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Operating Room: Special Report: 17th National AORN Congress Published online: 13 Jul 2010.

To cite this article: (1970) Operating Room: Special Report: 17th National AORN Congress, Hospital Topics, 48:4, 101-122, DOI: 10.1080/00185868.1970.9952281 To link to this article: http://dx.doi.org/10.1080/00185868.1970.9952281

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Special report: 17th national AORN congress

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Part I

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This is the first of two comprehensive reports on the 17th national congress of the Association of Operating Room Nurses, held in Anaheim, Calif., February 22-26. Part I1 will appear in May.

Tells indications for liver transplant, technics used, improved results ISRAEL PENN, M.D., associate professor of surgery, University of Colorado Medical Center, and assistant chief of surgery, VA Hospital, Denver: Since the first liver transplant was done in 1963, about I 0 0 have been done in the w o r l d 4 0 of them in Denver. In some countries, the procedure is viewed APRIL 1970

with skepticism; in others-England, for instancefan clubs support liver transplant. The first question asked is: Which patient needs a liver transplant? The patient whose life expectancy can be measured in weeks or a few months because of serious disease is a candidate for a transplant. One major indication is congenital pyloric atresia for which conventional surgery offers no help, and from which infants die at 12 to 18 months of age. These can now be saved. The majority of the 40 children who have had transplants had this anomaly. Other indications for transplants are end-stage cirrhosis, metabolic disorders involving the liver in young children, and acute liver failure in adults. When the liver has been destroyed by hepatitis or an overdose of a toxic drug, a transplant may be considered, but there is the risk of destruction by the disease process. When malignancy is confined to one lobe of the liver, lobectomy is possible, but when both lobes are involved, the only possible treatment is total hepatectomy and replacement. Transplantation is not considered if disease has spread beyond the liver or if the liver affliction represents metastases from another organ. A cadaver organ is matched as closely as possible to the recipient. The ABO group is the first concern. Donor and recipient are matched exactly as for blood 101

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transfusion. Leukocyte antigen profiles are obtained for both recipient and organ donor, because certain antigens on the white cells are also present on organs such as the heart, lung and liver. A lymphocyte culture test is desirable but seldom done, because results are not available for four or five days. When an organ is about to become available, the donor’s femoral artery and vein are cannulated and a connection is made to a cardiopulmonary bypass. When the donor is declared dead, the bypass is started. Oxygenated blood is delivered to the liver during removal. Then it is cooled because hypothermia will prevent deterioration. In young children, the technic is modified by perfusing a cold electrolyte solution through the liver to cool it rapidly before removal. Sometimes, the procedures can be coordinated with donor and recipient in adjacent operating rooms. A t other times, the donor liver will have to be preserved if the procedure o n the recipient is complicated and prolonged. There are two possible technics for transplantation -the ovthotopic. in which the patient’s diseased liver is removed and the healthy organ is put in the same position, or the heterotopic, in which the diseased organ is left in place and the second is placed in the abdomen and connected to the arterial and venous systems. In the latter procedure, any remaining function of the recipient’s liver is preserved. This is a distinct advantage in the event of rejection. The disadvantage is that there is little room in the abdomen for two livers; hence, the diaphragm is pushed up and the patient may die of respiratory complications. The patient is started on a regime of immunosuppressive drugs immediately after surgery, to thwart rejection. Iniuran, promazine and antilymphocytic globulin are the three main agents. The last has been used in 150 patients since 1966 with noticeable improvements in results. The patient is scanned postoperatively for the enlarged shadow that signals a swollen, tender organ about to be rejected. Results with transplants for malignant disease are disappointing. Five patients have developed metastases, and a decision has been made to forgo transplants for hepatoma. Early results with liver transplantation were disappointing because of ignorance, but experience and knowledge have accumulated. Since July 1967, results have improved so much that 33 percent of patients receiving transplants are alive after one year with reasonably good liver function. Six patients have survived a year or more; one patient has survived .more than two years but shows evidence of a chronic rejection; one boy is alive 19 months after transplantation with perfect liver chemistries. Five patients are alive n o w - o n e each at 2 years, 19 months, 7 months, 5 months and 5 weeks. These results are encouraging and similar to those achieved with the first kidney transplants. Operating-room nurses contribute enormously to success. They must be cooperative and ready to prepare as many as four rooms for simultaneous procedures, often at odd hours of the day and night. 102

Describes special nursing problems in care of transplant patient JANE K. LUNDQUIST, R.N., head nurse, transplant unit, clinical research center, University of Colorado Medical Center, Denver: The 10-bed recipient unit at the University of Colorado Medical Center is financed by the U.S. Public Health Service, and care is given free to recipients. The unit is independent in terms of location and management. It is away from the rest of the hospital, has its own laboratories, diet kitchen and dietitian, and houses both adults and children. T h e last fact may seem astonishing, but children are great boosts to morale. The unit is prepared for acute dialysis. The staff of 14 registered nurses may seem large but is often inadequate, because patients are seen through all phases of treatment in the unit. Nurses have total responsibility for nursing care; they provide their own coverage for illness, weekends and holidays, because registered nurses in the rest of the hospital are not prepared for this assignment. T h e supervisor interviews and hires her own nurses and is frank about the difficulties of work in the unit. Nurses d o not rotate through the operating room, but the transplant team has its own scrub nurse who participates in all team conferences on the wards. Nurses in the unit accept a responsibility for education of other areas of the hospital. If a patient is transferred to another floor, a nurse from the unit goes along to explain details of his care. The intensivecare unit and recovery room are not used postoperatively, except for the infant or small child who is given care in the pediatric intensive-care unit until he is extubated and stable. The major disadvantage in terms of nursing care is that patients often arrive with little or no time for good preparation for surgery. T h e nurse assigned to the patient will often go to the airport to meet him, and be the guide through the admission procedures. She stays through the preparation and accompanies the patient as far as the operating room. She meets members of the family, explains frightening equipment in the patient’s room, and encourages the family to rest during the hours of surgery. The patient’s room is organized with all necessary equipment so that nurses have n o reason to leave for the first 24 postoperative hours. Postoperative care is similar to that given any patient after a major surgical procedure. Two particular problems concern bleeding and respiratory care. All dressings must be weighed and measured. Because most patients are on respirators, respiratory care must be immaculate. There is always a danger of infection in patients receiving ventilatory assistance, but because these patients are receiving steroids, they are particularly vulnerable. The regime for fluid replacement is complicated. Nurses in the unit must have unusual technical competence. As a convenience for everyone, they are taught a few simple laboratory tests that are done every hour. Doing the tests, the nurse is immediately HOSPITAL TOPICS

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b At scientific exhibit on teaching technology for operating-room nurses, Joan Gowin, R.N., director of nursing, operating and recovery rooms, ,University Hospitals of Cleveland, displays self-tutorial instructional films on surgical scrub procedure and closed-cuff method of gowning and gloving. Interested observer is A. Marjorie Matthias, nursing officer in charge of operating theatres, Crawley Hospital, Sussex, England.

aware of her patient’s condition and often knows what treatment is indicated. After the acute period, nurses often will use their common sense if the physician is not in the unit. They have many opportunities for independent judgment and action. The patient and members of the family need many explanations during this time. Questions are answered honestly and frankly. Members of the family are allowed to stay in the room, within the limits of time and space, and are more often a help than a hindrance. The intubated patient awakes frightened, and a relative can be very reassuring-more so than a nurse. In convalescent Fare, an atmosphere of Formality is encouraged. Pafients are not isolated; they wear their own clothes; a hairdresser is available by appointment. Adults are concerned about long-terq survival; they worry too much and are encouraged to leave the hospital on passes. Because hospithlization may be four months or longer, they become attached to the team and ward, and experience the depression that is a natural part of any long hospitalization. The nurse can only listen, try to make things as easy as possible, encourage the patient to go out, and emphasize what he @ be .Iable to do after discharge. The medication schedule is difficult for the patient to learn but must be mastered before discharge. Children present different problems in care. Most have been chronically ill since birth and have never known a “normal childhood.” If they are going to do well after surgery, they recover quickly. After the immediate crisis, other problems arise. The children must begin school as soon as possible. It is better that they attend the hospital school, for most of them have had contact only with adults and do not know how to APRIL 1970

act with other children. Most are “spoiled,” and conferences with parents are necessary to define limits of behavior. All must agree on a reasonable pattern, for these parents have not been accustomed to thinking of the child in terms of a future and normal life, and discipline creates new problems for them. A child may be on the unit for six months or more, and nurses will start the task of discipline which parents can take over. Most children are not toilet-trained when admitted. Nurses have become experts at training them. Children are taken out on passes to the zoo, for bus rides, or to visit in the homes of nurses. Much of this diversion is for the benefit of parents who have stayed close to the child at the expense of each other. Because the nurse has a close relationship, she can encourage parents to spend time with each other. Although a nurse may get overinvolved, this is not necessarily bad, for she gets back in satisfaction what she expends in interest and energy. When children die, nurses grieve and must not stifle their emotions. They share sadness with the patient’s family and offer as much support as possible. Because they do become very involved, work overtime without compensation when the ward is busy, and share great stress, nurses are urged to take leave for a month or two every two years. Nurses are caring for surgical patients with medical

b Exhibit

on surgery without ligatures was presented by the AORN of Los Angeles. Use of clips in various types of surgery was featured in display. Zelpha Burbank, R.N., (I.), operating-room supervisor, VA Hospital, Sepulveda, Calif., and Rosemary Y. Denny, R.N., operating-room supervisor, Baldwin Hills Hospital, Los Angeles, answer questions of Frances Reeser, R.N., operating-room supervisor, VA Hospital, Bronx, N.Y.; Barbara Volpe. R.N., operating-room supervisor, VA Hospital, New York City: and Sue Miller, R.N., head nurse, operating room, Middletown (N.Y.) State Hospital.

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complications and must couple a healthy psyche with technical orientation. Because they must be versatile in arranging working hours, single girls are employed. Nurses need common sense to make independent judgments and to b,reak rules occasionally for the good of the patient. Doctors are spared recitals of unimportant details; nurses ask well-informed questions and give well-informed answers. There must be mutual respect between nurse and doctor, an atmosphere for a free exchange of ideas, and a shared concern that the patient receive the best possible care throughout his hospitalization and follow-up.

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Tells benefits of early surgery in treatment of arthritis LEONARD MARMOR, M.D., associate clinical professor of orthopedic surgery, UCLA Medical Center, Los Angeles: Until a cure is found, surgery has a definite contribution to make in the treatment of rheumatoid arthritis, a disease recognized as long ago as 1500 B.C., precipitated by unknown factors, and resistant to therapy. The disease process begins as synovitis-inflammation

b

Relaxing outside the convention center during a break

in the meeting were ( I . to r.): Lella I. Tamez, R.N., staff nurse, and Pamela DeMarco, R.N., operating room supervisor, Parkview Community Hospital, Riverside, Calif.; Jeanne Otto, R.N., O.R. instructor, Children's Hospital, Boston: Janet A. Masse, R.N., private scrub nurse, Overholt Thoracic Clinic, Boston; and Jeanne Colt, R.N.,

operating-room supervisor, Children's Hospital, Boston.

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of the synovial membrane that lines joints. For an unknown reason, it swells, often to a hundred times normal size, and destroys joints. There may be minimal deformity with swelling, but as the disease progresses, the synovium erodes the bone and destroys ligaments and joint capsules. Theories concerning the cause of this physiological change vary. Some support the possibility of an antibody immune reaction; others, that of a viral factor. The latter has been tested by injection of cell suspensions from diseased joints into mice. Identification of arthritic deformities in mice born of the experimental animals supports the possibility of involvement of a slow-growing virus. There are many regimens for treatment-aspirin, antirheumatoid drugs, indocine, butazolidine, gold, fever therapy-but complications of medical treatment run as high as 50 percent, and at least half of the patients who take corticosteroids have complications. When considered in the light of these figures surgery is seen as a less radical approach. Medical treatment does not prevent progress of the disease; its course continues, even in patients who take corticosteroids. Bracing is of limited value, for deformities will continue. Early surgery prevents joint destruction and gives immediate relief of pain. It is unfortunate that so few patients are seen in the early stages of the disease. Surgery is not a treatment as such; it is an adjunct to good medical care. When control with the latter is satisfactory, surgery is not indicated. Surgery is not contraindicated in the presence of active arthritis; one can operate on a hot, swollen joint. Age is no contraindication; surgery is indicated when pain and swelling persist despite good medical therapy, and when there is x-ray evidence of destruction of joints. Patients are chosen for surgery with great discretion. They must have a sincere and acknowledged desire for the procedure. Any patient who is reluctant to have surgery is a poor candidate; results are usually poor, and both patient and surgeon are discouraged. All patients who have ever taken steroids must be prepared with a preoperative course of steroids to avert the shock that is otherwise inevitable. In 10 years' experience with surgery on more than 1,000 patients there has been no mortality. Surgery on the deformed hand is very successful When the ulnar cleft is involved, surgery is performed as soon as the patient is willing, but not if the joint is beginning to sublux. At operation, the synovia is cleaned from the joint; the hood is left intact. Synovia may also be found growing over the top of the cartilage with great destruction. White sutures which do not show through the skin are used throughout. The digiti quinti can be transferred to act as adductors and reduce deformity. The same procedures are used for treatment of the knuckles. Prostheses have enhanced success in this reconstruction. The Swanson, for instance, a Silastic hinge has improved results which even before its development were good. If the volar plate is released, a Swanson prosthesis is essential. Motion is started as early as possible postoperatively with elastic braces for extension and flexion. HOSPITAL TOPICS

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The destructive process is identical in the knuckles, although the synovia in smaller joints has a shorter life. The boutonnikre deformity is particularly unpleasant and very serious, for the person cannot use his fingers. The synovium swells inside the phalangointerphalangea1,joint and pushes the lateral band off to the side. At operation, fingers are fused into more useful position. The phalango-interphalangeal joint is fused open when there is ankylosis. The thumb needs more power than mobility. When it is fused, the aim is a good grasp, Flexor tenosynovitis can occur anywhere on the palm of the hand, but tissue need not be removed. If the greatest part is excised, inflammation in the rest subsides, and the patient recovers. If relief is not provided surgically, tendons often rupture. The difficulty is also common to the back of the hand, and tendon rupture-a painless, sudden event-causes severe disability. As the synovium swells, the median nerve may be compressed, and a “carpal tunnel syndrome” results. Surgery gives immediate relief of pain, prevents deformity, improves function, and boosts the patient’s morale. Recurrence is likely and cannot be anticipated, but reoperation is possible. The elbow is frequently involved in this disease process. The joint is destroyed, and treatment usually includes excision of the radial head with synovectomy. There is immediate relief of pain. Medial osteophytes can also be removed. Ankylosis is relieved with transpiantation of fascia lata and arthroplasty. Similarly, the shoulder can be afflicted. Prostheses have been developed for the humeral head, which may be removed with the synovium. The knee is a unique problem because there is no good replacement. Rheumatoid arthritis is common and the aim of surgery is prevention of deformity. The clinical picture is that of chronic pain and a lack of response to medical treatment. Valgus or varus also complicates the picture, and the joint is unstable. The patient must be examined by x-ray in a standing position for good visualization of the joint. Synovectomy of the knee was described in 1877 and introduced in the United States in 1923. Surgery is not difficult, but there is always concern about a stiff knee. Indications are identical to those for surgery on other joints. Surgery is not contraindicated in the presence of active arthritis or x-ray evidence of joint destruction . Electric reamers and air drills have cut operating time to 45 minutes for each knee. Knees must be manipulated under anesthesia to regain motion. If they are unstable, arthroplasty is necessary with insertion of a MacIntosh plateau to fill the evacuated joint. Movement is encouraged as early as possible after surgery-often on the same day. Recurrence is likely, hut in I75 knees followed for periods ranging from 21 months to seven years, the rate has not exceeded 10 percent. About one million people in the United States have rheumatoid arthritis. It is hoped that more will be encouraged to seek surgical relief in the early stages of APRIL 1970

the AORN evening in Disneyland draws to a close, two nurses enjoy a ride in a horse-drawn carnage on Main Street. Below: Time to go home. b As

their disease for synovectomy and arthroplasty offer relief from pain and restoration of normal useful function.

Lists advantages of hypnoanesthesia, indications for use, induction methods WILLIAM C. MC CALL, M.D., general practitioner1surgeon, Anaheim, Calif. Centuries of myth and misinformation cling to hypnosis, obscuring its remarkable therapeutic abilities. Few other forms of treatment are benign. It is impossible to harm the patient because he retains control; the hypnotist instructs him, but he develops the hypnosis. Yet hypnosis is a powerful therapeutic tool. Surgery under hypnoanesthesia is usually almost bloodless; the patient is conscious, yet calm and COoperative, his sensation of pain changed to one of pressure or numbness. Hypnosis can completely alter the patient’s postoperative course; the recovery period is shorter, smoother, and less plagued by problems and complications. Any operating-room nurse can give this help just by taking a few minutes preoperatively to give the 105

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b Old

instruments and supplies given to the Hospital of the Good Samaritan, Los Angeles, over the last 30 years were featured in exhibit prepared by Mabel Crawford, R.N. (I.), the hospital’s O.R. supervisor, who discusses some of the items with Frances Reeser, R.N., O.R. supervisor, VA Hospital, Bronx, N.Y. Items in the display cupboard at the hospital are changed every three weeks. Operating-room technicians have had the historical exhibit as their project since 1965.

patient suggestions for a pleasant, positive postoperative course. Fearful, anxious or poor-risk patients are particularly good candidates for surgery under hypnoanesthesia. There are times and situations in which no other modality will serve as well. In general, the indications for using hypnoanesthesia are these: 1. To overcome fear, apprehension and anxiety, thereby reducing tension. 2. To aid in postanesthetic and postoperative recovery. 3. To raise the pain threshold, thereby reducing the amount of narcotics needed. 4. To produce anesthesia and analgesia thereby reducing the amount of chemical anesthesia necessary. Several methods will produce hypnosis. In one, the patient is told he will become cold and numb, or that he will feel pressure but no pain. Sometimes anesthesia is produced in an easy area then transferred to one more difficult for the patient to visualize. For example, the patient is told anesthesia will cover his hand like a glove; then, when the hand is anesthetized, he’s told to stroke a second area, a quadrant, perhaps, or one side of the throat in the case of a child undergoing a tonsillectomy. In this way, the patient “transfers” the anesthesia. A third method of hypnotic induction is by dissociation-the patient is standing off, detached. With a fourth technic, the patient visualizes the anesthetic being given and watches it, and the numbness spread. You need no extensive, formal hypnotic induction to smooth a patient’s postoperative course, however. All you need are simple instructions. Any inroads you make a n the patient’s subconscious will be helpful if you suggest the safety of the procedure, pleasant 106

relaxation, lack of anxiety, a feeling that this will bc a rewarding, interesting experience. More specifically, you can give instructions designed to reduce pain, nausea, vomiting, constipation, inability to urinate. Make your instructions as pleasant and positive as possible. “You will relax and sleep soundly tonight . . . you will feel relaxed and comfortable in every way . . . you will have a pleasant, normal bowel movement.” Semantics, the words you use, are extremely important. Avoid negative words or thoughts-never say, fo.r example, “You won’t be constipated.” Use positive words like peaceful, tranquil, restful, serene, relax. But avoid words like pain, discomfort, complications, hemorrhage, bleeding, nausea, vomiting, death. And avoid any suggestions that would prevent awakening. Only one precaution is necessary: beware of a patient’s psychological “sore toes,” any hang-ups he might have. I told one of my patients that he would find things growing dim, but he simply could not develop anesthesia. I learned later that he had a morbid fear of ‘black, and to him, growing dim meant blackness. Usually, such sore toes are easy to spot as you talk to the patient preoperatively; if he reacts negatively to a word, simply avoid it thereafter. It is difficult to say why some patients fail to develop anesthesia. I hypnotized one patient for delivery of her baby and she was delightful with the anesthetic; yet a few months later I tried to hypnotize her for removal of an ovarian cyst and she failed to develop any anesthesia. In such cases, it is the patient who fails; the patient is always in control, he is conscious and reacting, not off in a void. Hypnosis is being used on you all the time. If you don’t believe it, look at a child watching TV. But even this is benign, since it is the subject who controls the reaction. Similarly, if you want a hypnotist to help you to stop smoking, you must first understand why you smoke, that you have a conditioned reflex. It is

b Dorothy S. Kehoe, R.N. ( I . ) , La Habra, Calif., general chairman of congress committees, and Myra K. Slavens, R.N., director of education, AORN, exchange happy smiles on conclusion of successful congress.

HOSPITAL TOPICS

simple for the hypnotist to help you stop-but he can’t make you do anything. Other uses have been found for hypnosis outside the operating room: treatment of terminal cancer or tic doloreux; increase of joint mobility in arthritis. Hypnosis is a friend 100 percent of the time. A nurse need never fear to use it; all she has to remember is to keep instructions benign and general and to avoid psychological “sore toes.”

Panel looks at problems, future needs of nursing education and service

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EVELYN ENG, R.N., M.S., director of nursing service, University of Missouri Medical Center, Columbia: How can one discuss the nurse of tomorrow when so little agreement exists about the nurse of today? The challenge is to look critically at today, realizing that there is no magic to be projected into the future. Today is the result of yesterday and the f0rerunne.r of tomorrow, which never really comes. The fourth decade of a chronic shortage of health workers is beginning. Duties of registered nurses seem to be established in terms of availability rather than by professional standards. It is right that problems in nursing be identified, but shortages should not be allowed to be one of them. When a substitute for nursing is suggested, the b Denton A. Cooley, M.D., Houston, famed transplant

surgeon and keynote speaker at the congress, is surrounded by two award winners and the president of the National Association of Theatre Nurses in Great Britain. At left is A. Marjorie Matthias, nursing officer in charge of operating theatres, Crawley Hospital, Sussex, England, who won the annual travel award presented by Johnson & Johnson Ltd., Great Britain. Her countrywoman, Hilda

challenge of legality arises immediately. Commitments to nursing education from the pocketbooks of the consumer and the government are inadequate. Consumers have no appreciation of the cost of keeping operating rooms going 24 hours a day, seven days a week. Could this cost be minimized if the surgeon and nurse got together? There must be an opportunity to debate problems and questions about the cost of care. Nursing service, for its part, must offer formal training programs for employees-not orientation episodes. Graduate nurses are coming to hospitals better educated but less well trained. This trend will continue, because attending college is the norm in today’s culture. In Missouri, diploma programs have dropped from 22 to 17; associate-degree programs have increased from one to nine and baccalaureate programs from five to six in a I 0-year period. Directo.rs of nursing service have to be creative and provide training programs in the hospital setting. The head nurse and the supervisor must welcome new graduates and be prepared to train them to perform the desired tasks. Formal programs for training technicians may be necessary, as well as a redefinition of the role of the registered nurse in the operating room. Those in nursing administration have a responsibility to train their own workers, utilizing the knowledge these people bring to the work center. There must be educational programs emphasizing management and training. Few nurses are prepared to be directors of nursing, and nurse managers should be prepared before nurse specialists. R. Fletcher (r.), president of the British counterpart of the AORN, won that award in 1966. She is nurse planning officer of the project team planning the extensive redevelopment of Hammersmith Hospital, the postgraduate medical school of the University of London. Standing next to Dr. Cooley is Mary R. Nolan, R.N., O.R. staff nurse, Daniel Freeman Hospital, Inglewood, Calif., who won the 15th annual Johnson & Johnson O.R. nurse scholarship award.

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b Nurses

from V A hospitals throughout the nation hold their anual meeting during the congress.

The career-ladder concept should be initiated, and terminal programs-dead-end programs that plague hospitals-should be eliminated. Tomorrow’s registered nurse will have to put more into team relationships. Nurses will function more independently and with more initiative. Who the charge nurse, the scrub nurse or others will be in the future is difficult to predict. With the trend of today, it is a question whether she will be a professional person. Tomorrow’s nurse will not be steeped in the history and tradition of nursing. She will be more involved in the mainstream of life; she will be more active in labor movements, and will work to establish working conditions and salary scales. The nurse will need better relationships with her nonprofessional co-workers, recognizing that they make a contribution that is not menial. One strength of the nursing heritage has been the delivery of care accompanied by love. The preoccupation of today is with tools, but nurses of tomorrow will respond to man’s greater need for love in a time of increased technical development.

EMILY HOLMQUIST, R.N., H.H.D., dean and professor of nursing, Indiana University School of Nursing, Indianapolis: There is a movement among members of many professions and those in allied health sciences to work through a cooperative venture for the whole process of accreditation. Each profession now accredits its own group. and universities are exasperated because of the amount of time involved in catering to each group as it evaluates its own programs. For some reason. nursing is not included in this movement. Core programs that have been suggested for all students interested in the health professions would combine and unify preprofessional training, with a 108

break away later for professional p,rograms. This idea has not been tried anywhere but will be an important issue in the future of nursing. A national coalition of student professionals is using an interdisciplinary team approach to help solve social problems. These people have deep social consciences and want to work with others to make changes in society. There are also implications in this for the future of nurses. The American Nurses’ Association is currently in a crisis, but without this professional association, nursing could not survive. Each state would have a n independent voice; problems would be overwhelming. There must be a single voice to speak for nurses. Federal support for the health professions is increasing. Why should not nursing get more support? At a recent Washington hearing, nurses were advised to clean up their own house-to come with a single voice, demonstrate their need, and then ask for more funds. For a long time, multiple voices in nursing have spoken against each other, making strong pleas far particular programs or issues. It is not suggested that thinking and planning must all fit one pattern. but there must be one strong, loud, clear voice to speak for nursing in terms of responsibilities and needs. There must be open curricula with possibilities for advancement for those who want to move up educationally. Schools of nursing are becoming increasingly aware of this need. If the baccalaureate-degree programs are doing a good job developing depth in concepts appropriate to baccalaureate education, then it is hard to believe that a program intended for another purpose can serve as its preparation. To permit rapid movement of graduates of diploma and associate-degree programs through the baccalaureate program, recognition can be given to education of the applicants, so that time need not have been HOSPITAL TOPICS

wasted. Courses should be provided for demonstration of competence brought to the baccalaureate progralms. Operating-room nursing has been shifted out of curricula by baccalaureate programs. At Indiana University, operating-room assignment is recognized as an important experience for students-however, it provides not experience typical of the past decades but learning experiences unique to the operating room. T h e responsibility for asepsis, skill in assessing levels of consciousness, and the ability to cope with emergency situations and give leadership are facets of nursing learned best, if not exclusively, in the operating room.

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JERRY G. PEERS, R.N., senior operating-room supervisor, UCLA HospitalMedical Center for the Health Sciences, Los Angeles: Operating-room nurses have been accused of splintering off from professional organizations, but certainly they are now working to get back into the fold. Perhaps the trend of architects to design operating rooms without windows is a reflection of what has happened to operating-room nurses; perhaps they have been on the inside too long without looking out. I hope that operating-room nurses today are looking at the rest of the profession and becoming part of the general parade. They have made a good start with participation in national programs for nurse recruitment-not exclusively for the operating room but for nursing in general. The student belongs in the operating room. She will learn aseptic technic that will be vital to her whole career. She cannot learn by scrubbing for an hour or two, by working in a laboratory session for a few hours, or by helping someone clean up after a case. These experiences are empty. N o operating-room instructor or supervisor wants to make every student a competent instrument handler, but both instructors and supervisors want to expose each student to good basic concepts of work in the operating room and to develop a pool of graduate nurses for work in the operating room after graduation. Perhaps all the things said about the operatingroom supervisor are true. Perhaps she is a crank, a frightening personality, a “battle-axe.’’ Perhaps it is time to correct the image. The trauma of exposure to the operating room cannot be eliminated a i y more than that of experience in other aspects of nursing, but it is surely possible to prevent unnecessary trauma. Operating-room nurses must share the responsibility for community health care. The cost of hospital care is already frightening, and the cost of teaching graduate nurses who are not clinically adaptable at the specialty level would be another expensive burden for the patient. The operating-room nurse, as teacher and supervisor for the operating-room technician. need not be skilled in every technic personally but must know how and why a thing is done if she is to teach. t.rain and reinforce behavior in another person’s expertise. The nurse must face the future with great opti-

b Glea

Homan, R.N. (I.), operating-room supervisor, and Mary Pagel, R.N., member of the O.R. staff, Good Samaritan Hospital, Puyallup, Wash., chat in the patio area of the center before the final program session. mism. Nurses d o belong in the operating room, and it is hoped that educators will keep them there. The statement in brochures that schools of nursing “prepare graduates for first-level positions in nursing’’ may become truth for the operating room as well as €or other specialties.

’

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b Discussing their plans for a postconvention trip to San Francisco were Isabelle Barr. R.N. ( I . 1, operating-room supervisor, VA Hospital, Wilmington, Del., and Pauline R. Young, R.N., operating-room supervisor. Hahnemann Medical College and Hospital. Philadelphia. wtio was the first national president of the AORN.

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b After premiere of film, “Faces and Phases of Operatingroom Management,” presented by Ludmila Davis, R.N., director, operating and emergency rooms, Stanford University Medical Center, Stanford, Calif., members of audience stop in lobby to take notes from bulletin-board display from the center-“Reflections on O.R. Nurses-Distorted or True,” The nurses were also interested in the evaluation form shown.

MILDRED MONTAG, R.N., ELD., professor of nursing education, Teachers College, Columbia University, New York City: The community college is the “now” college. By 1975. 50 percent of all freshmen in college will be in 2year institutions. This is true in many states already. Associate-degree nursing programs are developing at a rate of one a week, and there are now more than 400. Twenty years ago. the programs were organized to prepare men and women for functions commonly associated with the registered nurse. They were predicated on the belief that patients deserve and require qualified personnel at the bedside. The associatedegree program is not the first two years of a 4-year program, nor is it a 3-year program with the third year cut off. It is a new program geared to immediate, direct care of the patient. It does not and should not include management. There is a place for a unit manager. but not every nurse has to be “the” manager. The program prepares nurses to work with common recurring health problems, chronic o r acute. N o attempt is made to expose the student to all departments o r all diagnoses or all variations of disease, because common needs of patients for nursing transcend o r overlap the specialties. Some hospital departments may never be used for teaching students in associate-degree programs. Work in the heart-transplant unit, for instance, is not considered appropriate for these students. Asepsis is of utmost importance in the operating room and can indeed be taught best there, but it has not been taught in a way that allows transfer of knowledge. If it were, the horrendous violations of good technic seen on every ward would never occur. 110

The associate-degree program tries to teach basic fundamentals that are transferable and that become part of the nurse’s way of thinking and working. Appropriate learning experiences must be selected with care. Time is short, and much has been wasted with repetitive acts that did not contribute to learning. The learning experience in the associate-degree program is selected according to the laboratory concept. The experience has meaning for the student at the particular stage of development and is not proffered because the hospital needs the student in a particular place at any one time. Students are rotated through services only if opportunities for learning exist. The whole question of utilization is more pertinent than that of shortages. In the first evaluation of the associate-degree program, 91 percent of the graduates passed state board examinations, and four out of five rated the same as or better than nurses with equal experience but different preparation. In the second evaluation, 85 percent passed the examinations-a rate comparable to that of other groups. Seventy-five percent rated as well as or better than counterparts with equal experience; 83 percent of the graduates stated they would recommend it to others. Graduates are complimentary about the quality of teaching and appreciative of the close relationships that exist between students and teachers. Properly prepared and utilized, associate-degree graduates can be meaningful members of the team giving direct patient care.

CYNTHIA R. KINSELLA, Ed.D., director of nursing. Mount Sinai Hospital, and dean, Mount Sinai School of Nursing, City College of New York, New York City: The conflicts in nursing are in the roles and responsibilities of education and service. Different definitions are needed. The educator questions improper use of the young nurse practitioner-designed to make the young nurse fail in her efforts to deliver safe and good care. Service is expected without thought to preparing a person to serve more efficiently. The capabilities of the new graduate or newly employed nurse need to be measured. Continuous assessment of her capability is needed, wherever she works. Transitional programs are needed for newly employed nurses working in the field, but the problem of preparing the new practitioner to meet patients’ needs exists in basic programs as well as within institutions. The worlds of the educator and the service administrator are different. The educator is oriented to preparation. to emphasis on the student and the process of learning rather than on the patient. Her commitment is to the student and her preparation for tomorrow. Educators say they must state and restate expected behavioral outcome of programs. The nursing-service administrator lives with insistent demands, therapeutic emergencies, community mandates. To the student, the educator is yesterday. T h e student’s role model is the staff nurse functioning in HOSPITAL TOPICS

the real world. Thus, there is a complex of conflicts throughout the profession-both of concepts and generations.

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RACHEL AYERS, R.N., M.S., director of nursing, City of Hope Medical Center, Duarte, Calif.: Nurses of tomorrow may be licensed vocational nurses, operating-room technicians, aides, corpsmen, or any of a host of people appearing on the healthcare scene. Nurses are beginning to realize they must think of themselves as citizens first, nurses second, and operating-room nurses third. Nursing is not in control of what is happening in legislatures in this country today. In this past year, legislation was introduced in California to allow licensing of vocational nurses after 30 units of nursing courses. Some may be licensed by waiver or with 6% years’ experience doing “something somewhere.” This means vocational nurses will sit for state board examinations without having been graduated from an accredited program in nursing. A candidate could go from school to school taking three, five, 10 units and sit for a state board examination when she had accumulated 30. Most persons in this group have not been educated beyond high school. Examinations for registered nurses are constructed to measure their qualifications to provide minimum practice in nursing-not to assess knowledge based on an educational program. More cannot be done to improve this because nursing has not defined differences in practice. The cry of licensed practical nurses, corpsmen, operating-room technicians is, “We are taking care of patients and doing all the work. Where are the nurses? We want recognition.” Nursing educators are debating with each other and with nursing-service administrators; nursing-service administrators are debating nursing specialists. There is no unification. A house divided will fall. Nurses cannot be heard before legislative committees unless they know what they want to say. The day of hiding behind “nursing is a profession” is past. Nurses must become citizens and concern themselves with laws and standards of practice if they are to survive. The possibility of eliminating all licensure is a horrible thought. Licensure offers the public some protection that people giving care meet certain crtteria. Support for legislation to define criteria for continuing education and relicensure should be supported. Q. Should membership in the ANA be compulsory? DR. HOLMQUIST: No, because a pride of this country is freedom of choice. But nurses should support their responsibility to the profession as a wholeshould want to belong to the h N A , and feel cheated if they don’t. Q. What about the possibility of credit toward the baccalaureate program for diploma-school education and experience? DR. HOLMQUIST: How to give credit for past training, experience or education is a question for all educators, because credit is no indication of how APRIL 1970

b Newly installed AORN president, Betty J. Thomas, R.N. (I. ) , operating-room and recovery-room supervisor,

Swedish Hospital, Englewood, Colo., presents plaque to outgoing president Ina Love Williams, R.N., operatingroom supervisor, Maryview Hospital, Portsmouth, Va.

much has been learned. Educators are not in a position to give credit for experience at this time. Students get credit for college time; otherwise, they have to start at the beginning. Advance placement examinations are given to assay a person’s qualifications. If possible, credit is given for previous education. All students take the senior year, and all make up deficiencies found on admission. Some students do it in two years; others take from 2% to 3 years.

Mrs. Williams accepts new post Mrs. Ina Love Williams, R.N., immediate past president, Association of Operating Room Nurses, has been named director of professional relations, Ethicon, Inc. She has been operating-room supervisor, Maryview Hospital, Portsmouth, Va. A graduate of the Portsmouth General Hospital School of Nursing, Mrs. Williams rose from staff nurse to assistant O.R. supervisor at that hospital, before joining the Maryview Hospital staff. She has held office in the Virginia Nurses’ Association, and has been president of her local AORN group as well as of the national organization. In a statement announcing the appointment, Walter P. Herz, vice-president of Ethicon, Inc., said, “As president-elect and then president of the AORN, Mrs. Williams has devoted much time and effort to helping define the emerging new roles of the professional and paraprofessional members of the O.R. staff. It is our intent that Mrs. Williams be given the maximum opportunity to continue her important work in this area.” 111

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Canadian O.R. nurses to hold first national meeting May 4-7

The first national convention of Canadian operating-room nurses will be held May 4-7 at the Queen Elizabeth Hotel, Montreal, Que. The Quebec group will be host to the meeting, which has evolved from the active participation of O.R. nurses’ groups in the various Canadian provinces. Miss H. Taylor, R.N., B.N., president, Association of Nurses of the Province of Quebec, and Miss M. MacLean, R.N., B.Sc., vice-president, Canadian Nurses’ Association, will participate in opening ceremonies on Monday, May 4. The keynote address will be presented by Dr. L. Lamoureux, Royal College of Surgeons delegate. “Acute Emergencies” will be the subject of the lecture Monday afternoon by Dr. R. Scharf, director, traumatic service, Halifax General Hospital, Halifax, Nova Scotia. “Basic Hazards in the Operating Room” will be discussed at the morning session Tuesday by M. J. Dogenais, electronic engineer, Maisonneuve Hospital, Montreal, and Dr. C. Beique, physicist, and Claire Brault, R.N., operating-room supervisor, both of Notre Dame Hospital, Montreal. Dr. L. MacLean, chief of surgery and transplant service, Royal Victoria1 Hospital, Montreal, and a panel from the hospital will present a symposium on chronic kidney failure, including discussion of tissue study, rejection, and transplants, at the afternoon session. The two sessions on Wednesday will be concerned with the theme, “The Professional Nurse or Technician in the O.R.” In the morning, the “pro-nurses’’ viewpoint will be presented by Miss T. Guimond, R.N., B.Sc., assistant director of nurses, Maisonneuve Hospital, and Dr. C. Gogron, surgeon, Notre Dame 112

Hospital. The “pro-technicians’’ viewpoint will be given at the afternoon session by Dr. Shirley Stinson, R.N., department of health and welfare University of Alberta, and Dr. I. Shrogavitch, chief of surgery, Jewish General Hospital, Montreal. A symposium on sterilization and asepsis will be given o n Thursday by the 3M CO. Operating-room and specialty-department tours are available for interested nurses o n Friday. Plant tours are being offered by Johnson & Johnson, Ltd., and Davis & Geck. Simultaneous translation-from English into French and French into English-will be provided at all program sessions. Technical exhibits will be open from 11 a.m. to 3 p.m. Monday, Tuesday and Wednesday. Nurses from the United States are invited to attend, said Mrs. Isabelle Adams, R.N., secretary-treasurer, Operating Room Nurses’ Group of Quebec.

of convention is reproduced below. Initials “S.O.” stand for the French words for operating room. b Symbol

HOSPITAL TOPICS

Trauma in children

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Part I1

DOROTHY w. ERRERA, R.N., TOPICS’ operating-room nurse consultant, presents the second and concluding report on lectures at a postgraduate course on trauma in children, during the 1969 clinicdl congress of the American College of Surgeons. Part I appeared in the March issue, pp. 92-99.

Tells factors to consider in evaluating thermal burns, selecting treatment JAMES A. O’NEILL, JR., M.D., assistant professor of surgery (pediatrics), Louisiana State University School of Medicine, New Orleans: Thermal trauma is second in incidence to automobile accidents in children between the ages of 1 and 4. Progress in treatment will be made only when there is thorough understanding of the pathophysiology involved. Everything about the burned child must be considered on an individual basis; surgical principles of treatment must be tailored to each child. There are several potential problems in care. One, temperature regulation, is related to the age of development, The sexually immature child has thin skin with a thin layer of insulating fat, and the heatregulatory mechanism is labile. The ratio of surface area to body weight is increased, as are radiation, heat and water loss. The child matures in this respect between 10 and 12 years of age-occasionally earlier. The heart works well in the child, but the peripheral circulation is labile. There is less blood volume in visceral structures, and clinical evaluation of perfusion may be difficult. In the pulmonary system, the general APRIL 1970

gas exchange is efficient, but the marginal reserve is small. Metabolic demands are high. Hence, if there is any degree of pulmonary impairment, the child will deteriorate rapidly. This is a factor for serious concern, even more so in the child than in the adult. In the severely injured child, one must consider that there is also renal immaturity. Children usually produce a large volume of dilute urine. Infusions should begin with a hypotonic solution, but never pure water. Mixed solutions are preferred. Because of the small blood volume and increased evaporative loss, children are more susceptible to dehydration and overloading. Skin in children is thin; appendages are sparse; reepithelialization is slower and the potential is less than in an adult. Appendages are more superficial because of the thinner layer; so injuries are deeper. Heat will penetrate readily and cause deeper burns. Donor skin must be removed in thinner layers in a child than in an adult. A careful history helps determine the depth of an injury. A nasogastric tube may be indicated; the central venous pressure should be monitored; an indwelling catheter should be inserted. Sedation is given intravenously because the child is initially unable to pick up the drug because of poor tissue perfusion and an increased peripheral resistance. Patients with tachycardia are candidates for digitalis, as are those who maintain poor peripheral circulation despite resuscitation that, according to central venous pressure, has been adquate. Any child with a burn greater than 40 percent of the surface, particularly one that is a full-thickness burn. should be digitalized prophylactically and the serum potassium watched carefully for the lethal effects of hypokalemia. The depth of a burn is of less importance with the use of topical treatment but is important from the standpoint of putting the surgeon in the proper frame 113

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of mind for deciding how vigorously to resuscitate the child. Partial-thickness injuries, ordinarily caused by scald o r flash, differ from chemical burns, which lead to full-thickness injuries. If the surface of a burn is wet and weeping, one thinks in terms of a seconddegree injury. If, after the char is debrided, there is visible vascular thrombosis, the burn is usually fullthickness. Because a proper determination of the extent of injury in terms of depth and percentage is important, a drawing is made of the child’s exact appearance. In the initial debridement, it is worth while to reniove all necrotic tissue and to debride vesicles as well. In lesser injuries, in which it is easier to control infection under blebs and bullae, it may not be necessary to debride. Escharotomy is often indicated. All regimens for resuscitation are effective if these are familiar to the physician. Infections in burns are being seen less often, but physicians should be familiar with the metastatic nodules of pseudomonas invasion.

Discusses use of systemic antibiotics, three topical agents in burn therapy THOMAS J. KRIZEK, M.D., associate professor of surgery (plastic), Yale University School of Medicine, New Haven, Conn.: A burn is a function of time and temperature. The thermal death point of tissue is 44” C., and there is epidermal necrosis in one second at 7 0 T . Yet the temperature of bath water is usually much too high80” to 85” C., which is well above the thermal death point for children. There is no such thing as a minor burn for a child. A great many children die as a direct result of burns sustained when clothing catches fire. Every article can be made flame-retardant, but the public continues to use the very flammable fabric+otton. In 1940, the death rate was 41 100,000, with shock the leading cause; in 1945, the death rate was the same, but patients died three to four days later with streptococcal septicemia. In 1950, the death rate was the same, but patients died seven to 10 days later of infections caused by penicillin-resistant staphylococci; in 1960, the death rate was the same, but the pseudomonas was the major killer in burns-at a time when potent systemic antibiotics should have given control. At present, there is still discussion of the pseudomonas, although it seems to be yielding to topical treatment. Too many physicians give systemic antibiotics in too large doses too soon; then, when septicemia develops, the antibiotic has to be withheld. Penicillin should be given for 48 to 72 hours and then discontinued completely. There is a role for immediate excision and grafting in the care of burns, and, if not this, use of a topical agent which can be preliminary to early excision and grafting. If sepsis is prevented, the burn wound may heal spontaneously. Neither antibiotic therapy nor topical agents should be used for treatment of electrical burns of the hand; excision and application of a split-thickness graft are in order.

Three agents are currently being used for topical treatment of burns: sulfamylon, gentamycin and silver nitrate. Sulfamylon is cheap and readily available, and has an excellent spectrum of antibacterial activity. It penetrates to the depth of a wound but causes pain, and allergic reactions are seen in as many as 10 to 15 percent of all patients. It cannot be incorporated into a dressing. Because it is metabolically active, acidosis is likely. It will keep a burn wound healthy, but no drug can bring back a full-thickness injury. Gentamycin, which is similar to neomycin, has a broad spectrum of antimicrobial activity against both gram-positive and gram-negative organisms when used topically. It is available in bulk only from the manufacturer and can be incorporated into dressings. It has a low toxicity point, so much so that even if the amount used is completely absorbed, the blood level recommended for systemic treatment is not reached. Silver nitrate is cheap and good when used from the beginning of treatment of a burn. It has a good spectrum of activity. A concentration of one percent kills normal cells; a concentration of less than 0.25 percent is ineffective. When the pseudomonas move in, silver nitrate has to be discontinued in favor of something else. Pseudomonas which arise from hair follicles and sebaceous glands cause an invasive type of infection. If a routine culture of a burn surface is just that-a “surface” culture-pseudomonas deep in the wound will be missed. The punch-biopsy technic, taking a core out of a burn wound for culture. is necessary to obtain a valid picture of burn colonization. At the end of 18 hours, a qualitative identification of wound bacteria is available. There may be several types of organisms. By diluting out the culture, more information about how many bacteria there are in the wound may be obtained. The level of growth in a wound is significant in terms of the likelihood that a graft will take. If there are fewer organisms than 1 Oil gm. of tissue, the graft will take in 90 percent of all instances; if there are more than 1O’Il gm. of tissue, the graft is less likely to take. There is early motion with silver nitrate treatment, and no sepsis. With an absence of bacterial growth, grafting is more secure and healing is often spontaneous. However, it is painful for the patient; allergic reactions are common, and occasionally spontaneous healing is delayed. Spontaneous healing may not be as desirable as generally believed. Contraction is a function of the length of time a wound remains open, not of the agent of treatment. With spontaneous healing, there is a thin epithelium. The main defense against streptococcal infection resides in the sebaceous glands. When these are destroyed and epithelium is being made instead of sebum, patients are candidates for streptococcal infection. In children, this occurs with astonishing rapidity. Topical agents have a role in the treatment of burns, but only as preliminaries. The only proper permanent agent for treatment of burns is the skin graft. CIRCLE 38 ON READER SERVICE CARD-)

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Warns of problems in diagnosing thoracic injuries in children

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JENS G. ROSENKRANTZ, M.D., assistant professor of surgery, University of Colorado School of Medicine, Denver: Injuries of the chest are not seen very often in children but are nevertheless important to understand. Because children are victims of automobile disasters, as passengers or pedestrians, the problem does exist. Because the thoracic cage is pliable in children, several difficulties can be anticipated. It is easy to underestimate intrathoracic injury because children d o not often have broken ribs or sternal fractures. External evidence and initial x-ray evidence may be insignificant, but suddenly the child deteriorates and it becomes apparent that he has a major injury in the chest. Children with flail chests deteriorate more rapidly than adults, perhaps because the extent of damage is not appreciated early. Children with thoracic injuries may present with signs of central nervous-system or head injuries. The physician should beware of the child with a history of trauma who appears to exhibit signs of brain damage. The child may be hypoxic. Children with classical flail chests are rarely seen, but the management is the same, even if the sternum and rib cage are intact. There is no real difference in the principles of management of pneumothorax and hemothorax in children, Other structures in the chest, such as major blood vessels and the heart, may be injured. and specific injuries must be suspected. Many types of cardiac damage are more common than realized, and lungs can be contused, with development of immediate and rapidly progressing pulmonary insufficiency. Intrapulnionary hemorrhage is one such distressing phenomenon, difficult to treat. Fortunately, it is rare. It has been confused with pulmonary damage called “wet lung,” which comes on more slowly as an indirect effect of shock. A child may go to the operating room for treatment of a fracture or something even less serious, and suddenly there will be signs of pulmonary insufficiency. There are limitations to the lung’s ability to react to trauma. An adult who dies two to three days after a closed-chest injury is found at autopsy to have a hyaline membrane. One is tempted to postulate that hyaline membrane disease in children is the same, but instead it is the end stage of a different pathophysiological phenomenon. “Traumatic wet lung” may include many situations that are different but have a commoli denominator-vomiting and aspiration. The child i:, usually hit hard, is unconscious, is handled poorly, and is likely to vomit and aspirate, and respiratory insufficiency is likely to result. Fat embolism is another possible etiologic factor that is poorly understood, but in a majority of situations it would appear that there is a precipitation of fat in the vascular bed without any aspect of embolization. It should be suspected in the injured patient, and steroids may be helpful in treatment of a patient with fat in the urine. It is always difficult to say

whether improvement is due to steroid therapy o r to the many things being done at the same time. Infection is another problem to consider, because the injured chest is vulnerable, particularly to pneumonia with gram-negative organisms. There is a popular theory today that “shock lung” is due to changes in pulmonary blood flow. It is known that a decrease in p H o r oxygen tension rapidly increases pulmonary vascular resistance. This is a new area of focus. Many measurements made in patients developing this syndrome show that pulmonary hypertension is a key factor in its development. The pulmonary vascular bed is not easy to understand, but it appears that the increase in pulmonary resistance is very important and that the quality of fluid going through the pulmonary bed may be altered, with its viscosity influencing the end result. Theories and studies of “shock lung” continue to develop. It is difficult to be rational about treatment when the disease process is not well understood, but palliative attempts must be made. Probably the most important feature of management is early recognition, because no matter what type of treatment is used, if it is instituted too late, the condition is difficult to reverse. The emergency-room physician must be on the alert for the small child who has no external evidence of chest injury, and must be particularly wary of the child who will have to be anesthetized. Early recognition and aggressive treatment are vital. In adults, there is some success with the use of continuous positive-pressure breathing, the theory being that progressive atelectasis develops and that one way to prevent this is to increase the positive pressure. There is degassing of the alveoli during the expiratory phase with the use of a respirator. Airway pressure of 6 to 8 mm. Hg. will prevent some progress of atelectasis. Some nitrogen must also be supplied, and 100-percent oxygen must be avoided. Oxygen at high tensions will damage lungs, but pulmonary damage can also occur at relatively minimal oxygen tensions if the patient is carried for a long enough period. When a patient is on a respirator, one is tempted to use 100-percent oxygen, and should initially, but then the arterial oxygen tension should be monitored. Oxygen tension in inspired air should also be measured to get a rough idea of the degree of left-to-right shunting. The use of central venous-pressure monitoring has been disappointing in these patients. By the time it shows that there is trouble, the problem is too far advanced, and when there is a high C V P in patients with “shock lung,” there is real trouble, particularly in children. Antibiotics are important in treatment of these patients, but evidence for the use of prophylactic therapy is not convincing. Diffuse intravascular coagulopathies may also be present in this group of patients. Perhaps these patients should be heparinized if such an abnormality can be demonstrated, but it is often difficult to find a hematologist at 2 am., and one is loath to heparinize a patient without being sure that the therapy is indicated. Specific organ damage can occur with trauma to the chest, but one must be o n the lookout for the child CIRCLE 39 ON READER SERVICE CARD

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with minimal signs of injury who may have serious thoracic injury that will become manifest over a few hours, with o r without treatment.

Special problems associated with use of respirator in small children

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D. VERNON THOMAS, M.D., professor of anesthesiology, Stanford University School of Medicine, Stanford, Calif.: The respirator is indicated in any patient with respiratory insufficiency, whether it is from some central damage resulting from head injury or from interference with mechanical aspects of breathing by fractured ribs, for example. The decision as to when to interfere i f a child is cyanotic can be made on clinical grounds without elaborate blood chemistries. The child will be cyanotic, breathing will be an effort, and there will be a change in his awareness. Measurement of blood gases would be ideal, but in many clinical situations an arterial PO:! cannot be obtained o n small children. A respirator is indicated if the PCO:! is 60 and rising and the arterial PO:! is below 60. A problem secondary to deciding when to use a respirator is deciding when to discontinue its use. It takes courage to discontinue a respirator, and a pediatrician or internist may continue its use much too long. In the debate over endotracheal tube versus tracheostomy, it is well to remember that the endotracheal tube is worth trying if the emergency situation is likely to last for a few hours (some would even use it for three to five days, depending o n the clinical situation), but if the emergency is likely to be long-term, tracheostomy may be preferred and likely to present fewer problems. In the newborn, prolonged intratracheal intubation is preferred to tracheostomy. Babies and small children are difficult to intubate, and the procedure should be done by the most expert person available. A slightly curved tube, one with a gentle curve of about one-third of a circle, makes the job a little easier. Occasionally, brief general anesthesia with use of a muscle relaxant will be necessary. The whole technic is dangerous in unskilled hands. It is too easy to insert a tube too far, and the right main-stem bronchus is often intubated by error. If necessary, an x-ray check should be ordered. Tubes come out accidentally when no one is around. In young children, it is more practical to insert tubes through the nose for security. If the tube is snug against the nose and is fixed securely to the child’s head, it is unlikely to slip down into the respiratory tract and into the lung. A mound of adhesive tape is useless for fixation because it gets wet. An oversized connector made to fit snugly at the nose gives better stabilization. Tubes are lubricated with alcohol because a slippery lubricant only lets a tube slip out. After many trials, a technic has been evolved for snugging a tube at the nostril with umbilical tape. In a hospital with no house staff, a tube can be kept in

position many days by a good nurse. It is advisable to sedate older children with morphine or meperidine, which introduces no problem of respiratory depression because respirations are controlled with the machine. The problem of maintaining patency of the tube is solved by using a heated humidifier and testing the tube frequently with a small suction catheter. Oxygen at relatively high pressure and low rates ( 2 0 to 40 cm. H.0 IO/min.) is preferred because large tidal volumes are less likely to lead to atelectasis than small, frequent breaths. The lowest possible percentage of oxygen, determined by measurement of blood gases, is used. A pressure-cycled ventilator gives a choice of 100-percent air dilution, which gives the child 60 to 80 percent. This is reasonably safe if guesswork must be relied upon. With the volume respirator, the patient is ventilated with air, and a definite amount of oxygen can be added, using any percentage between 20 and 100. Nurses are taught to listen frequently in the child’s axillae to judge whether ventilation is adequate. T h e child’s color should be good with 50-percent oxygen, but arterial determinations are still ideal, if possible. In the newborn, the umbilical artery will have to be catheterized for collection of blood samples. Sampling is more difficult in a larger child, but capillary samples for pH and PCO:! are fairly accurate, particularly if the foot is first immersed in warm water. A low PO:! is often accompanied by increasing pallor rather than cyanosis. Because the supine position is bad for drainage of the upper lobes, the child should be off his back as much as possible and turned side to side every hour. Because the tube does not make a perfectly tight seal, there should be no problem with gastric distention, because air can always leak upward and out the mouth and nose. But when it goes back down the esophagus, the child becomes distended. A nasogastric tube is usually inserted for control, always left open and allowed to drain on the bed. It should never be occluded; gas must be able to bubble out continuously. There is an abnormal amount of fluid gain in humidified respirators and ventilators. In adults, this may be as much as 300 to 600 cc./day. Because of poor oxygenation, the lungs may be unduly wet, and a small dose of diuretic may be helpful. Spontaneous pneumothorax is a threat in all respiratory disturbances and happens occasionally in children on respirators. Any sudden deterioration of a child is cause for suspicion of pneumothorax. which cannot always be diagnosed clinically. The smaller the baby, the greater the problem. Respirator care should never be discontinued suddenly. It is tapered off for short periods of five minutes per hour. There may be an improvement manifest in blood gases, or clinically the child may appear to improve. The weaning period is advanced to five minutes every -70 minutes, then five minutes every 15 minutes. Extubation is no problem. Obstruction at the larynx is rare, and it has not been necessary to reintubate for laryngeal spasm o r edema, provided the original problem was not laryngeal. CIRCLE 43 ON READER SERVICE CARD+

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