Saturday, December 24, 2011

Thank You! From Orfyn

Thanks to all of the regular readers of this blog and others for reaching a thousand visits just before Xmas! Regular readers that I know of: Alanna, Alexandra, Babaybee, Bradley, Debs, dkmapme, Nothing Profound, Thom, Tony B, Shirshir, Teresa and of course to all those "anonymous" readers. Special thanks to long time  friend Robin for advice and encouragement.

Sunday, October 23, 2011

Fourteenth Chapter

Fourteenth Chapter
In which a dependency issue has resurfaced, a blamestorm is resolved and a charity established.

   Chicky is waiting in the outer office of her boss, June Tinney, RN, the Vice-president for Patient Care. They are old friends and comrades in arms, having worked together in the Med/Surg unit many moons ago. They have watched each other climb the ranks steadily over the years. June has been away the past week dealing with issues arising from the acquisition of a smaller suburban hospital into the University Hospital system. The phone on the desk rings, answered by Stella, June’s secretary, and Chicky is ushered into the inner office. June rises from her desk, and she and Chicky sit at a smaller conference table by the window which looks out on a garden courtyard.
  “It seems I picked a good week to be somewhere else. Tell me about it” June says. “I guess I‘ll start with the bad news first” replies Chicky. “When Mary Stuart arrived early in the morning on Monday to set up PACU for the day, she found Connie going through the sharp boxes and in possession of a couple of syrettes of Fentanyl and Morphine Sulfate that had been partly used and then discarded.” (Narcotics come in cartridges called syrettes that snap into a special syringe. Intended to be a single dose, sometimes less than the full contents are given) “Connie fled, but was stopped at the door by security due to Mary’s call. They took her to the ER and to make a long story short, toxicology showed her to be positive for Opiates. She was terminated on the spot.” June gave a sad look out the window. “What a shame. She had been doing so well with that pre-op coordination post.” “Is there anything we can do for her?” asked Chicky. “Very little, I am afraid” said June, “ I have talked to Larry (CEO of University Hospital) and he is willing to keep her on the insurance plan long enough for another round of rehab, but that is all.” “That is very generous and a lot more than I expected” said Chicky “I have drafted a report to the State Board of Nursing. Connie was on probation, so now the only question concerning the Board is whether they suspend or revoke her nursing license.” “I would not be optimistic there” June said “the nursing board is much tougher about these things than the medical board. With the Compact (an agreement among the boards of nearly half the states in the country concerning reciprocal licensure) whatever the status of her license here, it would be the same automatically in the other compact states. And non compact states would not be likely to give her a license either. Let me see the letter and I will co-sign it.”
   Not like State Medical boards. Unlike nursing which had a single board exam for all nurses in the country, every state had its own medical board exam. Each state board of medicine was fiercely independent, not unlike physicians themselves, and not inclined to be cooperative with each other. Chicky was thinking of several physicians she knew of who got into trouble and had licenses suspended or revoked. They just moved to another state and set up shop there. Not to mention that while suspensions were given out regularly, it was rare for physicians to have licenses revoked. There was the case of the so called hotshot transplant surgeon that the hospital had recruited from Harvard. The hospital was so eager to get this guy based on all his publications and addresses to medical conventions, they gave him tenure before they actually saw him in action. While intellectually and academically gifted, he turned out to be incompetent at performing surgery.  The hospital was stuck with him, so he was shuffled off into running the workman’s compensation clinic. The clinic was where people with on the job injuries went for evaluation, treatment and therapy, and recuperation time off work granted. It was also where these people went to have their care managed and to get their prescriptions. One day there were an unusual number of tradesman’s vans and trucks in the alley behind the hospital, and an unusual number of men in overalls with various logo patches for electricians, plumbers and the like coming and going. At the end of the week, a number of hospital employees were led out in handcuffs, including the director of the workman’s comp clinic. It turned out that he was giving weeks of time off to employees in exchange for the pills from the prescriptions he wrote. While he was out on bail and his attorneys delayed proceedings with all the tricks of their trade, he just went to the next state over and set up shop there. In the end he only got a six month sentence, and went right back to practice when he got out in the neighboring state.
   “Connie is single isn’t she?” June asked. Chicky nodded. “Well at least there is no spouse or children to be effected. It would be heartbreaking to have a family involved.” Chicky and June were both thinking of the anesthesiologist who died with dependency issues and the tragedy of his family. June thought out loud: “When we had a problem before, we went from having narcotics in multiple dose vials to the syrettes to avoid dilution of the drugs to cover pilferage. Also, the narcotics could be tracked with more precision. We never thought of any one going through the sharp disposal containers.

 It is a miracle that Connie didn’t pick up AIDS or Hepatitis. It’s unfortunate that the syrettes have needles attached to them.” Sharps, such as needles, scalpel blades, suture needles, etc. were placed in plastic puncture proof containers for disposal. This was necessary to prevent injuries and the spread of infections such as hepatitis, aids, or even garden variety bacteria. “I have been thinking along those lines myself” said Chicky “I think we have to set a policy and practice of having incomplete syrettes squirted down a drain before they go into the sharps containers. The wastage must be witnessed and signed into the record by two nurses or a physician and a nurse, just like when the drugs are signed out from storage.” “I think you are dead right on that” said June “it will be awkward and slow things down a bit. The nurses are going to find it burdensome, but it has to be done. I want it in place by the end of the week. Get some of the other nursing managers together and get it done.”
   Chicky nodded and moved on. “Then there is the donnybrook Dr. Bensalem has stirred up. It seems an emergency C-Section came to the OR without a Foley catheter. It was an extreme emergency, a placenta previa, none of the OR nurses or even the anesthesiologist noticed in the rush. The patient suffered a bladder tear, and the baby had a significant depression of APGAR, and had to spend a couple of days in the NICU. Dr. Bensalem wants to blame it all on the OR nurse, claiming that she should have noticed, and that she was slow and incompetent at getting a Foley into the patient midway through the procedure.” “Yikes” exclaimed June “Am I to take it that your nurse was able to get a Foley in under the drapes in all the blood and panic? That doesn’t sound like incompetence to me, she deserves a medal. And if I know Dr. Bensalem, your nurse was probably being yelled at the whole time. How is the baby and mother doing?” “They are both doing well. No sign of any impairment of the baby, only time will tell. The initial depression of the baby could be equally due to excessive anesthesia time or lack of blood supply because of the detaching placenta. The time under anesthesia does not seem excessive compared to other C-Sections.” Chicky recounted. She continued: “I understand where Dr. Bensalem is coming from. Obstetricians are being sued out of existence. Many OB-Gyns are restricting their practice to Gynecology and abandoning Obstetrics. Their malpractice insurance rates are skyrocketing.” June interrupted “That is still no reason to blame it all on your nurse. I know that some surgeons can be very nasty when under pressure, everybody understands that, and my impression is that most are very apologetic once the dust has settled. I wonder why Bensalem is making such a fuss this time?” I don’t know” Chicky said “In her incident report my nurse observed that neither the L&D nurse nor Dr. Bensalem gave any report of the patient’s condition as they arrived in the OR as per policy. That is something we need to tighten up on. And the L&D nurse’s notes indicate that Dr. Bensalem ordered a Foley removed in L&D. I talked to the L&D nurse involved, and she tells me the Foley was removed to get a better ultrasound image when Dr. Bensalem was diagnosing the patient’s condition.” “I will have a talk with the Chief of Staff” June said “I am sure the case will be discussed at this week’s M&M conference on Friday.” (M&M or Morbidity and Mortality is a weekly conference where all cases with less than expected outcome, with complications or where there is significant injury or death are discussed by the medical staff. M&M can be a very traumatic experience for a physician who must present and explain his or her decisions and care given). “I will also make sure that our legal counsel is apprised of the situation and suggest that she have a quiet word with Dr. Bensalem about slander and libel. Does your nurse seem to want to make an issue of the situation?” “No” said Chicky “I think that a simple genuine apology would fix things up there. She understands where Dr. Bensalem is coming from.”

  “Lastly, I have some good news to report” Chicky said. “Since her trip to Africa, Molly has been collecting opened but unused dressing materials, gloves and the like, things we would be discarding, to send to her contacts over there. She would like to see if she can get the other hospitals in the University system to do the same. She has nearly 600 pounds collected so far. Could we arrange for her to visit the other hospitals in the system? She would love to do a grand rounds presentation with her photographs.” June nodded assent and said “I think we could get her some time at the next executive meeting and get the leadership on board. We could probably help out with the shipping costs and red tape. I think the CEO would love to see such a project.” June beamed at her old friend. “Tell Molly to get ready to wow the brass.”

Friday, October 7, 2011

Thirteenth Chapter

Thirteenth Chapter
A widow’s progress is traced and she endures a blamestorm
   It has been seven months now since Nancy lost her husband Steve, a policeman, to a tragic accident. There have been many adjustments, some more successful than others. She still sleeps on her side of the bed, often waking in response to the empty space next to her. She still keeps Steve’s pajamas under the pillow on his side of the bed, his scent now only very faint on them, but she can’t bring herself to remove them. Her loss was at first a numbing blow, which soon became a burning of the soul. With time it has scarred a bit and become an ache that waxes and wanes, but is always present. There are things Nancy can expect to trigger the pain, and she tends to avoid these whenever possible. But there are also the unexpected, surprising things that bring on the ache.
   This night Nancy is on call, she is sleeping in the on-call room at the hospital, her children staying with her sister.  Not many hospitals have on-call rooms for nurses, but University Hospital does. Being located in center city, most of the nurses live in the suburbs, and could not be to the hospital in the required response time. On-call rooms for nurses, residents and doctors are located on a former patient care floor of the old building. The rooms are still in unrenovated nineteen fifties décor, somewhat on the worn and shabby side but clean and comfortable. The nurse’s room features a television, microwave and lazy-boy recliner donated by the nurses, as well as a standard hospital bed and bedside table. There is also a bookshelf stocked with magazines and dog eared paperback books. The phone on the bedside table rings in chorus with the on-call pager going off. Nancy answers the phone, hears the brief message and heads out of the on-call room for the OR, already attired in surgical scrubs which also function as PJs. The case at hand is an emergency Caesarian Section, in this instance the result of a placenta prematurely detaching from the uterus, a condition called placenta previa, which would result in loss of blood supply to the baby. As emergency C-sections go, they do not get any more urgent than this.
   Arriving in the OR, Nancy finds that Debs has already set up the room, with all the sterile packages and cases ready to open. “You go and scrub, I’ll open up” Nancy tells Debs. Nancy begins opening all the packages in that careful, deliberate manner that creates the sterile fields, and exposes all the instruments so that Debs can unpack and prepare the items that will be needed, laying them out in order of use. Debs reenters the OR from the scrub sinks, arms dripping, but held with the hands up so that water will not run down from the upper arms carrying bacteria to the hands. Debs reaches and picks up a sterile towel from the gown pack set on a small stand apart from all the other sterile fields so that if she slips or drops something, nothing but the gown pack will be contaminated. After drying her hands, the forearms, still keeping her hands up, she drops the towel in the dirty linen bag, picks up the gown by what will be the inside, never touching what will be the outside, and puts her hands through the sleeves, but not through the cuffs. Keeping her hands inside the cuffs, Debs picks up a sterile glove by the cuff which has been folded down over half the glove, so that once again, she is touching only the inside of the glove. Deftly, she pulls it over her cuff enclosed hand, and then pushes her hand through the cuff into the glove. Now she picks up the other glove with her gloved hand, repeating the process so that she now hands both gloves on and the outside of the gown and gloves has not contacted her skin. Nancy fastens the gown at the neck, ties the ties that are inside the gown in back. Debs detaches another tie at her waist, handing the end with a cardboard card at the end to Nancy. When Nancy has the card in hand, Debs turns herself around, grasps the tie and pulls it free from the card, and ties the gown in front. The whole process has left Debs with her exterior surface completely untouched by anything unsterile. Debs completes the set up again maintaining a strict isolation of sterile items from the unsterile. Completing the set up, Debs looks around and sees that she has time for one last special thing she likes to do for C-sections. She unfolds one of the square multi layered gauze sponges called a 4x4 for its size (4 inches by 4 inches) until it is a square 12 inches on a side, and just a single layer thick. She then pokes the snout of a rubber bulb syringe through the center, and gathers the corners at the rear of the bulb, tying them in a knot. The result is the bulb syringe with a non slip grip. When covered in blood, as it will surely be, the bulb syringe can become quite slippery. The bulb syringe is essential for removing blood and mucous from the baby’s nose and mouth, the first thing that will be done when it is free from the uterus.
   Nancy and Debs count their sponges, instruments and sharps. Just then Archie, the anesthesiologist, enters the OR pushing the gurney with the patient. With him is Dr. Bensalem, OB-Gyn surgeon, and Linda, a nurse from the Labor and Delivery (L&D) unit. Dr. Petersen, a pediatrician rounds out the team. The anesthesia for emergency C-sections is very tricky. In non emergent C-sections, a spinal anesthetic can be used, posing no risk to the baby. But putting a spinal into a pregnant woman is not easy, and it is time consuming. A general anesthetic is quick, especially using a rapid sequence induction, but you only have about two minutes before it begins to adversely affect the baby. In the situation of a placenta previa, there is no time for a spinal.
   Quickly, the gurney was pushed up against the OR table, the patient lifted over, the gurney removed. Nancy moved to the head of the table to assist Archie with the rapid sequence induction, while Linda exposed the patient’s abdomen and began to paint it with an iodine solution. Nancy held an oxygen mask to the patients face, explaining that it was just oxygen to get her blood level of oxygen as high as possible. Archie attached his drug syringes to the lines. Dr. Bensalem, who went by Bea, came in dripping from the scrub sink. Debs got Bea gowned and gloved. Linda set up the incubator that would receive the baby, and opened the pack of supplies for caring for the baby. Debs and Bea draped the patient’s abdomen, handed off the suction line and the cord for the Bovie, also called the electro cautery, and Linda plugged them in. Debs handed Bea a scalpel and sponges and picked up a Richardson retractor. Everybody looked to Archie, who asked if everyone was ready. Getting the affirmative, Nancy placed two fingers on the patient’s throat, feeling for the cricoid cartilage just below the Adams apple. She nodded to Archie who injected his drugs. Nancy pressed down on the cartilage with two fingers of one hand while picking up the ET tube with the other. Archie tilted the head back, placed the blade of his laryngoscope in the patient’s mouth, slid it down the throat, and raised his open hand, not taking his eyes away from the patient’s vocal cords, exposed by the laryngoscope. Nancy placed the ET tube in his hand, and Archie slid it into place. He gave a squeeze on the ventilator bag, and when Nancy saw the condensation form on the inside of the ET tube, she inflated the cuff of the tube. Archie called out GO! And Bea made her incision.
   There are two incisions used for C-sections, the Midline and the Pfanstiel. The Midline starts just below the umbilicus and goes downward. It has the advantage of being fast, as there is only the skin, subcutaneous fat, fascia and peritoneum to go through before you are in the abdominal cavity. It is also easier to close because there are fewer layers to sew.  Its disadvantage is its lesser strength, and the fact that most bodily movements put stress on the closed incision, pushing it apart. The Pfanstiel incision goes from side to side, across the bottom of the belly, and is sometimes called the bikini line incision as it will be concealed even by a small bikini. It is a more difficult incision because going out from the center line the fascia divides into anterior and posterior layers with a layer of muscle in-between. So there are more layers to deal with. Its advantages are its cosmetic value and the curious fact that it is a stronger incision as all the bodily movements cause it to push together. Bea goes for the midline incision. As she cuts with the scalpel, Debs sponges the bleeders and places the retractor to expose what Bea needs to see. When they reach the peritoneum, Bea makes a small nick with the scalpel, and then Debs places a pair of Metzenbaum scissors in her hand. Debs tents the peritoneum with a pair of forceps and Bea quickly cuts t from the center to the left where Debs has held the incision open with the retractor. As Bea gets to the end, Debs shifts the retractor to the right, and Bea cuts from the center to the right. The swollen and muscular Uterus is now exposed. Debs has the Balfour retractor in hand and Bea places it in the incision, each of them pulls on an end, extending the ratcheting mechanism so that the uterus is fully exposed. Bea must now peel the bladder off of the lower front side of the uterus to avoid damaging it while incising the uterus and removing the baby. And this is where it starts to go wrong.
   “Shit!” Bea exclaims “the bladder is still full! Is the Foley draining?” Linda speaks up: “Remember? You had the Foley removed….” “Get a Foley in her now!” Bea shouts. Nancy grabs the emergency flashlight from the desk, and a Foley kit. “Hurry!” Bea exclaims. Debs moves her sterile table away from the foot of the bed; Nancy lifts the sterile sheets up exposing the patient’s legs which she puts in a frog leg position. Diving under the drapes she puts the flashlight in her mouth, opens the Foley kit, grabs the catheter, and attaches a syringe of saline and plunges further under the drapes. “Get that Foley in, can’t you move any faster?” All she can see of the patient’s perineum is blood. Nancy grasps the sponges in the kit and she wipes furiously, seeking the small target of the patients urethra. Bea is pounding her fists together in a fury. “Can’t you insert a simple damn Foley? We’re going t6o loose this baby!” The patient’s genitals are swollen and distorted as well as blood covered, and Nancy struggles to find the urethra. “I am going to see you in hell if you don’t get that Foley in!” Nancy sees the small hole and stabs with the Foley. Urine starts to flow down the tube and Nancy inflates the balloon of the catheter. At the same moment Bea gasps as a tear forms in the bladder, and the field floods with urine. Debs suctions madly, clearing the field. Bea continues to peel the bladder away from the uterus. She is now too busy to talk. The bladder retracting blade of the Balfour is inserted, retracting the bladder. Nancy puts the legs straight and replaces the drapes as best she can.
  “Scalpel” Bea calls out, and Debs places it in her hand. She makes a small cut carefully in the uterus, working down until the baby’s head is seen. Debs gives her the Mayo scissors, heavier than the Metzenbaum. Bea cut from side to side and more of the baby’s head is exposed. Debs supports the uterus, as Bea works her fingers in and gets a grip around the baby’s head, pulling it out of the uterus in one smooth, fluid motion. Debs hands her the bulb syringe, and Bea clears the baby’s nose and mouth, she is rewarded with a feeble cry. The baby is a blue color instead of a healthy pink, a bad sign called cyanosis. While Bea has been doing this, Debs has placed two Kelly clamps on the umbilical cord and cut it with the scissors. Bea hands the baby off to Linda. Bea reaches into the uterus and scoops out the placenta, placing it in the basin Debs holds out. Debs starts handing Pennington clamps to Bea, which she places all along the edges of the incision in the uterus. This stops the copious flow of blood from the engorged womb. Debs suctions as Bea mops blood with sponges. When the field is clear, Debs puts a loaded needle holder and forceps in Beas hands, and Bea begins to sew the cut in the uterus. She uses a locking running suture, like a blanket stitch. Deb and Nancy start counting the sponges, sharps and instruments, the count needing to be checked before the uterus is closed to avoid leaving anything behind. Retained objects have occurred in controlled, calm situations, and in an emergency like this the risk is much higher. The count is short one 4x4 sponge.”Remember the bulb syringe!” Deb says. “That’s the one we are missing. Counts correct!” Nancy states loudly.

“How is the baby doing?” Bea asks. Linda replies “APGAR is 3”. The APGAR is a score based on heart rate, respiratory effort, muscle tone reflexes and color. 0, 1 or 2 points are assigned for each criterion, so 10 would be a perfect score. Three represents a severely depressed infant. Bea reaches the end of her line of suture, Debs hands her scissors, the suture is tied and cut, Debs gives her another loaded needle holder, and uses forceps to pick up the bladder, grasping either end of the tear so that the edges are brought together, and Bea begins to sew. “How is the APGAR now?” “Four” is the reply from Linda. Dr. Petersen has used a laryngoscope to suction out the baby’s airway and place an ET tube. Now he is working fast to place an IV catheter into the large vein in the baby’s umbilical cord. Bea refocuses on repairing the bladder. When the sure line is complete, Debs cuts the suture. Bea takes another loaded needle holder and Debakey forceps from Debs and begins closing the peritoneum. “How is the baby now?” asks Bea. “APGAR 5, everything is looking better” Dr. Petersen replies. He has given Sodium Bicarbonate to raise the baby’s blood pH; Narcan to reverse the effect of narcotics picked up from the general anesthesia, and started an IV solution of glucose and calcium glucconate. “It’s your fault that the bladder got torn. I will see that this is addressed by your superiors” Bea directs at Nancy. Bea is obviously very upset and angry. Nancy is now in the classic bad place for OR Nurses. If she says anything, she risks getting the surgeon more upset, and the patient may suffer as a result. Best to let Bea calm down. Usually the surgeons recover from these sorts of tantrums, and usually apologize after the dust settles.  Debs gives Nancy a look and rolls her eyes. Nancy begins to mentally compose what she will write in an incident report, something a nurse must complete whenever something does not go as it should, be it an equipment failure, an injury or near injury to a patient, or just about any break I technique or error.
   Nancy and Debs count all the sponges, sharps and instruments again, to be sure nothing is left behind in the abdomen. Again, Nancy announces loudly that all is correct.  Bea should verbally acknowledge the count, but she is still stewing, so Nancy decides not to make any comment. Bea finishes sewing the peritoneum, a sort of sack of tissue that encloses the abdominal contents. Debs place another loaded needle holder and some Russian, or as they are sometimes called, bear paw forceps in Beas hands. The bear paws are more suited for tough thick tissue like the fascia than the Debakeys which are for delicate tissues. Nancy prepares the dressing materials for the wound. When the line of interrupted sutures in the fascia is complete, Debs give Bea the skin stapler and Adson forceps. Nancy and Debs do a final count of the sponges sharps and instruments, and this time Bea does give a sign that she heard the counts correct announcement. Nancy opens all the dressing materials to the sterile back table.
   Linda and Dr. Petersen begin to wheel the incubator to the door, announcing that they are headed for the NICU (Newborn Intensive Care Unit), and exit the OR, pointedly not saying more. Nancy wishes that she could have gotten Linda aside to find out more about her comment “Remember, you had the Foley removed….”. She makes a note to herself to have a look at the L&D records. If Bea had ordered the Foley removed, the L&D nurse who removed it should have charted the order and removal of the catheter. It is also something that should have been reported to Nancy by Linda on arrival in the OR, as a report of all the salient facts about a patient’s condition is supposed to be given when care is transferred from one nursing unit to another. In practice, the OR nurses almost never get such a report, despite the fact that the nurses on the floors howl if they do not get such a report when patients are transferred to them from the OR. It is also standard protocol for C-section patients to have a Foley in place before they leave for the OR. Of course if Bea calms down there may be no problem, but if Bea goes to the supervisors it could get ugly, as when things go wrong the crap tends to flow downhill. Nancy resolves to be prepared and write a good description of the whole incident in the report.

Saturday, September 24, 2011

Twelfth Chapter

Twelfth Chapter
In which we see how hands are restored and what our cast thinks of TV doctors
   The patient is asleep and draped on the OR table. He is a 42 year old male, right hand dominate, married, father of two, a computer and electronics repair man who works in his own wood working shop on weekends. He is here in the OR because he had an unfortunate encounter with a table saw and his right hand. Table saws are responsible for more hand injuries than any other power tool. In the music industry, the annual award is the Grammy, a miniature gold gramophone. If there was an annual award for hand surgery, it would be a miniature gold table saw. The patients right arm is extended out at a right angle to his body on an attachment to the OR table just for hand surgery. It is about two feet wide and three feet long. Seated around the hand table on stools are: Dr. Lamb, hand surgeon, Dr. Oriel, a hand fellow (a fellow is a fully qualified surgeon, who has completed a residency and passed his board exams, and is doing an additional year of training in a sub-specialty), and Debs, an OR Tech. Anne is the circulating nurse. Behind the sterile sheet raised to separate the patients head from the sterile field is Dr. Spiro, anesthesiologist. This raised sheet is referred to as the “ether screen”, the term an anachronism from the days when ether was used as an anesthetic agent. Lamb and Oriel are wearing loupes, glasses that have magnifying telescopes sticking out of the lenses, giving them highly magnified views of the field, while allowing them to look around the telescopes for an unmagnified view.

Lamb: OK, I think you have done a good job of exploring the injury, tell me what you have found, and what you plan to do next.
Oriel: Well, there are fractures in the proximal phalanges (the first bone outward from the knuckle) in the index and long fingers. There are injuries in the vascular and nerves as well as severance of the flexor tendons. The ring and small fingers seem to be just superficially injured, maybe a flexor tendon in the ring finger. I want to first get the fractures reduced and stabilized, then repair the veins arteries and nerves in the first and second digits. The tendons can be last. The ring and small fingers can wait until the others are finished. The core of the problem here is that the most important fingers for strength and precision are compromised, and this patient needs both to do his work. The ring and small fingers are not nearly as important, but have minor injuries.
Lamb: That’s exactly how I see it. The fractures are clean cuts, so pinning them with K-wires should be sufficient, no need for plates and screws.
Debs had already reached this conclusion herself and had prepared the pin driver with an .045 K-wire, and now extended it to Dr. Oriel. He begins to drive the pin.
Spiro: Anybody see “House” last night? It drives me crazy the way they always start a patient on some drug before they confirm a diagnosis, and big surprise, the patient gets worse!
Anne: He brings in a patient, makes at least three wild guesses at a diagnosis, orders treatments for each wild guess, the treatments nearly kill the patient, then gets inspired by some random visual cue to make the correct diagnosis! And as many professionals have noted: “It’s never Lupus!”
Debs: And House and his team seem to be the only people working in their hospital. No nurses, no lab techs, no radiology techs. No Radiologists, Pathologists either. They do it all themselves!
Lamb: As if any of us would know how to run the lab equipment or what reagents to use for a given test! And where do they find the time to do all that? It must be great to only have to deal with one patient at a time.
Oriel: And what hospital would ever put up with the way that House treats everyone, patients and staff? No way.
Anne: Not like the old TV medical shows. Remember Marcus Welby, Ben Casey, and Dr. Kildare? They were these saints who not only cured your illness, buy reconciled your dysfunctional family, took care of your bankruptcy, and helped you to find God, even.
Debs: I could swear that the AMA had control of the scripts back then.
Oriel: OK, bring in the C-arm.
A C-arm is a fluoroscopic device that lets you see an x-ray image as a still or video picture. It has an emitter on the top of a “C” shaped steel rail, and a drum shaped collector on the bottom. The “C” is attached to a console with a TV monitor on top where the Image is viewed. The “C” shaped part is draped with a large clear sterile plastic bag.  The hand is placed on top of the collector and a foot pedal activated by the surgeon produces an image on the monitor.
Lamb: Looks good. Turn it over. You won’t get approximation better than that. (Approximation is the lining up and joining the two ends).
Oriel: just need a second K-wire to stabilize it.
Spiro: I used to laugh at Ben Casey. Old Dr. Jaffe would always watch his procedure from way up in this gallery, where you couldn’t possibly make out the small delicate things that go on in brain surgery. Then after the procedure he always without fail tells Dr. Casey “Your technique is excellent”.
Debs: Anyone here ever actually see one of those galleries in an OR? They are such a staple on TV.
Unanimous answer: No!
Lamb: I’ve been in many, many hospitals and I have never seen one. I never could see the point. You can’t see anything that would matter from such a place.
Oriel: I always wanted to hear Dr. Jaffe say to Casey “Your diagnosis is mistaken and your technique is faulty”.
Everyone laughs.

Oriel: C-arm again. Looks good. Now the long finger.
Debs: Also known as the “flip” finger.
Anne: I think Grey’s Anatomy is probably the worst offender of all. Such an incredible bunch of sex crazed drama queens.
Lamb: C-arm again. Good.
Oriel: Bring in the micro scope. How are we doing for tourniquet time?
Spiro: Twenty-eight minutes.
Oriel: Let us know when we get to an hour.
Anne moves the C-arm out from the hand table and moves in the microscope, a binocular Zeiss with three sets of eyepieces. It also is draped with a clear plastic sterile drape. Anne removes the foot pedal for the C-arm and places the foot control for the microscope. Anne removes the loupes from Lamb and Oriel. The microscope affords them even more magnification than the loupes, but an un magnified view of the field is not available.
Lamb: They get so far-fetched on Grey’s. I get patients all the time with the most incredible ideas they get from that show. Very misleading.

Anne: The doctors are so caught up in their own dramas that they totally lose sight of the patients.
Debs: Those old shows with the saintly doctors stayed away from the doctors lives entirely. The focus was always on the patients, one good point for them.
Anne: Don’t even get me started on how they have portrayed nurses.
Oriel: Give me a double small vein approximator. (Two small clips attached to a small rod on which they can be slid back and forth. By use of the approximator the ends of the vessel can be brought together and held in place for suturing.) (Veins are almost always repaired before arteries in hand surgery. It sees counter intuitive, but the real problem is getting blood out of the injured finger, not into it. Like when you put a rubber band tight around your finger, it swells and gets purple colored and throbs in time with your pulse. There is pressure behind the arterial blood so it still gets in, but the venous blood can’t get out, causing the purple color, the swelling and the throbbing.)
Oriel: 9-0 nylon.
Debs: Here you go.
Debs places the Castro-Viejo micro needle holder with the suture loaded into Oriel’s right hand in the position it will be used, then guides his hand under the microscope until it is in his field of view. This is so that he will not have to look away from the eyepieces of the microscope. She places a jeweler’s forcept into his left hand. She then places jeweler’s forcepts and a micro scissors into Lambs hands, guiding thm into the field of view. Then she looks into her own set of eyepieces. She has a syringe filled with a solution of Heparin at the ready. Heparin is an anti-coagulent, and will prevent clotting until after the repairs are complete.
Oriel starts suturing the vein. Debs spreads a white towel out on the field. The 9-0 suture and needle are so fine, that if it should be dropped it could only be found with great difficulty on the blue sterile drapes. They show up well against white however.
Spiro: Yeah, always standing at the nursing station with perfect hair and makeup, holding a chart. Meanwhile, the doctors are doing all the things that nurses do. And they are always the ones that find when something is going wrong, not the nurses who are the ones who are actually with the patients.
Anne: Or else they are saintly paragons of virtue and self sacrifice, except when they are mentally deficient sexpots. I remember an episode of Trapper John, MD that had a nurse who was a stripper on the side.
Lamb: The classic naughty nurse fantasy. White thigh length high heel boots with spurs.
Oriel: (looking away from the microscope and making an exaggerated wink) You thinking of taking up a side job Anne?
Anne: You wish, you pervert!(Her eyes sparkling with mirth)
Debs: I forget which show, but they had a nurse that was a dominatrix.
Anne: Honestly, that’s about as likely as a physician doing those things on the side.
Spiro: Remember “ER” with George Clooney? I gave up on that one after they had the nurses stealing the resident’s coffee. In my experience it’s always the other way around.
Anne: Amen to that!
Oriel: I will give “ER” and “St. Elsewhere” credit for showing gritty inner city hospitals and taking on some tough story lines like AIDS. But again, too much on the doctors weird personal lives. But at least there was this thing that the exaggerations were just that, exaggerations for comedic effect. They were not presented as if they were serious. That show “Scrubs” is like that. They punctuate with sound effects to make the absurdities plain. Although a lot of the time when they use medical sounding dialog, it's just gibberish.
Lamb: That looks good. Let’s go for the money shot. How are we on tourniquet time?
Spiro: Fifty eight minutes
Oriel: Let’s let it down for five.
Spiro: OK. Tourniquet down.
Oriel: See the artery here? No leaks. And I don’t see it in the long finger. Looks like we got lucky with that one.
Debs: Doppler?
She extends the Doppler probe towards Dr. Oriel. The Doppler picks up and magnifies the sound of blood moving through a vessel. By the quality or absence of the sound, the presence and quality of blood supply can be established.
Oriel: Good idea, thanks.
He takes the Doppler probe, and extends the end with the contact plugs to Anne over the patient’s chest. Anne plugs the leads into the Doppler box and switches it on. Debs extends a small plastic cup filled with a clear jell to Oriel who dips the end of the Doppler probe into the jell. The jell increases the contact of the probe providing a better signal, just like the jell used for ultrasound examination of fetuses in a pregnant woman. He then applies it to the index finger.  No sound is heard, as expected. He then applies the probe to the end of the long finger. Aloud pulsing, whooshing sound comes from the box Anne is holding. A swishing sound would indicate diminished flow. No sound would mean no flow.
Lamb: good pulse there.
Oriel applies the Doppler probe to the ring and small fingers, resulting in more of the pulsing whooshing sounds.
Oriel: All the rest are good.
Spiro: I really hate the way they portray ERs. Like every person coming in has some big life threatening situation. Reality is that 99.9% of ER admissions are just routine stuff from people with no other access to health care providers, so they turn to the ER.
Anne: And doctors hanging out at the ER doors just waiting for an emergency to come along! As if!
Spiro: Time up. Tourniquet back up?
Oriel: OK, tourniquet up.
Lamb: Now let’s get that artery.
Debs extends an arterial approximator to Oriel. The difference between the vein approximator and the arterial one is in the strength of the clips. Arteries have thicker walls and a muscle layer so that they can constrict and dilate according to the bodies reflexes. The arterial clips must exert more pressure. Oriel applies the approximator and lines up the ends of the artery. Debs hands him a Weck spear, a small triangular cellulose sponge on the end of a toothpick size stick. Oriel uses it to clear the small quantity of blood on the ends of the artery so that he can see better under the microscope. She hands him another 9/0 suture, and jeweler’s forceps. She passes the forceps and scissors to Lamb. She readies a neuro patty (a ¼ by ¼ cotton felt pad) soaked in 2% Lidocaine solution. Because of the muscle layer in arteries, they often go into spasm. The Lidocaine will relax the spasm.
Spiro: I, of course, take offense at the portrayal of anesthesiologists on TV. Most of the time they just sit there doing nothing, just being another part of the furniture. On Grey’s they had one who fell asleep during a procedure, and they started calling him McSleepy.
Anne: You guys are the only ones who get even less respect than nurses.
Lamb: Give us the Lidocaine patty.
Debs: What kills me is how they do CPR on TV. Too slow, with elbows flexing, so that the compressions are worthless.
Anne: And the monitor alarms when it goes flat line, (asystole) instead of a wavy line that would indicate ventricular fibrillation. Monitors only actually alarm when there is a malfunction. Then they proceed to defibrillate even though the patient is in asystole, not a shockable rhythm.
Spiro: I remember an episode of “Medical Center” where Chad Everet, Dr. Gannon, defibs a guy in a parking lot with jumper cables from a car battery. Hah!
Oriel: And on “Gray’s” I even saw them defib a guy that was conscious and talking!
Lamb: How about how they do a surgical scrub? With no mask up, and talking to someone in street clothes!
Anne: They go into OR’s all the time in street clothes. But it drives me crazy how they are talking about all their deep personal tribulations while they are doing all of this.
Debs: And I have never seen them get gowned and gloved in any way that was actually sterile.
Oriel: OK, I think that does it for the artery. Let’s bring down the tourniquet again and get everything freshly perfused.
Spiro: Tourniquet down now.
Debs passes the Doppler probe and jell. A satisfactory whooshing sound is produced. The artery doe not leak. She has prepared the items that will be needed next for repair of the tendons. While they are waiting, they dab the wound with sponges and inspect their handiwork.

Oriel: OK, let’s have the tourniquet back up. Take the microscope away.
Anne pulls the microscope back, then gets the loupes and places them over the surgeon’s heads and in place on their noses. Debs places needle holders in Oriel’s right hand. The needle holder is armed with a 4/0 Dacron suture. She places a pair of DeBakey forceps in his left hand. She places a pair of suture scissors in Lambs right hand. They begin the repair of the tendons in all the fingers.
Anne: Can you believe the miraculous recoveries they have on TV? The patient can have just been defibrillated, and they are talking!
Debs: It’s even worse if they have been in a coma. In reality, they would be demonstrating Aphasia (they inability to retrieve words and generate speech. And they probably would have disphagia (inability to swallow). All that requires a lot of time and therapy to get over.
Spiro: Not to mention that their hair and makeup are in perfect condition.
Oriel: OK! I want to check with the Doppler one more time before we start closing the skin. Then we will need a plaster splint and all the dressings. Debs, great work as usual. You too, Anne.
Spiro: What about me? See? No respect here either. I might as well sleep through this.
Anne: Have any of you seen the new Nurse shows? They are even worse! This “Nurse Jackie” takes the flawed hero/anti-hero, breaking all the rules, up against the establishment, fighting for the patient non-sense that has become the standard for the doctor shows to new heights of depravity. In the show that I saw, she commits three huge felonies; forging a driver’s license, seducing a pharmacist to obtain drugs to feed her addiction that makes House look like a kid on candy, and flushes a patient’s ear down the toilet.

Lamb: Yeah, how do any of these characters keep their licenses let alone stay out of jail?
Debs: Well, at least they aren’t blowing things up, and shooting their way through dens of terrorists, torturing middle easterners on the way to truth like Jack Bauer.
Anne: They are the terrorists.
Oriel: Let me have the Doppler one more time. I think we are going to have a good result here. The fractures did not involve the joints, so there should not be any loss of mobility, we have good circulation. The only problems I see will be connected to the nerve repair. He may have areas of numbness or hypersensitivity; I expect that he will have cold intolerance. But he should have a fully functioning hand.
Lamb: It will take a year or more to see what recovery there is from the nerve damage. All will now depend on good physical therapy. I think he will be a good compliant patient.
Oriel: It is surprising how many patients we get that do not complete therapy, and then complain that they have less than optimum results.

Thursday, September 15, 2011

Eleventh Chapter


In which Molly travels to Africa as a volunteer, and writes up her experiences in a blog:


September 1st: I have completed many preparations for the trip. I started my anti-malarial meds today. Reading the list of possible side effects had scared me somewhat, and I had wanted Ed to be around in case I started hallucinating. I’d rather not have to see Gene Kelly in miniature dancing around in the kitchen sink tap dancing “Singing in the Rain” if I can help it. At least Ed could slap me back to reality before I try to flush Gene down the drain with the sprayhose.

Ed has assembled a kit for me: Swiss Army knife, insecticide impregnated mosquito netting, industrial strength insect repellent in sticks, wipes and sprays, bottles of water purification tablets, small maglight, spare batteries, army surplus rain poncho, a capacious rucksack with frame and padded compartment for my laptop, and a nifty small digital camera that uses the same size batteries as my maglight.

I will be busy the next couple of days, so I might not get to blogging again until after my departure.

September 5th: I arrived in the Republic of West Africa (hereafter RWA) after 26 hours of travel, New York to Amsterdam, then Amsterdam to Nairobi, Nairobi to Capitol City, RWA. I am staying in a guest house tonight, very nice, the family that runs it very friendly, they have six rooms here, furnished with very basic furniture, but all of it sparkling clean. My single bed has a mattress that has seen better days, but it is brightened up with Star Wars sheets. There is a convenient hook over the bed for my mosquito net.

I had my first sample of RWA food: some form of meat in thick gravy, served over a starchy paste that had a yellow color to it, very, very spicy hot! It really cleared out my sinuses and brought tears to my eyes. Later I had another version of this, but with rice instead of the starchy paste, and if possible, even hotter!

Water comes in little plastic bags instead of bottles; you nip off a corner and drink.

Cell phones are huge here, probably because there is no need for the infrastructure of poles and lines. There are little kiosks and stores everywhere that sell top off minutes, as prepaid service is the only game in town. Minutes of time are surprisingly cheap. Service is a variable thing, you often get cut off in the middle of a call.

September 6th: People here are very religious: All the taxis have “God Bless”, or “Jesus Saves” painted on them. Stores and businesses have titles such as “Fear God Cell Phones”, “God Is Good Fashions”, “With God All Things Are Possible Tire Repair”. Repair shops are common, unlike back in the States, it is more economical to repair things than buy new. Repairs are often marvels of ingenuity and improvisation, as spare parts are scarce, and when available are often cannibalized from the unrepairable. There is almost no litter here, as cans, bottles, cardboard, etc are all looked at as materials to be used. I bought a model helicopter for Ed made from scavenged wire. There is a lever on the side, and if you push and pull on it, the main and tail rotors spin. Aluminum cans are prized for the parts that can be made from them to repair things, and for all the things that can be made from them. I also bought a beautiful candle lantern made from a soda can. A popular toy here is a car made from soda cans that is about the size of a shoe box. It has a stiff wire that sticks out the top to about two and a half feet, with a circle of wire at the top making a steering wheel. When you turn the steering wheel, the front wheels of the car actually turn. The children “drive” these beautifully made cars all over town.

It is hard to say who is more influential here, Jesus or Bob Marley. Pictures of both are everywhere. Reggae music is the soundtrack to everything. It often seems to me that the whole country is bopping along to “One Love”, the music perfectly in tune to the laid back life style. I have to explain about RWA time, or it is more probably just African time. Among westerners, there are many jokes about this. If someone says “five minutes” they really mean “an Hour”. I had to wait two hours for food at a restaurant. But on the other hand, you do not have to rush for anything, there are no deadlines, and your lunch break is a s long as you want.

September 7th: People here are warm and friendly. English is theoretically the official language, but many other local dialects and languages are spoken. Everybody has some English, although individual words have novel meanings. It was an amazing experience to ask directions and then be led for fifteen or twenty minutes through a maze of narrow streets to the tro-tro station, then to exactly the right tro-tro for my destination, and then my offer of a small cash reward refused. I have to explain about tro-tros.

A tro-tro is a van outfitted with seats. They are uniformly in deplorable condition, rusted and paint peeling. They are the main conveyance for people and packages, all crammed in to fullest capacity. Private ownership of cars is rare here, so tro-tros are the way to go.

The roads here are another thing, with as many holes as a Swiss cheese, and that’s the paved ones! The drivers of the tro-tros must dodge and weave to avoid the largest ones, often into the face of oncoming traffic. After about twenty minutes of sheer terror, your adrenaline level comes down to just higher than normal. At every stop a crowd of people swarm to the windows of the tro-tros hissing at you (the way you get someone’s attention here) selling a bewildering array of things, bags of water, plaintain chips, toothpaste, batteries and other food products.

My seatmate is George, a medical student from England, on the way to the same provincial hospital as me. He has been here the past two summers and has picked up some of the local language called Twili. At a stop just outside the city, a man dressed in a black suit climbed aboard. As the tro-tro moves off, he gets up and starts speaking rapidly in Twili. I asked George who he thought the man was. I had guessed a preacher by his black suit, and the general level of religiousness I had seen in the country. George said he was a patent medicine salesman, and did his best to translate and summarize the pitch. He described the miracle spices in the tin he was holding up. He passed out little cards, like business cards, that listed all the things his medicine would cure. Diabetes, hypertension, stroke, headache, malaria, dementia, heartburn and indigestion to name a few. He was very entertaining and I was reminded of the TV infomercials back home (But Wait! There’s More…..). Next he pulled out a box of toothpaste with a picture of a pack of cigarettes on it. It was supposed to make your teeth shiny white. I hope it didn’t taste like cigarettes.

September 9th: We encountered heavy rains part of the way to the provincial capital, our destination. I had not considered that: dirt roads + heavy rain = mud. Our driver chooses to drive through a large puddle rather than around it and we get stuck. The water is so deep it begins to flood into the tro-tro. We all get out and after about twenty minutes of pushing, manage to free the tro-tro. Of course, it then refuses to start. And no bother about the mud and dirty water we were covered with, the rain washes it off. The sun comes back out and we wait in the shade of some trees for about an hour while the driver summons a mechanic on his cell phone. Thank god that was working! The mechanic arrives, does something under the hood, the tro-tro starts, we all pile in and we are off.

I am staying with a host family. The husband has a business manufacturing cement blocks, and selling lumber and other building supplies. She is a school teacher. They have two children who are away at a boarding school, which is the norm here for the wealthy. Their house is one of the more upscale in the town, made of stucco and cider block with a tile roof. The interior is very nice, well furnished with a modern western kitchen and electric ceiling fans in every room. Unlike in the west, there is no separate neighborhood for the more affluent. Next door is a mud walled shack with a thatched roof and no electricity. I am given a very comfortable room. My hosts speak very good English, the King’s version, as both have been to university in England.

September 12th: About technology: Africa capriciously decides when it will work, and when it will not. In a town you may have electricity to run technology, such as the internet café I am sitting in right now, the only internet access for this whole provincial capital. Like most of Africa, the power only works when it wants to. Half the time the power is out, so you get by with candlelight , and you don’t buy more food that needs refrigeration than you can eat in a day or so. This is also true of the water as well, so when you get in the shower, you fill a bucket with water first, so if it goes off before you finish, you can still rinse off. I was in surgery at the hospital this morning, a myomectomy (removal of uterine fibroids) when the power went out. The procedure had to be finished by flashlight, and suctioning had to be done with a foot powered pump. The hospital does have a generator for back up, but it steadfastly refused to start. They are used to things like that here

The hospital is a cluster of small buildings made of cement block with corrugated metal roofs and covered verandas on the side that faces into the yard that the buildings enclose. Everything is whitewashed, but the rains have given the lower portions of the walls a red-brown color from splashed up dirt. Patients see a clerk in one building, a doctor in another, get their prescriptions in a third, and then go to a fourth to get a bed. There are three buildings that serve as wards. One for men, one for women and one for children. If you do not have family or friends, you are out of luck, as the hospital does not provide food or linens. Family members provide the everyday care. Everything is done to conserve supplies. For example, gloves are very scarce, so they are only worn when absolutely necessary.

There is a secretary who does all the typing and filing of records, with a meticulous efficiency. The typewriter is missing the type bits on the end of the type arms for the letters “h”, ‘’e” and “s”. When she finishes typing a document, she goes back and fills in these letters with a fine point pen. Her draftsmanship is so good that her hand written letters are indistinguishable from typed ones. The documents are very easily smudged however. This is because the typewriter ribbons are re-inked with soot from the kerosene lamp chimneys.

September 18th: I have been so busy that I have a lot of catching up to do. As I expected, there is a very high incidence of malaria here, it is the leading cause of childhood mortality. Hypertension, cardiovascular disease and diabetes are also high here, even more so than in the states, the diet (high in salt, low in vegetables and a low level of exercise) is most likely to blame, but there appear to be genetic factors as well. Typhoid and tetanus are common as well, things almost never seen back home. There are cases of HIV as well, but due to the huge stigma attached, testing is mostly not done. As a rule, people do not seek attention until there is no other alternative, so most cases that come to the hospital are in advanced stages. I have seen some very advanced cases of anemia and malnutrition, especially among the children.

Clinical tests, like technology, are a sometimes thing. Maybe there are no testing reagents at the moment, or the equipment is broken down. Despite malaria tests coming back negative, doctors still prescribe anti-malarials on the basis that the symptoms are there, and the test results may be unreliable. As a result there are problems with drug resistance here.

September 22nd: Yesterday we went on a community outreach to a nearby village. It was obviously a much poorer place than the provincial capital in which we have been staying. There is very little car or truck traffic here, but there are bicycles. Goats and chickens forage everywhere. There is almost no western style clothing here, most are dressed in traditional clothing, brightly colored long skirts and full sleeved blouses for the women, trousers and brightly colored shirts for the men. Mothers carry their babies in shawls on their backs, the babies fast asleep. I almost never heard babies crying. The women and a few of the men carry large loads on their heads, sometimes heavy and bulky items. I even saw a heavy foot powered Singer Sewing machine carried in this manner.

There are many stalls in the market place, most made of plywood and brightly painted, the names of the stalls reflecting the religious nature of the culture, such as God’s Bounty Vegetables. Almost everyone seemed to be engaged in some sort of business in order to bring income for their families. No one was idle or just sitting around under the trees.

First we went to the school. Under the direction of the teachers, the children raced to set up tables and chairs in the courtyard of the school. We were directed to chairs and were not permitted to help. The children obviously knew from prior visits how to arrange the tables and chairs and seemed very happy and excited. The teacher then got the children lined up, and things got started with a triage at the first table. The other tables were set up for vaccinations, wound care and the last table for screening for TB, Sickle Cell, Malaria, etc. I got the wound and skin care. Many of the children have infections of simple cuts and scrapes because a common folk remedy here is to rub mud into wounds to stop bleeding. So I clean the wounds and dress them as needed, and try to teach them not to put mud in the wounds. The kids love bandaids, especially the colored ones, and will ask for a “plaster” as they call them even if they do not need one. There were one or two that I referred to our doctor for antibiotics, as they had more advanced infections. Everything is done without gloves as there are none to spare, but we had lots of soap and water to wash between patients.

After we finished at the school, we went back to the market area and by this time, our crew had set up a couple of tents and a canvas awning, and we had a clinic for prenatal, mother and baby care. I dispensed oral polio vaccine drops. Because of the lack of gloves, I was instructed not to touch the babies, just get the mothers to get the babies mouths open to receive the drops. One must not use the left hand. It has some connotation of insult; even beggars will refuse money offered with the left hand. Another volunteer entered the vaccination in the patient record carried by the mothers. One or two of these were very tattered, and these were sent to our clerk for replacement. Most however had been carefully folded and then placed inside a piece newspaper or other salvaged paper to keep them clean and intact. There was also screening for hypertension and diabetes, and appointments were made for follow up as needed.

A district Nurse then conducted a class where she covered a whole variety of subjects from breast feeding to basic baby care. She used stories and songs, humor and repetition, much in keeping with the traditions of oral history and culture. I couldn’t help but think of this as the African version of the pamphlets and flyers that are passed out at clinics back home. Though we were tired from a long day of it, we loaded up our van and boarded in good spirits for the trip home.

September 24th: I am writing from The Tall Horse Café. “Tall Horse” refers to a giraffe. This is the one place in town where there is some western style food (pizza, french fries and coca-cola). It is also a place of refuge from being the major side show in town. Western white people really stand out here, and everything we do is of great interest and a subject of much conversation, a major source of entertainment. There are a couple of things I want to write about before we leave in a few days, as this will probably be my last chance to post.

The Brain Drain. The Republic of West Africa loses a lot of the nurses and doctors they train to other countries, especially England. There are a couple of reasons for this. A nurse can go to England for two years and come back with enough money to buy a house, set up a business for herself and/or her family. Secondly, many nurses are assigned to positions by the government with little regard for or choice of location. Because of the brain drain, the government closely watches nursing students and graduates, and they may be refused visas for foreign travel.

Politics. Political influence peddling and maneuvering results in a far less than optimum allocation of the available resources. Some is also lost to bribery and corruption, although the RWA is reckoned to be one of the least corrupt in this area of Africa. The government tries to keep as many people as possible employed in the public sector, albeit at very small wages. This is part political patronage, part works program.

Ed, I have used everything in your kit many, many times, especially the Swiss Army Knife and the water purification tablets. You should market the kits to those traveling to Africa.

The people here are really lovely, and I will always remember them with great fondness. I hope I can come back again next year, and maybe bring some of you with me. See you soon!

Thursday, September 1, 2011

Tenth Chapter

Tenth Chapter
In which our neophyte reaches competence, and we learn about trauma

   University Hospital, the employer of our subjects, is a Level I trauma center. Trauma is the leading cause of death for people ages 1 – 44. The leading causes of trauma in rank order are MVA’s (motor vehicle accidents), falls and assaults. Trauma is a surgical condition by definition. Trauma Centers vary in their capabilities, and are rated level I,II and III, with level I being the most capable. To be a level I center, a hospital must have highly trained and specialized surgeons, nurses and technicians on duty 24/7, as well as the equipment and facilities. It is very, very expensive. The metropolitan area served by University Hospital originally had three Level I centers, after two years only University Hospital had the resources to maintain Level I status. For the trauma victim, being treated at a Level I facility can raise the chances of survival by 25% or more. For those that reach a Level I center within an hour of injury, the odds go up even further.

   The trauma area is adjacent to the ER. There is an ambulance ramp that goes right up to the doors of the trauma area, and directly across the ramp is a helicopter landing pad.  Inside the doors are four stabilization/evaluation bays, and directly behind the bays are two trauma ORs. There is one trauma team in the center at all times, with a second team available in the hospital. A trauma team is made up of an Anesthesiologist, a Trauma Surgeon, a Trauma Resident, two ER nurses, and two OR nurses.

   A patient arrives, by ambulance or chopper, and enters into one of the bays. The most severely injured go right back to one of the ORs. Lines are placed, blood samples drawn, IV fluids and O negative blood administered as needed, the airway assessed and stabilized. O negative blood is used as it is the Universal Donor, and can be given without the time consuming need to type and cross match the patient’s blood. Even with a medical bracelet or “file of life” with blood type information on a patient, the O negative blood is used, as the teams have learned the hard way not to trust such sources of information.  A Foley catheter is placed into the bladder. These steps are the provenance of the anesthesiologist and the two ER nurses. While this is going on, X-rays are taken as needed. The Trauma surgeon acts as captain of the team, and directs the activities of the team as a whole. The OR nurses assess the patient injuries and prepare the appropriate instruments and equipment on the OR, the patient moves into the OR and surgery begins. In more extreme situations the patient skips the bays, goes right into the OR, and all this happens at once. 

   It has been almost two years since we first heard Cates story as a beginning nurse in the OR. Things have “clicked" for Cate, and she has earned the trust and respect of the other nurses and surgeons. It has not been easy. Dr. Syriani, famed surgeon to the deceased, had been particularly hard on Cate. Syriani was known for his lack of tolerance of beginners, taunting and ridiculing them. He had one day gotten Cate to the point of tears, and then crowed to the assembled team “Look! I made her cry!”, as if he had scored some kind of goal. Cate sucked it in and finished the case. She had learned not to give in to frustration and anger. And Syriani never bothered her again. He zeroed in on the scent of fear. That was the day things started to go better for her in the OR. When you get to the bottom, it all looks like up.

   Cate has just completed sixteen hours of classes and passed an exam so that she can take turns  covering the trauma center for the OR. She has had to learn the ABCDE of trauma. A= airway, B= breathing, C= circulation, D= disability, and E= exposure. Always in that order. B is no good if you do not have A, etc. There are detailed algorithms for each of these letters that Cate has memorized. She has practiced the techniques and interventions for each step. Airway is getting the air to the lungs. This could be by inserting an ET (endotracheal tube), tracheotomy, or cricothyrotomy (A large bore needle placed into the trachea just below the cricoid cartilage, and then air or oxygen blown in under pressure). Breathing is the chest and diaphragm, getting oxygen into the blood. This is done manually by an ambu bag (a cylindrical rubber balloon that attached directly to a mask, ET tube or tracheotomy tube), or mechanically with a ventilator. Circulation is the heart and vasculature, getting the oxygen to the organs of the body. There were several avenues of attack here: 1) Replacing fluids by crystalloids (saline, or other IV fluids) or blood products such as whole blood, plasma, etc. 2) plugging the leaks (control bleeding). 3) Reduce the volume to be filled. This last could be accomplished by the use of MAST (Military Anti-Shock Trousers), inflatable pants with three chambers, one for each leg and one for the lower abdomen.

The pressure of the MAST diverts blood from the legs and lower abdomen to the chest and head. Disability is the level of function of the brain and nervous systems. Exposure is getting the patient exposed and controlling his body temperature. Trauma victims are by definition thermally compromised. Clothing has to be removed quickly, using scissors that look cheaply stamped out of metal, but their serrated edges and large leverage granting handles can cut a copper penny in half easily. The nurses refer to these as “Rambo” scissors after the Sylvester Stallone movie character. Karen once got a complete set of leathers off a motor cyclist in about a minute. There are two basic means of warming the victims, by IV infusion of warmed fluids utilizing the Level 1 warmer/infuser, and the use of a Bear Hugger. The Bear Hugger is a sort of plastic and paper blanket that circulates warm air around a body. The Level 1 is a piece of equipment that can push a liter of fluid or blood into an IV line in less than a minute, and at body temperature to boot. Both were absolute necessities for the trauma rooms.

   Cate was in a state of adrenaline infused impatience, as this was her first solo in the trauma room, without a preceptor to back her up. Mercifully, the phone rang and Dr. Murphy, the trauma surgeon for the shift picked up the phone and listened. He hung up the phone and announced to the team, “We have a penetrating injury to the neck, an older male, John Doe, trauma scale 4 coming in. He was found unconscious on the sidewalk, no witnesses.The EMT's scooped him up and are coming straight here.” Trauma scale 4 meant unresponsive, very low blood pressure, low respiratory rate, very low pulse. The key thing here was the very low pulse. This told the team that the victim was in the last stages of shock. In the early to middle stages of shock the pulse becomes very rapid, the body’s attempt to make up for loss of circulating volume and pressure. As shock progressed, this compensatory mechanism also fails.  A score of 4 was the worst score in the scale, an indication that the chances of survival were poor. John Doe meant that his identity was unknown. This one was obviously a problem to be addressed in the first of the ABCDE, airway. The team leaped up and prepared the A list items, for placement of ET tube (also known as a breathing tube, to be inserted through the mouth), tracheotomy, or cricothyrotomy,(means of making openings into the windpipe) as well as peripheral and central lines, O negative blood and Normal Saline IV fluid. The other thought that occurred to everyone on the team was that the score of 4 plus a penetrating neck injury probably also meant hemorrhage of a significant portion of the victims blood, so Cate grabbed and opened the tray with vascular instruments, as well as the tray of basic instruments. Once an airway was established and ventilation accomplished, the next likely thing was going to be control of bleeding. 

   With a screech of brakes, the ambulance arrived at the door. The doors of the ambulance flew open and the EMT’s ran the stretcher into the trauma area. Murph waved them past the stabilization bays directly into the trauma OR. Cate took in the MAST trousers, and the victim covered in blood from the eyes all the way down the chest. One of the EMT’s was pressing a wad of towels against the victim's neck. The towels were saturated with blood and the EMT was covered in blood. Several things happened simultaneously: Kurt, the anesthesiologist, got a laryngoscope in the victim’s mouth and was suctioning large amounts of blood, saying “I can’t see a damn thing!” Chloe, one of the ER nurses was hooking the Level 1 to the IV line the EMT’s had placed. She cursed in turn as she saw that the line was running Lactated Ringer’s solution. This meant that blood could not be pushed through the line as it would instantly coagulate, the coagulation triggered by the calcium in the Lactated Ringer’s deactivating the anti coagulant in the bank blood. Only Saline should have been used. Blood would have been the best thing that could be given at the moment, because it could also carry oxygen as well as increase circulating volume. Crystalloids such as Saline and Lactated Ringer’s expanded volume but could not carry oxygen. She started the Level 1 pumping with saline.  Nan, the Other ER nurse was struggling to place another IV line in the other arm, hindered by the omnipresent blood which obscured visualization of the veins, and which also made everything slippery. Cate was mopping at the neck trying to clear the blood, so that she could see the wound and prep it with iodine solution. She couldn’t find a wound. Murph joined her in wiping at the neck with an artery clamp in hand, ready to clip a vessel. The blood was all dark, indicating a venous source as opposed to an arterial one. There was no wound!

   The monitors at the foot of the stretcher alarmed and flatlined. Kurt rammed the ET tube home, suctioned more blood out of it and attempted to ventilate with an ambu bag. The chest rose and fell. The monitor showed no heart activity at all, a condition called asystole. This is not a shockable rhythm, so the use of the defibrillator was out. Cate began cardiac compressions. Chloe took over ventilations with the ambu, synchronizing to Cate’s compressions. Kurt began injection of epinephrine (also called adrenaline) through the chest directly into the heart. A shockable rythm had to be established before the defibrilator could be used. Nan continued to struggle with the IV placement, finally getting it into the antecubital fossa in the inner aspect of the victim’s elbow. She attached it to the Level 1 and started it pumping O negative blood. Murph explored the neck, still finding no wound.

   The team continued their efforts for one minute, the held compressions and ventilation so that it could be determined if a shockable rhythm had been restored. None. The team continued its efforts. After ten minutes Murph called it. Every one backed away from the table looking at each other, their breathing and pulses returning to normal. Kurt ventured an opinion: “The bleeding must be internal, there being no wound. And from the volume of venous blood I suctioned out of the airway, I suspect that what we have here is a case of esophageal varices that eroded and bled.” Esophageal varices are varicose veins of the esophagus, a condition caused by a back up of venous blood from the liver, which in turn is caused by liver disease such as cancer or advanced cirrhosis. He continued, “The victim was expelling all that blood out of his mouth, and the EMT’s could not see that there was no wound, but from the volume of blood expected a vascular injury to the neck.”

   The team turned to removing the clothing from the corpse. Each item was inventoried and recorded. Nan was the one who found his wallet, a few cards and eight dollars in it. There was an ID card. Nan announced " This is no longer John Doe, his name was Harold Morgan. Could we please have a moment of silence in respect for Harold Morgan." Everyone stopped what they were doing for that minute.Then Nan, Chloe and Cate Washed the body and the corpse was respectfully placed in a shroud. An orderly transported the body to the morgue with a bundle of clothing and his meager belongings in a paper bag on top. Paper was used so that the clothing and belongings would dry out and not molder. Then they turned to restoring the OR to a state of readiness. Murph made phone calls; to the police, to the medical examiner, to the 911 dispatcher. He made an attempt to call the number found in Harold's wallet, but there was no answer. Then he began his paper work. To Cate fell the responsibility of filling out the rest of the rest of the records. Murph told them that they had done a fine job, that he could not have expected any better from the team. Everyone looked to the clock willing the hands to speed to the end of the shift. The autopsy report two days later confirmed Kurt's opinion.

Tuesday, August 16, 2011

Ninth Chapter

Ninth Chapter


In which we see how uneasily the crown lies on the head of the OR

   Chicky sat down at her desk and sighed deeply. She had just returned from a meeting of the OR committee. As always it was a trial by fire, with the surgeons in an uproar. It was a misconception to think of them as a group. They were actually a pack of rabid individualists, each pursuing his own goals and the devil take the hindmost. Trying to get the committee to move in the same direction was like trying to herd cats. Cats that varied from grumpy to angry.

   When Chicky first took over the OR, the problem was scheduling the surgeon’s procedures. Space on the OR schedule was given on a first come first served basis. This had led to numerous problems. Surgeons would book fictitious patients when they did not actually have one, so as to save a favored time in the schedule. Often they would then call in a change, putting a real patient in when one came along. If they didn’t have a real patient, they would simply cancel the fake one. Sometimes they would forget to cancel the fake patient and much time would be lost trying to locate the fake, and a hole in the schedule would result, and there would be lots of difficulty in trying to rearrange the schedule at the last minute. Sometimes the fakes were easily spotted: Clark Kent, John Smith and Jane Doe were frequent entries on the schedule. The first effort to deal with this situation was the Chief of Surgery’s idea. Patients could only be entered on the schedule after they were registered with the hospital and assigned a medical record number. This led to some more counter tactics: posting patients who had been patients in the past, so there was a valid MR number. Or posting a patient who was actually in the hospital but would not be coming to the OR for surgery. The most egregious example was when Dr. Syriani booked a patient, then forgot to cancel when he didn’t have a real one to substitute. Many phone calls were made trying to locate the patient in the hospital, and on the last call it was found that the patient in question had died a week earlier. This led to many jokes about Dr. Syriani’s bedside manner, and that he made a specialty of operating on dead people.

   Chicky’s idea for solving the scheduling problem was to assign each surgeon a block of time that would be held for him up until twenty four hours before surgery. No need to fill in with fake patients, dead or otherwise. The problem the idea posed for the surgeons had to do with when the blocks of time would be. They all wanted to start first thing in the morning, and time in the afternoon was not as desirable. After all, what every surgeon wants is to have an OR staffed and ready for him twenty four hours a day, never mind that he would only use a small fraction of that time. An MBA candidate did a thesis which showed that the cost of maintaining an OR at the ready was about $120 a minute. This included all the overhead, such as HEPA filtration in the air handling, heating and cooling, electricity, salaries for nurses, techs and anesthesia, depreciation of equipment and instruments, generating and maintaining pressurized steam for autoclaves, gasses piped in such as oxygen, compressed air, nitrogen, nitrous oxide, and many other items. This study was published in a number of medical and nursing journals and made the all-time hit parade for OR managers. The surgeons were less than impressed. After all, it didn’t cost them anything. Chicky always wondered at the privileged position surgeons enjoyed. What other profession was there that someone else hired all the help, bought all the tools and equipment, carried all the overhead, and then begged you to come use it for free?

   It took a year and a half of intense politicking to get block time approved. The surgeons of course were the most vocally opposed to the idea. Chicky was barbequed at several OR committee meetings before block time was implemented. The surgeons with the largest case loads got the prime start of the day time and the smaller case loads the less desirable afternoon time. The gaming of the system was not over however. Now surgeons booked their cases for shorter than actual time to get more into their block, or exaggerated the time so as to fill their blocks. This meant that afternoon blocks were delayed because morning blocks ran over, afternoon blocks ran over, and staffing budgets were out of whack because a lot of overtime was needed to cover the overages. Conversely, when times were exaggerated to fill blocks there were holes in the schedule. It was often remarked that the OR schedule was in the running for the Pulitzer Prize for fiction. Chicky lost two very good nurses because they couldn’t get their children out of day care by the time the daycare facility closed.

   Molly came to the rescue by writing a computer program that tracked the times need by a surgeon for a given procedure. It took the times for the last ten times he did the procedure, tossed out the longest and shortest time and averaged the remaining eight. This was the time entered in the schedule when a surgeon booked a case. Cases that ran over the block were put on an add-on list, and worked into the first available spots, usually when block time was unused twenty four hours before the day of surgery. Alternatively, it was put in the surgeons next block. True emergencies bumped block time, but these were surprisingly small in number. This worked out very well, the overtime came within budget, the nurses, techs and anesthesia providers were happy with much more regular working hours, and even the surgeons were a lot happier after they got used to it.

   Now the issue was on-time starts in the mornings. Chicky and Molly had been collecting data on delays to first case starts and the reasons for the delays and who was the person responsible for the delay. Out of 336 first cases in the study, 161 were delayed. 153 were delays due to surgeon problems, such as patients showing up without History and Physicals (H&Ps), admission orders, or surgical permits: all of these were clearly things that the surgeons should have taken care of. There were 6 delays caused by the nursing staff, and they all had to do with equipment problems, three of the six were considered to be problems that could have been avoided. There were 2 delays on anesthesia’s tab, both due to serious medical problems that had to be resolved before surgery could take place. Chicky didn’t need a crystal ball to know that she would need to bring the barbeque sauce to the next OR committee meeting. The surgeons were not going to be willing to consider that they were the chief cause of morning delays.

   The next thing on Chicky’s list for the day was the yearly evaluations of her staff. This was a very complicated business, as the hospital had implemented a “merit based” system for raises, computed from the scores on the evaluations for each nurse or technician. In reality, it was a forced distribution system. If it had been a true merit based system, the amount of money to be awarded in raises would not be fixed. The reality was that Chicky got a sum that would provide all her people a 2% raise. So if she gave someone 3%, she had to give someone else 1%. So the scores had to be juggled to make everything come out even. Chicky knew that her people had worked hard all year, and having had this “merit based” system spun up to them in staff meetings and flyers posted to their homes by the HR department, they would be expecting a payoff. It was going to be a big disappointment. Maybe she should just order a case of BBQ sauce.

   While she was contemplating the “merit based” fiasco to come, there was a knock on her door. Chicky called out “come on in”. Linda entered the office, and closed the door behind her. She looked very upset. Chicky motioned to her to sit and extended the jar of jelly beans she kept on a corner of her desk. Chicky often joked that instead of jelly beans, her jar should contain capsules of Prozac. Linda shook her head, declining, and launched right in. “It’s about Connie.” She went onto relate how she knew that Connie had been having a lot of problems lately, and had been drinking hard. In fact she had shown up for work today visibly impaired. “I don’t want to get her fired or in trouble, but something has to be done.” Now the policy of the hospital was that any employee suspected of intoxication was to be taken to the ER and blood drawn for a toxicology screen. If drugs or alcohol were found, they were to be terminated on the spot. However, if an employee went to employee health and turned themselves in, admitting to a dependency problem, they would be sent to rehab, and could keep their job. Chicky decided to go out on a limb. “Bring Connie to my office” Chicky instructed Linda.

   When Linda returned to the office with Connie in tow, Chicky told Linda to wait outside, and had Connie sit down. Chicky got the aroma of alcohol on Connie’s breath as she started to cry. Chicky gave her a tissue. She reached into her book case and removed one of the many three ring binders there. Chicky thumbed through it, and reaching the section she was looking for and gave it to Connie. It was the section of the HR manual detailing the policies about dependency. “I want you to read that carefully before you say anything to me. “ Connie made as if to speak, but Chicky cut her off “Don’t talk, read” she said to Connie. Connie read. “Now,” said Chicky, “do you want to go to employee health?” Connie nodded yes. “Do you know what you have to do?” Connie nodded again. Chicky went to the door and told Linda “I just had you come to my office, and you don’t know anything about what is going on with Connie, comprende? Don’t answer that. Please escort Connie to employee health.” After they departed, Chicky sat back in her chair and breathed deeply, letting it out slowly, repeating it again and again, waiting for the relaxation to start. She knew that a similar situation with one of the anesthesiologists last year had not turned out well, and hoped that this would turn out better.

   In preparation for the OR committee meeting, Chicky was running through the on-time report with Dr. Hunter, the Chief of Surgery. He agreed with her that it was going to get a contentious reception. Chicky shared with him part of the data collected that was not included in the report. It showed that an overwhelming number of the surgeon related delays were accounted for by only eight surgeons. Another group of twelve had only one or two attributed delays, and another group had none at all. “I want to get all the bluster out front and let the steam out before making these figures known” confided Chicky. “You notice that the biggest offenders are also the ones who make life difficult?” Dr. Hunter agreed: “The way forward as I see it is to ease this in at a later meeting, but only after I have let it be known to some of the guys who always come in with their ducks in a row. Maybe we could get some peer pressure built up before we make this public, and get the committee to come up with some ideas to remedy the situation.” “Then you and I will not have to come off as the heavies and the opposition to the community of surgeons” said Chicky. They nodded to each other. Since the block time plan had created a stable and realistic schedule, Dr. Hunter had come to trust Chicky and worked very closely with her.

   It was eight weeks later, and Chicky was driving past the tall stone pillars and large wrought iron gate of a country estate that had become one of the better private rehab clinics. She was there to meet with the Director of the clinic to prepare for Connie’s upcoming discharge and return to the work place. The hospital had arranged for the best for Connie. After parking in the shaded and landscaped parking lot, Chicky walked up the short flight of stairs to the ornate doorway. The impressive manor house had been built at the end of the nineteenth century by a robber baron who had made his fortune in making saws and other hand tools, and later on arms and ammunition for the Spanish-American war. It had gone into decline in the sixties and was bought by a foundation and renovated into a clinic specializing in drug and alcohol rehab for those of means and requiring discretion. She was met by a receptionist and shown to an office, every horizontal surface of which was piled with journals and papers. The director of the clinic arose from the organized chaos and introduced himself. He got right down to business and detailed the requirements for Connie’s return to work. It was all pretty much as Chicky expected except for one thing: Connie could not work in an area where there were any controlled drugs, nor could she have access or administer them. This told Chicky that Connie’s problem was not just with alcohol, a surprise. When Chicky questioned the director on this, he dodged the question, and reiterated those conditions. This was going to be a problem. Chicky said she would get it worked out and was given a copy of the schedule for follow-ups that Connie would have to keep. Chicky also had to report the whole business to the state board of nursing. They would have additional requirements that would have to be met.

   Chicky created a position to put Connie into. Connie would be calling all the surgeon offices and following up on getting all the H&Ps, permits, copies of x-rays and lab work either mailed or faxed into Connie's little office, where she would collect the paper work into files to be delivered to pre-op on the day of surgery. Hopefully, the surgeons would see this as a customer service initiative instead of nagging. She would also contact the patients on the day before surgery and go over things with them. She would also make follow up calls to patients to check up on how things were going for them. This not only would meet the conditions for Connie’s return but should solve a good many of the delay issues as well. The OR committee had not been able to get past arguing about the delays. The public relations aspects would please the hospitals marketing department. That had been a big help in selling this position down on mahogany row. And it would also help the bottom line of the OR as well, since at $120 a minute, it could cover the cost of Connie’s position by reducing unproductive OR time. But most important to Chicky, it meant a chance at recovery for Connie as well. Still, the fact that drugs had been involved, and that no shortages in the inventories had been noticed, bothered Chicky in the back of her mind. When things had gone this way with one of the anesthesiologists, there had been drugs missing from the inventory, vials of drugs that had been watered down, and two rounds of rehab had failed. It had ended with a funeral. As it was, Chicky was going to have to report on Connie to the state nursing board weekly. Connie would also be subject to weekly and random drug testing. Chicky sat back in her chair and started to breathe in deeply, letting it out slowly…..