench away from the wall, dusted it off  and barked out, "OK fellas step right up. Let Nurse Fool shine your shoes. Let me buff them up to a brilliant shine in nothing flat."

Patients were reluctant at first, but after encouragement from the attendants,  a few disheveled  patients stepped forward and propped their lusterless shoes on the bench for an enthusiastic shine by my deft hands. At first I chatted with them about the condition of their shoes to get them talking. The role reversal and lateral delivery of care was off putting at first, but the shoe shine did help to build trust.

Caring and trust were in short supply at Downey VA, but at least I tried.

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.

Nursing Career Choices - My Journey from the OR to Downey VA

It's so easy to get locked into one particular nursing specialty and latch unto for life. The problem is further exacerbated by seeking more education in that particular area which further encapsulates a career within one particular bubble. Stepping outside your current nursing  comfort zone and engaging in something completely different can bring a new perspective to a divergent specialty arena. Maybe if psych nurses ventured into the OR they could ratchet down some of the everpresent angst and emotional hub bub. Maybe if OR nurses tried psych, they could implement some useful interventions. Who knows? I figured it was worth a try.

I had a life long interest in OR nursing or  in the vernacular of you whippersnapperns "perioperative" nursing. I still like the old fashioned scrub nurse terminology, but then again, I'm an OldfoolRN. Psych nursing always seemed so very different. The long term custodial care of chronic schizophrenics seemed to be the exact opposite of slapping instruments into a surgeon's hand for an immediate solution to a health problem.


I thought that this  expertise, if you could call it that, could be applied to another nursing specialty like psych. Youngsters do indeed generate some foolish ideas when they are out to cure the world and I was no exception. I like dramatic quick fixes and doing something to really cure the underlying problem. Proven interventions that get sick people back on their feet and back into the business of life. Psych was to be my new alternate universe and I would somehow help those institutionalized souls with novel and pioneering interventions. I was probably as delusional as some of the patients!

Downey VA Hospital, just north of Chicago was to be my new stomping ground. I was hired and told to carefully review the employee orientation manual. They actually wanted me to start working on the very same day as my interview. Desperation does not make for clear, level headed thinking so I declined and agreed to report the next morning.

The nursing supervisor escorted to my new assignment, Building 66 ( AB  ward) in a VA facility that was indeed  providing long term custodial care to chronic schizophrenics with a smattering of manic depressives thrown in for variety. She opened the massive door which resembled a bank vault with heavy robust hinges   to "A" ward and as we stepped in, a pool ball thrown with the velocity of a Nolan Ryan fast ball whistled just over my head. In the far corner a patient was doubled over in pain after beintng "bayoneted" in the abdomen with the end of a pool cue. The blue pool chalk was mixing with a small amount of bright red blood. I remember thinking to myself..how patriotic his plain white t-shirt looked with a red and blue stain.

"Is this the therapeutic milieu  mentioned in the orientation manual?" I foolishly asked my orienting supervisor. "Not exactly," was her reply as she quickly wrestled the pool cue from the agitated patient who was brandishing it like a he was preparing for another vicious  strike to the body. The supervisor complained bitterly that she had ordered the pool equipment locked up and set about for an attendant to shoulder the blame.

After resolving that issue, she suggested that I remain on the ward to observe. There were 40 patients in the cavernous, exiguously furnished dayroom, most of them pacing to and fro muttering unintelligible ramblings. Everyone smoked and a thick blue cloud enveloped the entire scene. A huge ceiling mounted unit that whined and whistled like a 747 on a take-off roll was sucking up some of the cough inducing smoke. I asked one of the attendants about the strange device and was told that it was a "smoke eater." At least they are trying, I thought to myself.

There was no danger of anyone leaving this facility. The windows had heavy wrought iron bars that rivaled the entrance door in terms of shear mass. The place reminded me of a maximum security prison or a Fort Knox for people.

I concluded that I needed to do something physical to establish mutual trust and get the ball rolling with these guys. Attendants and other ward personnel were chatting with some of the patients, but from what I observed, this did nothing constructive. These guys had been talked to for years and it did not seem to do much for them

I noticed that they were all wearing scuffed, dirty, leather dress shoes that they had obtained from the hospital canteen. The ubiquitous athletic shoe of today's world had yet to be invented. In a supply closet there was a shoe shine set-up complete with a fancy gizmo to prop feet up at the optimal level for a seated operator to shine the footwear.

I had an epiphany. This is how I could engage some of the patients and develop some sort of therapeutic relationship with their tortured souls. I think it was called making therapeutic inroads or some other term firmly rooted in the rubric of psychobabble nonsense. Anyhow., I decided to give it a go and  when I returned the next day  I reported to the ward with some newly purchased tins of shoe polish and a couple of worn out scrub suits that I had collected from my previous nursing life. I knew from experience they were perfect for buffing shoes to a deep shine

"Shoe shine..Get your shoes buffed up to a nice shine," I shouted out toward the pandemonium emanating from the dayroom. Whenever a patient approached the door, I greeted him with a friendly smile and cheerfully offered my shoe shine services. Even some of the more withdrawn patients began accepting my services and this was a great way to learn their names. One of the attendants cautioned me to limit my shoe shine services to when the supervisor was off ward, but I did not worry about that too much. After all, I was doing a heck of a lot more than they were to help the patients.

It touched me deeply when after about a week of my shoe shines, a motley collection of disheveled patients approached me and asked to polish my shoes. I was really getting somewhere with these guys.

For my next Downey VA post, another OldfoolRN innovation: Teaching violent patients to request restraints to avert injury. Supervisors thought I was a nut, but the proof was in the pudding- It worked

Downey VA Hospital Restrains Assaultive Parients

Yes, I have a personal  history with patient assaults. Here is a link with the gory details if you would like to peruse the sad tale  http://oldfoolrn.blogspot.com/2015/08/knock-out-punch.html

Part of the problem with patient vs. staff  assaults  at Downey was the lackadaisical attitude of the administrators who were supposedly running the show. Assaults were so common that the hospital director's office had a form letter that was sent to all victims. The themes of this letter were that we were dealing with very psychotic patients and such unfortunate incidents were inevitable and oh, by the way, thanks for trying to help these poor unfortunates. Next time learn how to duck. OK I made that last one up, but that seemed to be the underlying message. There was no such thing as patient accountability or accountability of anyone for that matter.

The head nurse,  Matty,  of Building 66 where I worked  was a stout pit bull of a woman who rarely ventured past the safe  confines of the nursing office. She was an office-sitter of the highest order. Of course she had strong feelings about how to manage patients on the ward, but had no experience in the clinical realm.

Miss Matty loved to pontificate about patient assaults on employees. It was one of her favorite topics and her main point was that the employee's insecurity and lack of confidence communicates a sense of vulnerability to patients who then slug them. Her favorite refrain was, "Carry yourself with a sense of authority."  This made no sense to any of the staff. Ward attendants and nurses used to discuss this while on the ward within earshot of patients.

I quickly deduced that some patient on staff  assaults were entirely unpredictable and were deeply rooted in the psychopathy of the patient's illness. See, I can use that psychobabble speak just like all those highly educated big shots! Other assault episodes seemed to follow a pattern of escalation and were somewhat predictable. Some assaultive patients even expressed regret for the incident.

After an assault the patient was always placed in full leather restraints with a robust leather cuff around each extremity which was anchored to a steel bed frame with a heavy leather belt. The cuffs had a sliding lock mechanism that required a key to release. The bed itself was bolted to the floor to prevent the patient from kangarooing the bed around the restraint room. Some of the more experienced patients knew how to bounce an unbolted bed up and down when in restraints to move about the room. "Kangarooing" was a very good, descriptive  term for this phenomenon.

Putting an uncooperative, assaultive patient in restraints was not a pretty picture. One technique involved at least 4 nursing staff members to do the dirty work. A secret code word was agreed upon and since I was always hungry, "Big Mac" did the trick for me. After hollering the code word each staff member grabbed one extremity and physically carried or in the case of a really big patient, dragged him to the restraint room and tethered him to the bed with the leathers.

The alternative  technique involved a couple of staff members grabbing a twin mattress and while holding the mattress vertically, force the patient into a corner. Once cornered, the patient usually surrendered after an interval of punching and kicking at the back of the  mattress. It required a seasoned nurse's best judgment to ascertain when the pugilistic activity subsided enough for restraint application. The attendants were fairly good evaluators of the degree of "fight" left in a cornered patient and I usually left the decision up to them as to when restraints could be used. If a patient had too much "fight" in them when the mattress was retracted, it could always be pushed back into position pining the patient back in the corner. I always thought that the sudden eruption  of the punching  fists on the surface of the mattress looked just like that carnival whack-a-mole game. When the surface of the mattress settled down, the game was over.

I really detested the drama that accompanied the restraining process. There were about 4 patients out of 40 that required restraints. The youngest, Danny, was a Viet Nam veteran and had a predictable pattern to his violent outbursts. He would scream like a Howler monkey before striking out and once secured in the restraint room, he voiced remorse for his behavior. Danny told me that he felt like striking out when he felt threatened and out of control. I assured him that he was safe and maybe the next time he felt the urge to strike out to come and talk with me and we could figure something out to avoid that unpleasantness of being wrestled into the restraint room.

Whenever Danny approached me with that rage in his eyes, I always asked him what would work to make him feel better. Sometimes he just needed to lie down for a spell and other times he requested restraints. I complied and after the restraints were on, I always said, "Just let me know when you feel like coming out and I will release you."  This worked well for Danny and we established mutual trust because I promptly let him out at his request. For Danny this worked really well, but when he made his request to other nurses, I got called out by the head nurse who thought my interventions were unwise to say the least. Oh well, at least I tried.

Danny's schizophrenia suddenly went into remission and he was discharged to live happily ever after. APRIL FOOLS on that last sentence.

When The KARDEX Was King of Communication

Glen from Texas emailed me with a suggestion to write about my experiences with the nursing KARDEX which he advised is disappearing. I had no idea. How could something with so much utility just up and disappear?

Christians have their Bible, Jews have the Torah,  and nurses from a bygone era had their KARDEX. Named after a company that specialized in using index cards for data storage, KARDEXES  were the center piece of any nursing station. Patient charts come and go with whoever snatches them up, but the KARDEX is always front and center at any gathering of nurses. Change of shift report without this wonderful collection of data would be impossible.

The front and back of  a vintage KARDEX was a solid sheet of gunmetal grey steel with a piano hinge through the midsection. When you opened this hefty collection of vital information an audible, metallic  CLUNK would echo around the room. That harmonious sound reminded me of a church bell announcing that something important was about to happen. The flipping through the KARDEX index cards  made a gentle rustling sound like the wind blowing through a Midwest cornfield just before the combine moved in for harvest. What a contrast to the contemporary clicking, bleeping, and clacking of a computer keyboard. I loved this bit of KARDEX  acoustic candy because it was an auditory sign that my shift was over and more peaceful, restful times were ahead.

What information was included in the KARDEX?  Everything a nurse needed to know when providing patient care: demographics, treatments, medications, allergies, consults, code status,
 urine reductions, diet, surgery, I&Os, IVs, and  IM injection rotation sites (everyone received these painful ministrations and rotating the  sites distributed the pain over a larger area).  The patient's name and physician was written in ink, but everything else was written in pencil and unlike the medical record, subject to erasure. The Kardex was not a formal document and when the patient was discharged, the cards were ceremoniously tossed in the circular file. No HIPPA - No shredding.  Identity theft was unheard of.

From my blogging foolishness, I can attest to the fact that people say different things under the cloak of anonymity and the KARDEX was no different. I was a quiet and reserved scrub nurse and just look at the blowhard  I've become  with an anonymous blog.  Notations in the Kardex were not signed and nurses perfected a generic form of printing to avert handwriting analysis. This cloak of secrecy  promoted blunt and sometimes crude KARDEX entries.  KARDEX notations often liberated many a nurse's free spirit and foolishness was not too far away.

Nurses who came  before me often had to administer painful and unpleasant (to say the least) treatments and never took "no" for an answer. Rather than write that it was necessary to restrain or hold a patient to the bed for a treatment, code words were used. "Patient needs assistance maintaining proper position for enemas," sounds better than "restrain his arms to prevent fighting to dislodge  enema tube."  In pediatrics the youngsters often needed "help" to receive painful injections or treatments. Those old school nurses were a force to be reckoned with and their KARDEX entries sometimes bordered on fiction. I vowed to never cultivate a mean, sadistic nature present in these hard core care givers.

As I was thinking about the KARDEX, a stream of odd ball and memorable entries returned to my obtunded consciousness. Every student nurse remembers their very first patient. Mine happened to be a pleasant, young Hispanic man recovering from a heroin overdose. Prominently displayed on his index card was a very good suggestion: No heroin on discharge.

Downey VA could be a very dangerous place to work and assaults were an unfortunate occurrence. A night  nurse pulled from the medical side of the facility left an ominous warning taped to the front of the KARDEX: Unsafe to be in attendance here  at ant time. DO NOT ask me to cover this ward again. I heartily concurred but could not do much about my situation. Building 66 was my permanent assignment.

Folks addicted to drugs had a very difficult time in vintage hospitals and old school nurses seemed to delight in social engineering to make their stay as miserable as possible. The old "That'll learn ya" attitude on steroids. A frequent entry on a drug addicted patient's Kardex was: Known drug abuser-no pain meds of any kind.

Floor is slippery. Patient expectorating giant phlegm globs.  Enough said.

If patient is experiencing difficulty voiding, have him blow through a drinking straw. Along with running the sink, this trick really worked.

On the post-partum unit: Remind patient to pull inverted nipples out. Ouch..as if the delivery experience wasn't bad enough.

A patient, Dudley, that I cared for as a student nurse smelled of urine no matter how carefully I bathed him. A perusal of the KARDEX offered an unusual explanation of the pungent odor.  Remove patient's prosthetic leg  from the room on PM shift. He awakens at night and fills it with urine.

Have footwear at bedside for AM pulmonary function testing. We all knew what this entailed.  PFTs were conducted in the stairwell at the end of the hall. If a patient could ascend  2 flights of steps with a  resident encouraging him from behind, he was deemed an acceptable surgical risk. Just be careful not to slip on the giant pools of phlegm/mucous left behind on the steps.

Some patient families are prepared for just about any contingency. I remember well the family that brought a 3 piece suit to the hospital with a dying patient. The KARDEX notation:  Make sure the suit in the clean utility room goes with the undertaker when he comes for the body. Yikes!

KARDEXES were the hospital equivalent of a jungle telegraph and revealed information that you were afraid to ask about or never knew existed. I think rigid and permanent forms of medical record keeping, electronic or paper, can block nursing inventiveness that drive holistic care. The old KARDEX unleashed the nursing free spirit by delineating what really worked for the patient.
                                                                                                                                                                                                                                               

Healthcare Paradoxes

  Wake up! It's time for your sleeping pill.

Go Lytely...This stuff is like a Mount Vesuvius eruption purge in a bottle! Not exactly lightly about anything.

Lifesaving surgery...Red Duke, the famous Texas trauma surgeon, debunked this one many moons ago. "When God punches your ticket, he does so with profound authority, without regard to human intervention." 

Soft code...When the notion that CPR was good for all surfaced, the concept of a muted code emerged: walk, don't run, pediatric compressions for 300 pounders, etc. There really is no such animal as a soft code.

Bathroom privileges... This is a biologic need. Do we have room air privileges for patients to breathe?

Therapeutic milieu... I learned the fallacy of this one early on at Downey VA hospital. A nurse office sitter was orienting me to my psych unit announcing that this was their "therapeutic milieu" as she opened the locked door to the ward. A pool ball sizzled by my head like it had been launched from a mortar and 2 patients were bayonetting each other over in a corner with a cue, while a third was struggling to remove an impaled rack from his head. Therapeutic???  I don't think so.

Normal saline...How normal is an IV solution when it can cause metabolic acidosis and renal function changes?

ILL health...Health is health and there is nothing ill about it.

Pressure ulcer... Nope, if pressure caused ulcers, divers would be one giant bedsore. It's the shear forces that cause decubitus ulcers.

Confined to a wheelchair...As an occasional wheelchair user, this one really grinds my gears. Wheelchairs provide mobility and freedom!