Saturday, January 13, 2018

A Scrub Nurse's Prayer

May your Mayo Stand rise up to meet you.
May the Bovie smoke always be at your back.
May the overheads shine glare free upon your sterile field,
and until the skin margins meet again,
may God load your needle drivers with 3-0 silk.

Wednesday, January 10, 2018

New Year - New You Thanks to Tapeworms


A penny in the fuse box solution for weight loss. Maybe I can launch a new career in retirement as a tape worm sanitizer by training the little critters to jump into a bottle of Phisohex.

Thursday, January 4, 2018

Trauma Blankets - A Macabre Masquerade

Let's face it trauma can be a visually offensive mess.  Before the age of enlightenment with paramedics and trauma centers, seriously injured patients were initially seen and promptly covered up in a trauma blanket by none other than ambulance attendants. The out of sight, out of mind  philosophy at it's finest. Trauma blankets were designed to camouflage the blood and gore making the victim appear aesthetically  pleasing to horrified onlookers  while essentially overlooking  the underlying trauma.

Bleeding? Get that trauma blanket STAT

  Ambulances were just converted station wagons like  Chevy Brookwoods or the Dodge Dart (below) and were maintained and operated  by funeral homes. Attendants were frequently apprentice undertakers and perhaps the skillset of closing body bags helped with trauma blanket application. Ambulance medical supplies were limited to a poorly designed stretcher with tiny wheels that fluttered back and forth like a butterfly's wings when in motion and of course the trauma blanket. Just the sound of those stretcher wheels clicking and clacking as they moved was enough to trigger nightmares and then a glance at a blood soaked trauma blanket was the coup de grace for a peaceful night's sleep.

Trauma blankets were heavy woolen affairs that could absorb their own weight (which was substantial) of just about any liquid or semi-liquid goo like sanguineous  substance. A chartreusy/maroon  color could obscure practically any blood  no matter the volume lost. Attendants made sure the victim was lying on the trauma blanket to mitigate the mess from pooling blood and rapped them up mummy style for the mad dash to the nearest hospital with that big V-8 roaring and drum brakes a smoking. The air  siren sounded like one of those air raid shelter blasts from old WW2 movies.

Removing trauma blankets upon arrival in the ER was like opening a Pandora's Box. Ambulance attendant transfers were done quickly with little finesse and no report from attendants who vamoosed as quickly as they arrived. Upon opening a blood soaked trauma blanket we found glass shards and a severed rear view mirror on the patient's chest. Alas..this must have been a motor vehicle mishap.

Ambulance attendants never heard of trauma shears so the bloody victim often had clothing that had clotted in place. A sort of crude hemostasis mechanism for the not so enlightened. Starting an IV on someone with blood stained extremities is a challenge and darn near impossible with the hypovolemic state induced by traumatic exsanguation.  Trauma blankets were probably one of the most useless, insensitive, and dimwitted items used in yesteryear's hospitals. They certainly creeped me out.

Before people regaled themselves with the flicker of glowing screens, events occurring in the immediate environment garnered diversion.  There was an oversize metal bath basin in the ER and a staff nurse noticed me inspecting the container with a quizzical expression. "That's for treating the trauma blankets. It's worth the show, so hang around after the next trauma," she said with a smarty pants look on her face.

Old time hospitals never discard anything; it's clean and reuse, trauma blankets were no exception. The blood assimilative nature of trauma blankets was reversed by placing it in the oversize bath basin and dousing it with a couple of liters of hydrogen peroxide. The explosive bubbling of the peroxide as it did it's work rivaled a Mt. Vesuvius eruption with the red foam serving as a stand in for volcanic lava. An impressive sight indeed.

History always repeats itself and trauma blankets have strong connective tissue to modern hospitals with their fancy atrium like  lobbies decorated with lush mini-forests of tropical plants. Those gaudy chandeliers  and fancy hardwood moldings add to the ambience. Patients who cannot pay for their treatment are not welcome here. These contemporary trauma blankets hide the uncontrolled diabetic or end stage pulmonary patients that lack resources for care and are forced to fend for themselves. The end result of untreated chronic illness is not pretty, but there is no blood on the ornate hospital's balance sheet.

Monday, January 1, 2018

Aortic Tears on New Years Day According to Dr. Slambow


New Years crashes sometimes resulted in torn aortas. Dr. Slambow
explains and acts out the mechanism.

When one year dissolves into the next, I often lapse into some serious retrospection of New Year's Days  past.  It's not the big time lifesaving trauma  surgeries  (I hate that all too common lifesaving balderdash. It's like a literate canker sore that shows up conjoined to it's favorite twin, trauma surgery.)  No, it's not those bigtime dramatic measures. It's the feckless and stupid little frivolities that come to mind like the way ratcheted instruments so neatly clicked in your hand or the way overhead lights glimmered and danced off a freshly prepped surgical site or being called in to work with my all time favorite surgeon, Dr. Slambow. I really miss him.

I've never been one to celebrate on New Year's Eve. Maybe it has to do with the fact that every one of these occasions resulted in a trauma call  when I was on duty.  I remember a variety of injuries; beer bottle broken over victims head and then stabbed with the left over glass shards, a young man that sustained a 12 gauge shotgun blast to his butt (not a good way to lose 20 pounds,) and of course the usual automobile wrecks on Lake Shore Drive with the victim sustaining an aortic tear that usually resulted in the poor souls  rapid demise.

One long night scrubbed with Dr. Slambow, I began asking questions as they popped into my young foolish, but curious brain, "Why do automobile mishaps cause torn aortas?" Dr. Slambow's eyes lit up like a New Year's Eve fire cracker and I knew I was in for a rare treat- the good doctor was going to act out his answerer. I could not wait.

He asked for a bloody 4X4 to use as a prop and as soon as I tossed down a needle holder that had been in play and fished around for the requested blood soaked  sponge it was show time. Just  as I expected, the rolled up sponge was going to play the part of the aorta and Dr. Slambow's partially closed fist was going to be a stand in for the chest cavity. This was going to be as good as his lecture on Sengstagen/Blakemore tubes when he inflated a used surgical glove (size 8)  that was partially filled with blood until the thumb portion of the glove exploded creating a colorful scene. The mess he created rivaled that of the grandma wrecked on  the Harley case we had last month. What a mess.

Dr. Slambow explained in his deliberate, eloquent tones that the great vessels in the chest were not tethered to anything and could rock back and forth in the mediastinum like a pendulum. He almost teeter- tottered of his booster stand as he rocked back and forth. Coleen, the circulating nurse was standing nearby to catch him in the event of a backward fall. OR nurses are taught to always anticipate the surgeon's action and we knew Dr. Slambow and his antics  all too well.

The good Dr. made a partially closed fist and suspended the twisted sponge between his index finger and thumb so that it resembled the tubular aorta hanging freely within the confines of his partially opened fist model of the chest. His next move was to make a punching motion with his fist just inches from my masked proboscis and suddenly arresting it's movement just before impact with one of the overhead lights. "There you have the mechanism of a torn aorta-the movement of the patients chest is suddenly stopped by impacting the steering column, but the heart is still moving forward a 65 MPH. The shear force tears the aorta."

Thanks for enlightening us Dr. Slambow, maybe next time you could explain why ostomy patients have so much trouble with excess gas. On second thought-never mind.

Friday, December 29, 2017

What was the most viewed post of 2017

This cold weather has induced a Winter brain freeze. I've been working on a post about old school trauma blankets, but  trouble with writer's block has slowed me down-if you could even call my foolishness writing!

I have zero insight about which of my posts are popular with readers. Sometimes my idea of a good post only comes up with a hundred views or less. Subjects that seem on the lame end of the spectrum end up with a thousand or more views. "Go figure," as I've heard youngsters exclaim when something doesn't make sense.

Drum roll...please. My  most viewed post of 2017 was this gem with about 2,200 views.
http://oldfoolrn.blogspot.com/2017/01/not-on-my-back-table.html  (Caution contains disturbing image.)  I did not have the appropriate insight and judgment when publishing this little gem to add the disturbing content disclaimer and this got me blacklisted on some referral sites. My bad (another expression I learned from you  clever youngsters,) and a thousand pardons for my crude behavior. I will try to contain my inherent barbarity in the future.

Wishing you the best New Year yet!

Thursday, December 21, 2017

Technology-The Perils of Early Adoption

When knowledge, experience and technology
fall into place concurrently amazing things happen.
Sometimes this takes time.


The latest and greatest in new technology provides contemporary hospitals health care entities with
ample fodder for advertisements and bragging rights.  Lack of experience and knowledge with technological capabilities can produce some unforeseen problems; antibiotics cure infections, but microorganisms fight back, X-ray treatments of enlarged thymus glands in children gave rise to cancer later in life, and bone marrow transplants for metastatic breast cancer were a big disappointment.

This is my personal tale of an encounter with a brain MRI done back in the good old days of the 1980's when these gigantic imaging machines were called NMRI-the "N" was short for nuclear. The neuro radiologists of today were likely in Kindergarten and ordinary run-of-the-mill radiologists interpreted these vintage scans.

After a fusillade of neuro problems including confusion, right upper extremity weakness, and visual field distortions I had one of those new fangled NMRI imaging studies performed. While I was reclined in the tight confines of that sewer pipe of a machine, I was aware of a commotion commencing in the procedure room. Turns out mine was one of the very first NMRIs that showed significant pathology at this facility and an audience had gathered to witness the premier event. I walked into the NMRI room and left on a Gurney for an acute neuro ward-not a good sign.  Here is the radiologist's interpretation.

The striking finding is an increase in T2 signal intensity in the right occipital area and to a somewhat lesser extent in the right frontal area. Differential might include CNS lymphoma, primary demyelinating process, encephlopathic or infectious etiology less likely. Correlation with clinical findings is suggested.

Now the real fun began. Neurosurgery was consulted and felt the scan was consistent with a glioma and a stereotactic biopsy would be necessary to determine the type. Alas, this was impossible because of the unavailability of a non-ferrous stereotactic head frame. Using the standard head frame would wind up with my head plastered to the magnet like a bug on a windshield. I remember thinking about calling Jack Kevorkian to see if he could squeeze me in as the prognosis seemed more grim as time passed, but there were many more consultants waiting in the wings so let's wait and see.

Next on the parade of consultants was a neurologist whose primary area of expertise was MS, of course he concluded that MS was the diagnosis and a spinal fluid study for monoclonal antibodies would be the confirmation. The studies later proved negative for monoclonal antibodies so the diagnosis was changed from MS to "demyelination syndrome," whatever that means.

Let's consult a clinical pharmacologist to get his opinion. I was taking Azulfidine for Crohns Disease and a review of the literature suggested an encephlopathic process could be a result of taking this drug. The final diagnosis: Azulfidine induced encephalopathy. Stopping the Azulfidine made no difference in my neuro status, but jump started the Crohns, not a pleasant situation.

I slowly recovered and started backing away from follow-up appointments, figuring that whatever it was would take its course. My  neurosurgeon died about 5 years ago and I started to marvel at my survival skills having outlived him. He had given me a prognosis of 5-7 years.

So 28 years after the original excitement  a  NMRI  MRI was scheduled and it was nothing like the old time days. The machine had a wide bore and I actually missed the intimacy of being stuffed in that old sewer pipe of an NMRI machine. The technician also insisted that I use ear plugs to muffle the signal generator. I missed the booming and banging. This time sure was different.

A genuine neuro radiologist interpreted this MRI and there was none of that old school beating around the bush. This lady knew what she was looking at, no bones about it. I certainly could have benefited from her expertise 28 years ago. Here is her impression.

abnormal foci of T2 hyperintensity within the subcortical and periventricular white matter are much greater in size and number in the right cerebral hemisphere compared to the left. There is a more confluent area of abnormal T2 hyperintensity posterior to the right lateral ventricle. The asymmetrical appearance of these lesions effectively rules out classic multiple sclerosis. This MRI is indicative of an acute disseminated encephalomyelitis.

It's nice to have a definitive diagnosis even though it required a 28 year wait. Some problems cure themselves if you can wait them out. Time is the most valuable commodity and the neuro Gods have cut me a break. I'm still vertical and my foolishness remains intact but sometimes I wonder about my cognitive abilities.


Thursday, December 14, 2017

Nursing Awards - Emmitt Knows Where They Belong

Proud winners of a nursing award. At least
their trophy has relevance-looks like a bath basin.
When Emmitt Smith, the hall of fame running back for the Dallas  Cowboys received the"Galloping Gobbler" award from John Madden, he knew what to do with it. No pretentious acceptance speeches or bubbly gratitude for a meaningless award.  When Emmitt thought he was off camera that pointless award was unceremoniously deposited in it's rightful place, the garbage can.

It's too bad that some nurses lack Emmitt's judgment and discretion regarding meaningless, phoney baloney awards worth their weight in wormwood. Hospitals of today often have a shrine-like  area where garish gold plaques are displayed honoring a select group of nurses. Nothing wrong with this concept if it gives recognition to deserving nurses who have honed their technical skills to help patients, but frequently the awarding entity is far removed from patient care and  has little insight into bedside nursing excellence or comforting patients. Physicians, administrative nurses (if you could even call them nurses,) insurance companies, and the nurse academic/ office sitter complex all have very minimal working knowledge of what makes a good bedside nurse. Doctors just love nurses who know their rightful place and never question orders or call them up in the middle of the night. Administrative types view nursing through the distorted lens of corporate goals and please don't get me started on office sitters of any permutation. Discretion is the better part of valor, I keep muttering to myself. Sometimes it's better to keep my foolish mouth shut.

We certainly had nothing like this when I was a nurse. Our instructors and mentors (if you could call them that) always stressed that the satisfaction of helping patients recover from injury or ailment had to come from within. If a trauma patient walked out the door or a patient's pain was relieved, you did a good job and that was your reward.  In their mind nursing was a calling and required self motivation which was also a good reason for paying nurses a poverty wage. If you are looking for good time Charley back slapping rewards or big money you are in the wrong profession.

As a public service the OFRN institute for nursing practice is going to separate the wheat from the chaff when it comes to awards for nurses. If you notice any of the following words or combination of words in the criteria or award title, its of  dubious distinction: influential, pinnacle, showcase,  emerging, distinguished, rising star, engagement, transformational, breakthrough,  paradigm, cameo, illustrious, or eminent. It's time to go above and beyond or even eschew these  nonsensical awards. It's time to take a lesson from Emmitt Smith and deposit these chucklehead awards in their rightful place.

Here are a few worthy nursing awards that have straightforward criteria and reflect nursing as it's clinically practiced, untainted from pie-in-the-sky bafflegab.

The Last Nurse Standing Award... An endurance award of sorts to the scrub nurse that can hang in there on one of those knee aching  surgeries that start before sunrise and end after sunset and I'm talking about Chicago - not the Arctic circle. My personal best is close to 8 hours on a complex trauma and that's not even worth mentioning because  my mentor Nancy went for close to 12 hours on a Whipple with complications. She deserves a standing ovation and a well deserved trip to the bathroom.

The Stink Finger Statue... Goes to the nurse who never shied away from any mess-you name the body excretion and this nurse gets down to business, sans gloves. I really admired this nurse because almost everyone has an Achilles heal when it comes to messes, mine was that gooey blood/bone chip slurry mess left on the floor of the ortho room after a long,  messy case.  Blood..no problem, bone chips..no problem, but mix them together and the resultant ooze-like  combo brought me to my knees every time. Thanks to Colleen and Gail for bailing me out on this one. You deserve this and remember to refrain from sniffing those fingers.

Venous Access King or Queen...goes to the best IV starter. Bring me your hypovolemic, phlebotic and sclerotic patient and I'll slide that angio cath in faster than you can say central line.

The Sailor Award...goes to the most fluent user of off color language. I usually avoided this one because it resulted in much childhood unpleasantness if caught uttering swearwords, but I  some how felt a sense of relief when others spouted out colorful descriptive language. Nurse  Felix deserves this award for coming up with the u;timate inclusive cuss word (sh++t,f**k.G++d**n it) all in one breath. What more can I say?

Most Likely to Cry...I always admired nurses that could do this. It's better than alcohol or drugs at diffusing sadness. The most I could come up with were a couple of stray tears, but at least I tried.

Most Kind nurse...We all know one of these. This nurse is nice to everyone and always sports an infectious smile that's even visible under a mask. As nurses age this trait seems to decline although I have met a couple of these angels in white who were well into their 60s. Rita you deserve this award if you can stop puffing on that Winston long enough to claim it.

The Walking Wounded...These tough nosed, hardened nurses can work through bone on bone hip joints, unremitting Crohns Disease, or even while on chemo for aggressive cancers. Tough as nails; the primary objective is to die at the bedside with their Clinic Shoes on. I did manage to scrub on a case one day after having impacted wisdom teeth removed and I was never so grateful that it did not involve oral surgery. The pain sharpened my senses, but I would not never,  ever want anyone to work for this award.

A really good nurse will do whatever it takes to help a patient in need not because it's about award procurement, but because it's the right thing to do. The fact that the obsessive pursuit of awards leaves profound deficits in other areas of direct  nursing care is a definite reality. Emmitt got it right.