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Archive for January, 2016

Teaching the Law of Unintended Consequences to First-Year Students

The Law of Unintended Consequences is deeply etched in the history of nursing and other health professions. And teaching first-year nursing students how to critique modern technology can employ nursing history and its artifacts, as Assistant Clinical Professor Lisa-Marie W. Griffiths, MA, MSN, APRN, recently demonstrated to her students in Introduction to Health and the Discipline of Nursing.

Reading an article last winter in the Hartford Courant, “Global Call for the Use of ‘Smart’ Syringes,” Griffiths reflected on the changes in this basic instrument, from the glass syringes she used early in her career in the U.S. Navy in the 1980s, to the disposable plastic syringes commonly in use now, to the new “smart” syringes that self-destruct after one use.

Glass Syringes from the Dolan Collection

Glass Syringes from the Dolan Collection

Older glass syringes could be readily sanitized in an autoclave or even boiling water in order to be reused. Glass syringes can admittedly be fragile but may be reused many times when handled carefully, requiring only the initial investment in the instrument. Disposable plastic syringes may seem like a perfect solution, but they should be replaced after each use, which adds an additional cost to healthcare settings that are often resource constrained in many locations around the world. As a result in developing countries, “disposable” syringes are often reused, but because they cannot be boiled, and bleach is often not available, they are not adequately sanitized.

Assistant Clinical Professor Lisa-Marie Griffiths with Students in NURS 1110

Assistant Clinical Professor Lisa-Marie Griffiths with Students in NURS 1110

The Courant article brought to Griffiths’s attention that “25 percent of the 18 billion medical injections performed worldwide each year are done with dirty needles. Unsafe injections cause as many as 1.7 million new hepatitis B infections annually, 315,000 hepatitis C infections and 33,800 HIV infections” according to the World Health Organization.

Aware of the complexities of global health, Griffiths decided to explore these issues with her first-year students using glass syringes from the Dolan Collection and a plastic syringe of her own.

As she explained to her students, “What will happen to third world needs when syringes are destroyed after one use? There are communities that wash latex gloves and hang them to dry to have ‘clean’ gloves to use. Not enough donated medical supplies arrive for the needs of communities in Haiti and Africa, so people have to make do.” Single-use syringes may be in short supply, preventing administration of life-saving medications. Plastic syringes also create more hazardous waste, which entails both environmental impact and economic costs.

Griffiths showed her students how glass syringes were handled and sterilized. Then she invited them to brainstorm strategies for remedying the unintended consequences of innovative syringes: Advocating for the remanufacturing of glass syringes? Strategic donations of bleach and isopropyl alcohol? Developing a new cleaning product or mechanism?

Professor Griffiths Demonstrates a Syringe from the Dolan Collection

Professor Griffiths Demonstrates a Syringe from the Dolan Collection

Single-use self-destructing syringes are currently pre-loaded for vaccines, but there has been difficulty for optional dose sizes (e.g., 0.5cc to 1.0 cc).

Concluding this class, Griffiths reminded her students, “Nurses need to be involved in all health care innovations and think globally, not just nationally, because what we do in America does affect the world and those in most need.”

 

Iron Lung Exhibit: Our Alumni Remember

Visitors to the UConn School of Nursing’s Widmer Wing atrium cannot avoid observing the Dolan Collection‘s permanent exhibit of an iron lung, a contraption that looks more like a small submarine than a medical device.

A patient's head lay outside the iron lung. portals on both sides allowed nurses to care for the patient. (Source: Barbara Slater)

A patient’s head lay outside the iron lung. portals on both sides allowed nurses to care for the patient. (Source: Barbara Slater)

Donated by the Veterans Home and Hospital in Rocky Hill, the iron lung is technically known as a negative pressure ventilator (fabricated primarily of steel rather than iron). Weighing about 500 pounds the device was used to help patients with compromised lung function to breathe. The patients lay in the airtight container, with only their heads protruding while pressure inside the tank changed to manipulate the lungs into mimicking the mechanics of breathing, its rubber mechanical diaphragm doing what the patients’ diaphragms could not. Alumna Jean Petrov (Class of 1956) recalls manually operating the lever attached to the diaphragm when the electrical power went out.

Iron lungs were often associated with patients who had contracted polio, and some of our alumni from the 1950s were prepared to oversee the around-the-clock care of patients in iron lungs.

Until the introduction of the Salk vaccine in 1957, polio had reached fearsome epidemic status, with children particularly vulnerable (thus it was often called infantile paralysis). As alumna Phyllis Foley (Class of 1962) recalls, “I was a kid during the polio epidemics, and I do remember my mom (a nurse) warning and worrying about all of us, especially in the summer when we would go to the beaches in New York.”

Diaphragm end of the iron lung showing motor, manual lever, and rubber diaphragm (Source: Barbara Slater)

Diaphragm end of the iron lung showing motor, manual lever, and rubber diaphragm (Source: Barbara Slater)

Alumna Peg Hevel (Class of 1956) recalls: “Polio, a word during those years that created body shivers when spoken out loud. The words iron lung sent feelings of dread to the ears of family and friends. Emotions rippled that all was lost.”

For Mary-Lou Faubel Waite Simpson (Class of 1959), simulating the role of an iron lung patient during her nursing education provided her not only with skill but more important with empathy: “I will never forget the day we were required to be the ‘patient’ as our classmates transferred me from a gurney into the iron lung and locked it shut with only my head outside of the unit. Then they turned it on, under our instructor’s supervision, and I vividly remember the panic of not being able to breathe until I finally relaxed and let the ‘lung’ breathe for me. Each time I inadvertently fought the lung, it was very scary; I could not breathe! Eventually I learned to ‘go with the flow’ as the pressure the machine exerted was impossible to overcome. Along with that was the anxiety of not being able to escape the confines of the entrapment; I was locked in and totally dependent on my fellow classmates and instructor to get me out, which gave me absolute empathy for my future patients, mostly polio victims.”

Polio patients were not alone in requiring respiratory assistance, and Lou also recalls a “. . . young Yale student who attempted suicide by overdose. His respirations were so compromised and/or non-existent that he was ‘our’ iron lung patient for 6 weeks. We worked in pairs, one on each side, turning him every two hours, bathing him and providing skin care to prevent breakdown, exercising his limbs within the lung, and feeding him. The iron lung was one of the most memorable learning experiences of my life.”

Joann Griswold (Class of 1954) vividly recalls three patients in iron lungs for whom she cared. One was a four-year-old child: “We accessed her bedding and body through elasticized portholes, and this as I recall intrigued her; she would try to grab our hands. I realized that human contact was exceptionally important with a baby or child, and she certainly showed a positive response to holding my hand, and or my gently rubbing her forehead, and bathing her. Although rest was important, once her fever had subsided, she was able to do gentle exercises within the respirator to retain the musculoskeletal function she had. We had to closely monitor her breathing, because people with this type of polio mainly affecting the respiratory system could die suddenly, and because of her age, there was always a nurse or a student nurse with her. She enjoyed being read to, and with the respirator mirror we could show her pictures, which she also enjoyed. It was important to keep her calm so that her weakened respiratory system would not be further compromised by her crying, shouting, etc. We sang to her, talked, read, drew pictures, told stories.”

Joann also recalls caring for a nurse in her mid-20s: “As a nurse, she knew what was going on, and what her condition meant, that she would never again walk, use her arms, be able to do the things she loved, and very likely thinking about the change in the course her life would take. . . . Her care required one person on each side of the iron lung working through the portholes, freshening her, positioning her frequently to preserve her skin, caring for her IV. Her condition was so serious that we could not pull out her bed to change the sheets; we had to do that through the portholes. To lift an adult or turn one to change a sheet was very difficult, and of course we always worried that we might be adding more discomfort. . . . One day during a storm, the power went out and we had to pump the respirator to keep it functioning until power returned.”

The third patient was a young mother whose positive attitude seemed indefatigable: “She talked and laughed. Every morning she wanted her hair combed just so, and she would indicate which ribbon she wanted in it. Her makeup was applied to her satisfaction as she watched the proceedings in a mirror. Her name was Joan, and she would read because there was a way to position a book, and by holding a straw in her mouth she could use it to turn the pages. Joan spoke happily about her children and delighted in having many pictures of them around her.”

Peg Hevel vividly recalls and wrote a poem about one child for whom she cared:

“During my pediatrics rotation, I took care of a young girl with polio. She spent 24 hours each day in an iron lung. . . . I don’t recall the girl’s name. Memory’s picture is hazy, but I still can see her wan face, brown hair in two braids— one to each side of her face—on a small embroidered pillow from her grandmother. For me, the best way to tell you what I experienced being with this seven year old girl is through a poem.”

 

Child in an Iron-Lung

Fear with a disease unknown resides

In body darkness it creeps to paralyze

To a child’s question of seven

Mom says, It’s called polio.

Your new bed is an iron-lung, don’t be scared

Strangled crying erupts

Mother’s soft lips kiss forehead, eyes, nose and lips

Hush now,

I’ll always be here.

Questions swirl through this child’s mind

Slowly in halting speech to find

Why am I in this thing?

When do we go home?

Why does it make that swooshing sound?

My voice sounds funny to my ears– why?

Will you hold me now?

Tears slide down this child’s cheek

Hush now,

I’ll always be near.

A mother’s heart skips a beat as she says,

While you’re sick this machine will breathe for you.

Will I be alone when you go to sleep?

No dear,

someone will always be near.

That someone else was a student nurse,

me.

For the rest of my story, I will call this

young child “Amy.”

Each day began with attending to her physical needs

I prayed the touch of my hands would give her comfort

During her routine care, Amy would make up rhymes

like a favorite Dr. Seuss book.

I concentrated on her mental health with

reading books such as: Princess and the Pea, Velveteen Rabbit, Goodnight Moon

and Harold and the Purple Crayon.

I developed a game using crayons to draw circles, lines and dots on paper

Amy directed my drawing by saying,

top of page; center, dot, move right, circle

bottom, line to left— and so on.

When finished, the fun began by saying what our picture was;

sometimes we made up stories.

Her eyes lit up; mouth smiled wide

her musical giggles warmed my heart.

And so, monthly calendar pages fluttered by until

a new month where

Amy went home wearing a leg brace.

Tears of sadness and joy mingled as we all said goodbye.

I watched them walk down the hospital hallway.

Mom, Amy and Dad— hands entwined.

I murmured— Love.

Thank you, Amy, for teaching me that each life has its unique rhythm!

In addition to the vaccine’s eradication of the polio epidemic in the United States, the later development of the positive pressure ventilator that delivers air directly into the respiratory airway came to make the iron lung obsolete. However, nursing care continues to employ both high tech and high touch. The latest sophisticated health technologies still require humane, empathic nursing care.

For more information, see G. Chapman (2015, July 6), From iron lung to independence, O Say Can You See?: Stories from the National Museum of American History, (Washington, DC: Smithsonian Institution), http://americanhistory.si.edu/blog/iron-lung-independence