Thursday, July 13, 2017

Paper Medical Records

A paper medical records trifecta; med cards, kardex
and paper chart. Med cards and anything recorded in
Kardex was tossed after their purpose was served.

The importance of the medical record cannot be overstated. Communication of patient information in a usable format has been a priority for many eons. Where else can you find a blow by blow account of surgical treatment, response to drugs, and basic diagnostic information. Whippersnapperrns complain endlessly about electronic medical records and older practicing nurses often  dream of a return to paper records.
Paper records had a certain charm and ease of use, but there were problems with divergent formats, inaccurate data, and unauthorized access, which in some ways, mimics problems with electronic records. At least with paper records nurses were not distracted by a wheeled monster of a computer that followed them everywhere. I don't think there is anything more frustrating than communicating with a person distracted by a  computer screen.

 Most private and charity hospitals were writing progress notes and physicians orders on standard 8 1/2 X 11 size paper. Federal agencies such as the VA medical system had a very unique paper size which was 8 X 10 1/2. This was another example of that infamous VA tag line, "The right way, the wrong way, and the VA way." President Reagan established a government Committee for the Simplification of paper sizes in 1980 and the VA switched to the 8 1/2 X 11 standard.

 When a VA patient was admitted to a private hospital the combination paper sizes were difficult to stack (VA patients always had voluminous records) and the end result was a leaning tower of medical records. How acute the lean angle became was dependent on the volume of the record and the sequence of the odd sized paper. Old nurses always characterized the medical record lean orientation as port or starboard. For some obscure reason port side canted records usually foretold a very difficult patient care situation.

Everyone approached patients with leaning  paper medical records with due caution. These were complex, time consuming patients. One nurse summed it up nicely with this little ditty. "Those patients have every case but a suitcase." It was amusing until one of these patient care conundrums actually brought their suitcase with them to the hospital. It could have been much more morbid. When a patient was not expected to recover one family sent along a three piece suit. "Make sure one of the nurses gives that suit to the undertaker when he comes for Gramps," was the instruction.

Today nurses must be concerned with hacks and computer glitches upsetting the delicate order and sequence of recorded medical data. Paper was not immune from unpredictable  disorder. Old time hospitals were never air conditioned except perhaps for the director's office. This meant that nursing stations were equipped with gigantic fans capable of moving as much air as a Piper Navajo on take off roll. That prop wash at the nursing stations was capable of sending any and all stacks of paper flying off into the wild blue yonder.

I vividly recall one sweltering August afternoon  at Downey VA  Hospital when a stack of newly minted physician's orders was placed on the ward secretary's desk for transcription. Unlike patient care areas where the windows had security screens, administrative zones like nursing stations  went screenless. The massive floor fan actually blew the new orders directly out the open  window. I quipped that the records were "gone with the wind." The head nurse, Lois, had the last laugh and ordered me out of the building for order chasing duty.

Another problem presented by paper  pages was how to organize them into a format for ease of perusal by health care workers. There were clipboards and spring loaded metal chart jackets that worked the best. Later ringed  notebooks came into favor, but there were compatability problems with 2 hole or 3 hole. The VA Health system actually  came up with a  novel and unique system of punching 2 holes into the top of the record and affixing it to the chart with a metal hasp.

Data security is a big deal today with HIPPA this and HIPPA that frequently cited. Paper records did not require mixed character passwords to protect. In hospitals there was someone present by the chart rack 24/7 and physician's offices made a ritual of keeping records under lock and key. When a chart was sent with a patient for a procedure or diagnostic test, the chart was encased in a canvas bag with a locking zipper. Data security at it's finest.

Finally. since paper records were always physically close to the patient they communicated a sense of presence. Nothing tells the story of a harried trauma surgery like an anesthesia record splattered with blood or prep solution. The physical appearance tells the story better than the data recorded. Nurses frequently did their charting while taking a break for a Coke and a smoke. It was common to be ceremoniously greeted by a cascade of cigarette ashes when opening the chart to the last nursing note.
Sometimes the "presence" of paper medical records resulted in a messy situation.

Thursday, July 6, 2017

Crash Cart - Circa 1921

Inventory of ancient crash cart: Tracheotomy set, solutions of H2O2, adrenalin, tannic acid, and gallic acid. Equipment to administer a stimulating enema and if that failed, how about some smelling salts?  Sterile supplies with the notation, "If carefully done up, these will not need to be frequently sterilized."

I should probably publish  this post without pontificating about crash carts, but like the oldfoolrn that I am, here I go shooting off my old wrinkled up mouth. Mouth flapping and jaw jacking at it's finest about a subject I have no current experience with.

There is something almost talismanic, I think, about having an assemblage of lifesaving equipment and pharmaceuticals gathered together in a  mobile crash cart or trolley. The individual components assume a far greater reverence and respect than they would on their own and the ability to move them throughout the hospital is indeed  magical.  If a patient is circling the drain, it's always prudent to park that crash cart right outside the door to chase away that bad juju.

Whippersnapperns were quick to admonish oldfoolrns like me for failing to respect the supernatural  powers  of  collective resuscitation equipment, "Hey you need to have the crash cart at the bedside when you do that," was their frequent outburst. They were just shocked, and awed by my magical power to convert tachy arrhythmias to normal sinus by slight of hand vagal tricks  like applying gentle ocular pressure, a trick old nurses learned from watching the 3 stooges. There were no crash carts in the stooge era and I never converted anyone into cardiac stand still, but the youngsters had a good point and I became more concerned about access to a crash cart later in my nursing life..

Whippersnapperrns were always flabbergasted to learn there were no crash carts in the OR and we never called a code for a patient that was on the table. The rationale for this practice was the notion that anesthesia was on the ready with all  equipment at hand for resuscitation. I was explaining this in my usual blowhard, know-it-all tone of voice to a young whippersnappern and she piped up with the question, "Where is the defibrillator, fool?"  I did not have an answer as all that we had available were defibrillators with  internal paddles. "Well..I guess we could run over to ICU and borrow their defibrillatoer," was my lame reply.

Old nurses knew and practiced resuscitation without new fangled devices like ambu bags using mouth to mouth. I once performed mouth to mouth on a chap with about a weeks worth of whiskers and it felt like trying to blow up a water ballon studded with porcupine quills. Ambu bags were one of the greatest inventions for lips-off resuscitation.

This cart is so important that a nurse is obligated to check on it every shift. I knew a nurse that accrued big time trouble because an amp of bicarb was a month out of date and her initials were last on the checklist when a supervisor went through a crash cart. Nurses can get into trouble for the most inconsequential of misdeeds. It never paid to worry about supervisor admonishments because trouble always accrued from something totally unforeseen. Don't happy and carefully check that crash cart was always good advice.


Thursday, June 29, 2017

The Metrecal For Lunch Bunch

Old time surgeries could last for a very long time as a result of their complexity, a lackadaisical attitude about anesthesia time, or unforeseen pathology. After 6 hours of standing on your feet (never, ever lock those knees) a sense of fatigue would settle in and it was tough to be at your hypervigilant  best. I always knew I was in trouble when my head started to feel heavy or my hands began to shake. I devised some strategies to deal with hand tremors and they are O.R.  tested. You can find these tips at this link. It's a common problem with some straightforward  solutions that worked well for me.

For that generalized malaise and heavy headedness feeling there was only one remedy and that was intraoperative nourishment. You can't eat a Big Mac in the midst of surgery although I did witness an attempt to ingest a hot dog which  was accompanied by an assortment of gastronomic complications. Those tube steaks are hard to slip under a surgical mask and difficult to properly masticate with mask ties impeding jaw movement.

Philadelphia Eagles quarterback, Mark Sanchez knows all too well the down side of eating hot dogs on the job because of the trouble he got into eating a tube steak  on the sidelines. It did not work well in the OR either. The consistency of a traditional hot dog makes it an aspiration hazard if eaten quickly. The diameter of the hot dog is the perfect size  to occlude a trachea or if further down the line, a main stem bronchus. At least in the OR, a Magill forceps is close at hand to extricate that wiener plug from an airway. For hot dogs to work in a surgical setting, the contents of the meat in the casing would have to be similar to toothpaste. Just have the circulator inset an end of the hot dog under the mask and once the scrub nurse chews the end off, squeeze the meat paste into her mouth. The Surgi Dog is born.

This illustration of Hawkeye of MASH eminence shows some of the challenges with intraoperative nutrition. The circulator, Hotlips, just contaminated the front of the surgeons gown with her nutririve ministrations. Solid food which requires sacrificing the surgical mask coverage is not prudent. The ideal mid surgical procedure meal is a liquid, nutrient dense, and shelf stable. The name of that miracle surgical sustenance was an old time product that was one of the very first diet products, Metracal.

The longing for a svelte body is not a new phenomenon. Mead Johnson came up with the diet drink, Metracal, which soon became a pop culture icon in the 1960's. Each can which required the use of a genuine can opener, delivered 225 calories derived primarily from soy protein. The consistency was a miserable watery, pasty slurry that often contained tiny lumpy glops of congealed soy protein. To disguise the unpleasant taste, novel flavors like Danish coffee and egg nog delight were offered.

Ad copy from the mid 1960s touted, "Join the Metracal for lunch bunch on a new kind of treasure hunt. Discover Metracal which tastes just like a milk shake." The ad suggested that 4 cans per day of this diet drink would trim off the pounds in nothing flat. It was a popular product and sold for 12 cents a can at your local grocery store even though it tasted nothing like a milkshake.

We discovered that Metracl was a near perfect nourishment for intraoperative sustenance. In the OR can openers were readily available for popping the tops off multi-dose vials and also  worked great to open the Metracal cans. The next step was to obtain a straight catheter (18 Fr. worked just perfect) and insert the business end into a can of Metracal. The flared distal end of the catheter was carefully threaded through the side of the anxiously awaiting scrub nurse's mask  and it was lunch time while the surgeon searched for that last persistent bleeder.

There is nothing quite like savoring the gastronomic delight of a Danish coffee Metracal while inhaling putrid Bovie smoke. That combination of gustatory delights is bound to induce an anorexia syndrome that practically guarantees weight loss. Maybe Mead Johnson should have figured out how to can and sell Bovie smoke.

Since Metracal was mainly protein, we would add a 20ml ampule of D50 ( concentrated Dextrose)after about half the can of Metracal was consumed. I just loved the loud snap-crack noise those big ampules made when they were cracked open with bare hands. The scrub nurse knew that a pick me up was close at hand when that crack thundered throughout the room. Metracal and  D50 really did enhance vigilance when lassitude settled in during a lengthy case. My all time favorite flavor was called Thahitian treat - a taste of coconut delight from the islands while sweating it out in a Chicago operating room. Life  was good.

Thursday, June 15, 2017

Whatever Happened to Sluice Rooms?

It's a conditioned response. Whenever I observe a Whippersnappern wearing gloves for routine patient care or  worse, comingling sheets soiled with scatatolgical resideue and run-of-the-mill dirty linen my anxiety mounts to intolerable levels. Someone is going to be raked over the coals for these misdeeds. Hospitals of yesteryear had unique protocols for these unpleasant circumstances.

Any sheet soiled with solid matter-what a euphemism-required a sluicing in the dirty utility room. A lovely, white 6 foot porcelain slab lined one of the walls of the dirty utility room. It was not for napping. At the elevated end of the sluice there was a massive faucet capable of unleashing a Niagra Falls torrent of water flow. The depressed end of the slab terminated at a slop sink which had a massive drain. This drain could accommodate a bolus biomass of stool the size of a bowling ball. Don't ask how I came to know that  little factoid. Someone had the foresight to install a trap on this sink which seemed to me comparable to the diameter of a subway tunnel. At least once the fetid fecal foosball facsimiles were beyond the trap they were gone for good and you could breath again.

To properly sluice a sheet place the origin of the offending substance at the lowest point of the sluice nearest the slop sink. If you enjoy inhaling aerosolized particulate matter simply reverse this procedure. Now for the fun part; turn that mighty faucet to full blast and watch that mass of olfactory offensive material sliding away on it's merry way to the waiting slop sink. Some types of residue affectionately referred to as smears, mucilaginous masses messes,  or pasty blobs require some encouragement from the intrepid sluicer and for this unsavory task a squeegee borrowed from housekeeping acted s a pusher. I always found it strange that the housekeeping personnel never asked for nursing to return their squeeges.

Suddenly, like a bolt out of the blue in the very early 1970s a memo from the nursing director came out stating that sluicing was no longer required due to improvements in the hospital laundry system and we could simply toss soiled sheets into the hamper. Sluicing like the lobotomy was gone for good and nurses were ecstatic.

This really piqued my curiosity and called for a personal visit to one of my favorite places which was our on site laundry operation. The Hispanic staff working the laundry were among the most content of all hospital staff despite working in a place that reminded me of Dante's inferno. This place was hotter than a brick oven, louder than a Pittsburgh steel mill and to top it off, smelled funny and that's putting it nicely. These folks made $2.20 an hour and were overjoyed with their pay (minimum wage was $1.65 an hour.) They were some of the nicest people in the hospital and even helped me with my lackluster Spanish skills.

When I asked about the new sluice free linen policy they happily showed me their brand new washers that had a built in sluice cycle. The washers had huge outlets that opened before the start of the wash cycle that permitted a huge flow of water through the batch of linen before the wash was initiated.

I was invited to observe a mechanical sluice cycle and it was very impressive. The mighty roar of the water being injected through the linen sounded like a 747 on take off roll in the midst of a rain storm. These giant sluice/washing machines had to be one of the greatest engineering accomplishments in healthcare history-and you thought anesthesia was an impressive invention. An open drip ether drip mask is nothing compared to these sluicing behemoths.

A few years ago nurses from my alma matter were invited to a homecoming. Changes made in the use of space at the hospital were depressing. The old OR suite, home to much drama and lifesaving (I hate that "L" word with a passion.) had been remuddled remodeled to fancy administrative offices. The beautiful terrazzo floors had been covered with Karastan carpet and pretty pictures hung on the walls. The sluice room on one ward had been converted to a data processing room filled with computer doo dads with blinking LED lights.

Crude rooms that were vital and offered maximum utility for patients  were converted to an office sitters paradise and an electronic wasteland. A depressing commentary on contemporary healthcare.

Wednesday, June 7, 2017

Operating Room Superstitions

 Old time operating rooms were fertile ground for the proliferation of  superstitions. Surgeries performed with equal technical excellence can have profoundly divergent outcomes causing thoughts of supernatural powers. Unexpected complications can occur without reason or explanation. Practices and behaviors that accompany good outcomes can be elevated to cause and effect status even when there is no supporting science. A Cartesian circle of the highest order develops. (I tossed that Cartesian word in there to try and sound smart..I'll be darned if I know what it really means.)

Superstitions have one thing  in common with science, they gain real traction with repetition. Thoughts like "Hey..the patient always does well when I use that scrub sink near the door." Pretty soon another nurse notices the same phenomenon and a "lucky" scrub sink is born. If a superstition does boost confidence it becomes much like a positive affirmation. Thinking positively was not one of my strong qualities and some superstitious actions do serve to boost confidence in nervous Nellies like me. If there is no danger to the patient and superstitions boost staff confidence a positive aspect of such non - science backed behavior becomes apparent. Without further ado, I present the magic superstitions I have encountered over the years and there is not a single full moon or "Q" word among them. No nurse would dare tempt fate by uttering the "Q" word especially when the moon is full.

Intracranial aneurysm surgery is a high stakes and nerve wracking procedure. Dr. Oddo, my favorite neurosurgeon had a couple of unusual habits for aneurysm clippings. Rule #1, No talking during the surgery and now comes the mystical  photon diminution exsanguination challenge. After the offending aneurysm is clipped, the overhead and ceiling lights in the OR are turned OFF for one full timed minute. The bone flap cannot be wired into position until the lights out test is completed and assurances of a dry field confirmed. I asked Dr. Oddo if the rationale for this test was the fact that it would be dark in a closed skull and he admonished me for overthinking the matter. "I do it because it's effective," he muttered.

Surgeons love to brag about their "bucket time." This refers to the interval from incision to when the diseased organ is ceremoniously tossed into the kick bucket. Every circulating nurse worth their salt  knows the sooner that pathology infested gall bladder or ripe appendix is bagged up and out of the room the better. If a resident wants to fool around with the specimen looking for stones or what not-do it in a scrub sink outside the room. Get that thing outta here-It's bad JuJu of the highest order! Skin approximation at closing time is so much easier when that specimen is gone and the anesthetist will thank you too when it's emergence time. Everything is just...better.

This lucky maneuver was brought to my attention by a very bright Filipino surgeon. In his native country, the surgeons would place a huge leaf from a tropical plant under their  scrub caps as an aid for cooling. Serendipitously, it was discovered that surgical outcomes improved with the tropical leaf  undercap maneuver. We don't have tropical forests in Chicago unless you count that flower shop on Belmont St. in July, but we have cabbage leaves readily available in the hospital kitchen. This green vegetable worked just fine and there was usually a head (of cabbage) in the OR refrigerator. Just look under all those blood bags-yep we comingled food, blood, and (get em outta here) specimens in the same refrigerator. Our overseers were safely hidden away in their offices and dared not even approach the double doors to the OR.

Here is an oldie but goodie that every old nurse has probably practiced. The idea of transferring this maneuver from the bedside to the OR was a stroke of sheer genius. When a patient is declining rapidly old school nurses would tie a knot in a corner of the bottom sheet usually at the foot of the bed. It's best not to question superstition practitioners, but the explanation had something to do with binding the soul to the body. If a problem developed during surgery some circulators would duck under the table under the guise of adjusting a Bovie pedal and knot the sheet covering the OR table.

If sheet knotting is such a great thing I thought maybe we should just knot the sheet before each case prior to draping. An old nurse was quick to admonish me, "It doesn't work that way Fool. The knot has to be secured after the patient begins that downward slide. You should have learned that in nursing school."  I stand corrected.

Thanks for indulging in my foolishness. My blog always experiences a marked decline in readership after the traditional school year ends. Somehow, I did not think foolishness and academics mixed, but I must have been wrong.

Thursday, June 1, 2017

Let's Stop Using These BS Terms

Calling a doctor's office an INSITUTE such as Two rivers Orthopedic Institute. When a doctor hangs out his shingle he can't be the founding father of an institute. The term "institute" refers to an entity that combines clinical practice, research, and academic endeavors under one umbrella (another BS term if I've ever heard one.)  I better be more careful.

Clever spellings of terms like orthopAedics, just to sound like a bigshot. It's orthopedics unless you happen to live in England. I interviewed  asked an orthopedic man the rationale for this nonsense and he said it was being used a  nod to the history of the specialty. That's piling BS on top of BS if you ask me.

Calling patients "consumers."  This was tried in the past by calling patients "clients." It did not work back then and won't work now because it depersonalizes sick people seeking help. History is on the side of calling sick people patients, so let's not mess with it.

Let's stop calling dense urban centers with lot's of health issues "medically underserved."  There are lots of medical folks in your nearby hospital. The problem is horrendous, intractable social problems not a lack of medicine or medical personnel.

Doctors who refer to the number patients cared for as a "patient panel." I'm not sure where this one came from, but suspect it has something to do with remuneration. How do you determine the size of your "panel?"  Maybe the number of patients you see per day times  the number of days you see patients. Patients have highly variable levels of acuity. Maybe it would be easier to categorize by acuity before assembling a panel or just say how many people can give you a phone call and be seen by a provider. Yikes, provider sounds like another BS term and that's stacking BS on top of BS. I'm getting into some really bad habits here.

Free pharmaceutical samples from your local, friendly Doc that are not free or samples. UPMC the dominant domineering health system here in Pittsburgh hands out bottles of cheap generic drugs plastered with advertisements for their brand of health insurance. It's enough to make me sick!

Physicians that promote themselves by proclaiming they are a Harvard educated medical specialist. From my experience an Ivy league education does not promise a good outcome. That sounds like a misguided superiority complex to me.

 Two BS terms for the price of one - "experience" and "journey."  Your weight loss journey begins with a surgical experience with our Harvard educated (oops) bariatric surgeon.  Weight loss is not a journey and having your gut rearranged is not an experience.

Here is a real gem. "Work needed to undergrid  healthcare  reform involves a new paradigm in perception." That "paradigm" word has been around forever. Dr. Slambow, my favorite person to scrub with, said that whenever you here that paradigm word it's someone attempting to sound smart when they don't know what they are talking about. Maybe I need to come up with a new paradigm with this foolish blog.

Friday, May 26, 2017

What is This Newfangeled Juxta Business?

Medical terminology is in a constant state of flux and I'm all for change if more concise or precise - hey it rhymes- information is provided by the new term. But what's this new fangled juxta prefix  applied to anything and everything all about?

We have juxtaglomerular, juxtacortical (brain or kidney?), juxtapyloric,  juxtavertebral, juxtachondral, and who knows what juxta  else. In the good old days we had prefixes like peri-,circum-, or in plain speak,  thereabouts. These old school terms worked very well but,perhaps lacked some of the cache of the newfangled juxta speak. However, I think the lingo from yesteryear was more straightforward and served it's purpose well.

Youngsters seem to have a preoccupation with inventing new  terms to replace old school terms that have withstood the test of time. On a recent visit to the Carnegie Museum it was a shock to find all the dinosaur names unrecognizable. A taxonomic smart aleck had pulled a switheroo with all the classic dinosaur nomenclature. The venerable T. Rex (I can't spell the full name) was renamed Tarbosaurus. I think that sounds like the name of a docile creature like some delicate avian species. It certainly does not jibe with a apex predator like the T rex.

All this terminology and taxonomy malarkey calls for some harsh correction from the Oldfoolrn  Institute for the Advancement of Medical Terminology. It's always nice to know the prognosis when various medical terminology terms ejaculate from the tongues of sophisticated medical  banterers. It's a simple matter to tack on a suffix to the medical term to indicate prognostications.

If a good outcome is anticipated the suffix is  -goodjuju which can be abbreviated GJJ. If  a  storm is brewing on the medical  horizon and the patient is juxtaing the drain-oops I mean circling the drain, the appropriate suffix is badjuju or simply BJJ. Here is a sample: Aortic dissection BJJ or erythematous skin lesion GJJ. My system is straight forward and fun. Feel free to use the next time you are typing in a diagnosis on the EMR. Maybe if enough folks use this system it will gain traction, just like that silly Juxta prefix.