Pedals, Pain, and A Resurrection

 When I relocated to Pittsburgh in the 1970s I was unable to find a position open in the OR so I accepted a position at Montefiore Hospital that offered a month-long critical care course if I agreed to work for a year in their neurosurgical ICU. My home in the OR was the neuro room so it seemed like a good fit. One of my first patient experiences fossilized itself onto my heart and with my low emotional IQ, that's  really saying something! I have never seen a patient with so much neurotrauma make a recovery like hers.

Before she received a depression generating "C" grade in thermodynamics, before her suicidal drive shifted into high gear, before she blasted down Bates Street with pedals pumping and a chainring spinning like a top, before the deliberate impact with her road bike impacting  a brick wall fronting a moving and storage building, before a 4-hour session in the OR to tease and release a huge subdural hematoma, Jenna had been an outstanding mechanical engineering student at the University of Pittsburgh with a spoiled little Shi Tzu as a pampered pet..

The Neuro ICU at Montefiore hospital was a huge room with 10 beds separated by curtains, but there was an alcove like area hugging bed "1" and that offered a modicum of privacy for staff interactions with comatose patients and Jenna was going to need all the stimuli she could get. She was transported directly from the OR to neuro ICU and her entrance was memorable. Jenna was a young looking 21-year-old who could have easily passed for a teenager. She looked so tiny and helpless in her ICU bed with her thick blond hair cascading below the cranial dressing on the unshaved side of her head. 

It didn't take an assessment via the Glassgow Coma Scale to see that she was well beyond obtunded and her consciousness had exited the time/space continuum long ago. Her pain was captured in the coarse weave of the gauze carefully wrapped around her fractured skull. The number of surgeons, nurses and anesthetists accompanying her foretold a grave prognosis. Prodigious pumping was always a bad sign and the anesthetist was squeezing the Ambu bag like a sailor squeezing a sponge to bail out a sinking boat. A harried nurse was pumping away on the syphgmo to tease out a blood pressure and one of the critical care medicine fellows was maintaining pump pressure on the infuser for her arterial line. A trio of pumpers was not a good omen.

We connected her endo tube to one of the newfangled Puritan-Bennet MA-1 ventilators which had just recently replaced our old Engstroms. Those old ventilators had a nice soothing swish/whisper sound to them while the new Bennets had disturbing bark-like noise when the inspiratory cycle was initiated. I didn't  like them. Untangling her mannitol, pressor, arterial and blood lines made me wonder if anesthesia folks were macrame aficionados! What a mess.

We did not have dedicated gizmos to secure endotracheal tubes and the heavy adhesive tape applied in the OR was snagged in what little hair that was hanging like a stalactite from her cranial dressing. After she was settled in, I explained to her, "I'm going to free your hair from the tape and comb it out so you can be styling." I always liked to plaster two pieces of tape together sticky side to sticky side where there was contact with hair. Sometimes it's the little things that matter the most.

Neurotrauma is a beast that maliciously extends its tentacles to outlying organ systems inducing problems like diabetes insipidus, hypotension, thermal dysregulation, and in women, disordered menstrual cycles. On the second day of Jenna's coma her menstrual period began with the intensity of a Mount Vesuvius eruption. I didn't know if it was her time, but the intensity suggested a jump start secondary to her neurotrauma.

Her Mom brought in a box of tampons for her, but ICU policy restricted their use, so I explained to Jenna what we were going to do. I said, "Jenna, I really hope you can hear me (I was hoping that despite her comma I could communicate with her on some level.) We really need to monitor your flow so I'm so sorry we can't use tampons. You have so many internal devices that pads are really a better option. I'll change them every couple of hours and tidy you up. I really hope this is OK with you." I rolled up a chucks blue pad like a burrito with the absorbent side facing out and used it to prop an ABD pad into position.

Slowly Jenna began to show signs of the coma lifting and on the fourth day we were able to extubate her. Her eyes were open and beginning to sluggishly follow moment. 

I had a couple of days off and upon return to the unit the nurses were excited because Jennna was awake and verbalizing. One of the first requests she made was to meet the male nurse who apologized for the pad substitution for the tampons. I strolled over to her bedside and told her how happy I was to see her awake and she began crying. "When I heard that masculine voice apologizing for the tampon ban, I just knew that I had to meet you. I think that gave me a reason to wake up. I will never forget you."

I certainly never forgot Jenna!

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. 

Student Nurse Uniforms-Rules and Regulations (Circa 1969)

 

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On a recent glance through some old nursing school papers a peculiar document jumped out at me. It was a signed copy of our school's uniform requirements which were aggressively enforced with weekly uniform inspections. Since I'm just going to copy the agreement, this post will have a more cohesive narrative arc than my usual foolish ramblings. I guess it's about time for a clean linear narrative that's more coherent than my dementia fueled posts!

UNIFORM REQUIREMENTS

The uniform of the school of nursing should be worn with dignity, respect. and in strict accordance to the following regulations. The complete uniform is worn only in the buildings of the hospital. If worn with a lab coat, the complete uniform may be worn to and from the mailbox at Wellington and Dayton.  (With no quick stops at the Wellington Ave liquor store.)  Sorry sometimes my foolishness just pops out! 

Students are in complete uniform when they are wearing the following:

1. The blue school dress which may not be shorter than the midpoint of the knee.

2. The white school apron, with it's hemline two inches above the hemline of the dress, it is to be worn in all clinical areas except the operating room, obstetrics, pediatrics, and isolation wards.

3.The white school cap (beginning after capping ceremony,) which is to be clean, Argo starched, and properly folded. Seniors are to wear a 5/8 wide black velvet band. The band is placed parallel to the very last row of stitching. The cut edges are folded under the band at their terminus. the cap is secured by white bobby pins and may never be worn outside the hospital.

4. Hair is to be clean, neat, simply styled and away from the face. No loose strands of hair shall contact the face. Hair must not touch the uniform collar. It may be secured by a barrette if the appliance is totally inconspicuous. Pincurls,curlers, or hair ornaments are never to be worn with the cap.

5.Under clothing must be clean, white and in good repair. foundation garments must be serviceable and inconspicuous. Condition of under garments is subject to verification at uniform inspections. (Hmm...maybe that's why I was always rejected when I volunteered to assist with uniform inspections)

All students in complete uniform must wear white clinic shoes, polished and in good repair. Laces are to be clean and white.

Wear hosiery that is white clean and in good repair.

Hands must be clean, and the nails cut short (the optimal subungual space is 1 mm.) No nail polish including clear may be worn. When going off duty a lotion should be applied to the hands-a dermatitis makes the proper cleansing impossible, thus rendering hands unsafe for duty.

Not wear decorative jewelry (this includes wires or plastic appliances for pierced ears.) Name pins are to be worn on the upper left chest.

Each student must carry accessories to complete the uniform. these include a red and black pen, notebook, a watch with accurate second hand, and a bandage scissors.

The student nurse who is properly attired in her uniform has an air of vigor and a joy for the privilege of caring for others.

As usual, male students got a break when it came to uniform regulations. We wore a white scrub top and white cotton pants. I never attended a uniform inspection!  

Portrait of Oldfoolrn As a Young Man

A few recent emails inquiring about my dearth of recent posts with concerns about my health really warmed the cockles of my arteriosclerotic laden heart. Yep...I've had a few recent issues; bilateral knee replacements with complications, cataracts, and an overwhelming (almost) klebsiella sepsis. I would have never survived as a devout weaver of more foolishness without the caring expertise of so many outstanding whippersnapperns! I was deeply touched by their caring and skill. My nursing world was so far removed from theirs that I cloaked my identity as an Oldfoolrn! I lied and told them I worked in a produce warehouse which was partly true.

So I ventured down to my basement junk pile nursing archives to search for an inspiration to write something. Sometimes not writing is as important as writing, but lo and behold I stumbled across this image of me posing in all my foolhardy grace with my esteemed classmates well over 50 years ago. This was a time when 3 year hospital based nursing education (if you could call it that!) ruled the roost.

These archaic programs promulgated some very bizarre notions and customs where consciousness was outsourced to the will of the school. Diploma nursing schools were bastions of laissesz-faire zeitgeist. It might be foolish to describe a Chicago based nursing school using French and German words, but this terminology fits the culture like a glove.

By way of further and complete obfuscation explanation, we were expected to be totally non-judgmental when caring for patients while being subjected to judgments that were akin to dogmas established by religious fanatics. We were prohibited from ever carrying money to reinforce dependency on the school despite living in a building that had marble clad walls, terrazzo floors, and a chandelier in the auditorium that rivaled the one in the opera house. The generosity of well heeled donors extended only to durable structures not people.

We were expected to exhibit an instinctive kindness even when working all hours of the day and night. Our first clinical rotation was during a hot Chicago summer on a detox medical ward. I will never forget the hodge-podge of smells (paraldehyde, emesis, sweat, and Kayexalate induced stools.) The intrepid instructors believed if a student could survive in this environment, they would be able to limp to completion of the program 3,000 hours and 30 months later. We started with 78 probies and graduated 23 nurses. I think the graduates envied the folks who had the sense to bail out!

It's interesting to note from the class picture that only those with the grim sour puss expressions (self included) managed to graduate. My friend, Rhonda, the smiling, ever pleasant young lady on my right left after 6 weeks to escape the mind numbing, soul shattering world of a vintage Chicago training hospital!

Gastric Freeze-A Cold Hearted Idea

A stomach freezing machine. That eggplant size balloon
in the MDs hand was inserted transesophageally and zero
Degree F. ethyl alcohol circulated via a double lumen catheter.

 Whoever came up with that old medical adage stating if there are 3 or more treatments available for a single ailment, none are effective, was likely talking about duodenal ulcer treatments of the 1960s.Whacky dietary regimens featuring half and half or whole cream as the main ingredient, antacids, and of course tranquilizers because nervous folks suffered from ulcers were medical interventions of the day.

About 15% of ulcer patients had a dismal response to medical treatments and required surgery. The operation of choice was a gastrectomy with or without vagotomy (cutting the nerves that stimulate acid secretion.) This was big time surgery of the day and carried about a 5% mortality rate along with patient dissatisfaction from digestive problems. Every old nurse was acutely aware of the dreaded dumping syndrome where high carbohydrate foods entered the duodenum like greased lightening causing dizziness and occasional fainting.

Intractable medical problems like gastric ulcers often produce nonsense like this textbook edict, "The disease is easy to treat but difficult to cure."  (That classic was from our Brunner's Nursing textbook.) About one in ten Americans harbored an ulcer and the disease favored men. The combination of lots of suffering folks and the medical mind set to do something... anything... for a cure frequently produced disastrous results. Medical breakthroughs touted on newspaper front pages sometimes proceeded to the obituaries as time passed. Certainly, this was readily evident with frozen stomachs and their hemorrhagic complications.

In 1960, a group of surgeons headed by the famous Dr. Wangensteen, inventor of the lifesaving intermittent suction named after him came up with the notion that gastric ulcers could be cured by freezing the stomach.  General hypothermia (lowering the body temperature to 86 degrees F. (or 30 degrees C.) was occasionally used to help patients survive brain or cardiac surgery.  Under general hypothermia, gastric acid secretion was noted to decrease.

oldfoolrn: Wagensteen Suction - Elegantly Simple Without Electricity

Dr. Wangensteen questioned, instead of cooling the whole body, what would transpire if only the stomach was chilled? He took the notion one step further and wondered about not merely cooling the stomach, but actually freezing it. I guess he never thought about what happens to a frostbitten ear; it falls off.

Desperate for an ulcer cure, freezing the stomach seemed worth a try. A balloon shaped like the stomach and a double lumen catheter to circulate freezing cold ethyl alcohol (zero degrees F.) through the balloon was devised. Experimental trials in animal trials commenced. I could never, ever work in an animal lab with dogs whose internal organs were rearranged and fooled around with in the dubious name of science.

One of the bizarre demonstrations of the frozen stomach efficacy was to oxygenate a frog and lower it into the stomach of a live dog. From an untreated stomach the completely digested frog was pulled up 6 hours later. From the frozen dog's stomach the frog would emerge hopping away at a lively pace. Yikes.. and I thought watching my cat vomit mouse parts was disgusting!

The May, 1962 Readers Digest ran an article, (They're Freezing Ulcers to Death,) and thousands of patients began demanding the treatment. Maybe they should have renamed the magazine The Digesters Reader! Sorry, blame that one on my foolishness.

The medical industrial complex quickly responded and stomach freezing machines were manufactured for eager hospitals and physicians despite the reservations of more conservative practitioners. This was not another innocuous pill that could be discontinued in the event of complications, but an anatomical alteration with the potential of real morbidity and mortality.

The gastric freeze did eliminate symptoms for some folks, but the ulcers always returned with virulent ferocity. A few unlucky souls experienced immediate separation of the lining of their stomachs and uncontrolled bleeding which required emergency surgery with sometimes catastrophic loss of life. The gastric freeze treatment lasted about 5 years (1963-1968) before practitioners gave it up. Too many complications with loss of life.

A bona fide cure for most gastric ulcers came about when a 1985 article published by Warren and Marshall in The Journal of Gastroenterology described a bacterial infection by H. Pylori as the cause of ulcers. The good doctors proved their point by infecting themselves with the bacteria. an antibiotic regimen proved to be the bonafide cure for gastric ulcers.

Happy Armed Forces Day!

 To all those amazing folks on active duty and veterans, you are deeply appreciated and there is really no way to thank-you for the sacrifices you make. I think of you folks daily!

On Tenterhooks with Atrial Fibrillation!

 Despite the pledge I made to myself to refrain from personal health related complaints, here I go with more foolishness about my recent hospitalization. The nurse-turned-patient phenomenon can be fertile ground for peculiar insights into the illness experience.

I've had episodes of atrial fibrillation now for about 13 years. They are usually no big deal, but combined with a Klebsiella sepsis, the last one was tough to shake off and required more intensive intervention. I was minding my own foolishness in the ER holding area, awaiting an inpatient bed to avail itself when all of a sudden it felt like there was a kettle drum pounding away in my chest. I was going to say that it felt like an elephant sitting on me, but my wife is right, I tend to exaggerate. The medical resident was close by so I told her that my chest was feeling "funny." I really don't like to disclose that I was a nurse to providers so I understate and use foolish vernacular to illustrate my plight. My nursing experiences are too dated to be relevant today.

She took a quick listen with a fancy electronic doodad festooned stethoscope and shrieked to a nearby nurse to put me on a monitor. The nurse hastily applied the electrodes, gazed at the monitor with that avian eyeball intensity and flipped out, shrieking to get the crash cart. I was doing just fine up to this point, but in all the ensuing drama, I felt panicked-not a good thing when you are in atrial fib.

The arrythmia was promptly converted to normal sinus, but I felt guilty for all the excitement my predicament caused.  I was perusing some of the tips for novice nurses on atrial fib that Kati Kleber RN MSN had on her nurse education site, FRESHRN. One of her suggestions really hit home, "Put on your nurse face when caring for a patient in atrial fibrillation." From a patient's perspective, I offer up a hearty AMEN to that one!

For all you bright whippersnapperns out there take a gander at FRESHRN. I really admire Kati's fine work and it's a wonderful resource..