Olden Days of Nursing: Dialysis

I still remember the teenager but not his name or how long he had been getting peritoneal dialysis (PD). I recall him walking between his parents down the long hospital corridor. He was going home to die. A father with small children had preempted the teenager’s spot on the dialysis unit. Restricting patients was necessary because supplies and personnel were in short supply at the time. Dr. Norman Lasker, head of the Renal Division made that decision unilaterally. 

I  had taken care of the teen when he came in for twice weekly treatments. His mother and father came with him bringing magazines with pictures of sweaty wrestlers, which I found repulsive. Not having any brothers, what did I know about teenage boys? However, we did have something in common: the new TV show, Batman. I would watch the show each week (no binge watching then) so when the teen came on the unit, we would have something to talk about. 

What happened to him after he was sent home? Hospice or palliative care hadn’t evolved, as yet. How did his parents manage? Did he wind up in a hospital at the end of his life? 

I called Carol Passarotti-Novembre. She and I worked on the same research floor: a 15-bed unit at Pollak Hospital in Jersey City. Carol was the first renal nurse in New Jersey, working alongside of Dr. Lasker in one of the first Dialysis Centers in the US in 1961. Only three other major Dialysis Centers existed then: Boston, Seattle and New York City. Dialysis nurses received on-the-job-training. 

Carol didn’t remember the teenager.

 

Of course, she wouldn’t since she had so many other patients. Some were on chronic PD, like the teenager. Patients came twice or three times a week, interspersed with emergency dialysis for acute problems like drug overdose, end stage renal failure, and post-surgical renal shutdown. For eight years, Carol was on call 24/7. Only once did she miss an on-call emergency. Another staff nurse from the research unit stepped in. The patient survived. 

Later on, Dr. Lasker was no longer the lone decider. Carol told me that a “board consisting of physicians, administrators, clergy and others reviewed potential patients to receive dialysis treatments.” She sat on this board. 

Carol ran the show at the Dialysis Center. The “Dialysis Center” was in reality four beds devoted to renal patients on the 15-bed unit. 

The procedure for PD was as follows:

After warming two-liter glass bottles of dialysis solution in the sink, Carol hung them from an IV pole. The fluid flowed into the peritoneal cavity and remained in the patient for 30 to 40 minutes. The bottles were taken down from the IV pole, inverted and placed on the floor so the fluid would drain back into the bottles, which took another 10 minutes. Repeat. The patients stayed overnight since each treatment lasted 36 hours. 

Carol managed up to four patients on Monday, Wednesday and Friday or Tuesday and Thursday. The day shift helped when we could. Evening and night nursing staff managed the PD during their shift. Carol discontinued the PD the following morning only to see the same patients come back the next day. 

Not surprisingly, Carol got to know her patients and their families well, as did all us nurses, since each patient came to the unit so frequently. 

One patient, Ellen, a slight Italian women with a large family, stopped breathing and became pulseless when I was in her room. I did what we were taught to do at that time. I slipped her on to the floor, struck her sternum with the side of my hand, breathed into her mouth and started chest compressions. The doctors on the unit came to assist me. We revived her. When she awoke, she told us she didn’t want to be resuscitated. We didn’t ask these questions in 1965. Happily, for me, when Ellen stopped breathing next, I wasn’t in the room. 

Carol had an uplifting story to share: 

“One of our patients was on PD for four years. Her local internist came to her home for each treatment, inserted the trocath [to make the pathway into the peritoneal cavity], and left. Her husband carried out each treatment. Even her little children helped with warming the bottles of dialysate. She switched to home hemodialysis for five years, then continued In-Center Hemodialysis for ten more years. At that point she received a cadaver kidney transplant, which lasted for a good number of years after.“ 

The following is from a speech Carol gave to nephrology nurses and technicians of North Jersey at Marriott Newark Hotel, Newark, NJ, May 6, 2011:  

“The role of the nurse has changed along with each modality of treatment, the changing needs of the patients and families, the advances in technology and the increasing demands for specialized education in nephrology.

. . . My knowledge of nephrology was ‘on the job’ everyday type of learning. I depended upon the physicians I worked with. . . .Working for the medical school had its advantages. The most important being able to be involved in research projects. e. g., vitamin studies, various solute clearance studies, cardiac output studies in the chronic PD patient and also, in developing the original cycler and starting home training programs for PD and hemodialysis.

 

(Carol was the first nurse to be included in a research study citation in the Annals of Internal Medicine.)

Today’s nephrology nurse is involved in direct patient care, teaching in all the fields: PD, hemodialysis, transplantation to the patients and their families as well as research and development. National and local organizations, such as American Association of Nephrology Nurses and Technicians were formed in order to ensure a high standard of education on both a local and national level and making nephrology nursing an accredited and recognized area of nursing. 

For me, the rapid growth and development in this area of medicine over the past 49 years, has been totally mind blowing, awesome, most exhilarating. The potential for future development is limitless!”

Carol married in 1968 and remained with the renal unit of the New Jersey College of Medicine and Dentistry Renal Division until mid 1969 when she left to have her first child. In 1971, she worked as a staff nurse in hemodialysis unit and later in the Hemodialysis Home Training unit at  Saint Barnabas Medical Center in Livingston, NJ. In 1976, she joined a Renal and Hypertension practice as both an office nurse and researcher in many drug studies. Carol worked  full-time, sometimes 50 hour weeks, before she retired in 2010 at the age of 70.  

After reflecting on Carol Passarotti-Novembre’s long career in nephrology, I ask the obvious question. How could the development of peritoneal and hemodialysis have progressed without the collegial partnership between nurses and physicians? 

Jersey Journal. Carol and Dr. Lasker are standing beside the first hemodialysis machine.

 

Olden Days of Nursing: Coronary Care Unit

 

I helped open the first CCU in New Jersey in 1967. New monitoring technology and implementation of coronary-pulmonary resuscitation precipitated the development of CCUs across the country in order to reduce deaths from acute myocardial infarcts (AMI).

Bethany Hospital in Kansas had opened the first CCU in the United States on May 20, 1962. The second one opened soon after in Philadelphia’s Presbyterian Hospital. It was at Presbyterian Hospital that Rose Pinneo, head nurse of the unit, along with physicians, Lawrence Meltzer and Roderick Kitchell, coauthored Intensive Coronary Care: A Manual for Nurses in 1965. 

I remember the manual and especially Rose Pinneo. Pinneo became a role model for all the new CCU nurses at the time.

I kept this picture in a photo book over the years. Just recently, as I went through all my old photos as a “sequester in place” pandemic project, this picture took on a new significance. It would fit under: “Olden Days of Nursing,” a new grouping of stories I am starting to post on my Blog.  

It was only after I began to do some research that I recognized that right from the inception of CCUs, nurses ran the show. At the time this benefit eluded me. I was still a neophyte. I had not yet dealt with the paternalist health care system and rigid legislation that limited nursing practice. 

I was pleasantly surprised to read about how nurses were positioned to take charge right from the inception of CCUs:  

The opening sentence (in Intensive Coronary Care: A Manual for Nurses) in set the tone: “It may seem curious that the first book dedicated to a new concept of treatment for acute myocardial infarction has been directed primarily to nurses rather than physicians.” They (the authors) emphasized that the new treatment technologies had to be used immediately in order to save lives. To achieve this goal doctors must abandon traditional notions of a nurse’s limited role in clinical decision making.The authors declared, “Intensive coronary care is essentially an advanced system of nursing. It is not an advanced system of medical practice based on electronics.” Their prescription for saving lives was explicit: “A CCU nurse must be able to perform…therapeutic measures by herself without specific orders.”[Italics mine.]

. . . Support for giving specially trained nurses authority to defibrillate patients grew quickly in the late-1960s as concerns about the legal implications of the practice declined. The CCU-inspired empowerment of nurses represented a critical first step in the evolution of team-based care that is such a conspicuous part of current-day cardiology practice.

Resuscitating a Circulation Abstract to Celebrate the 50th Anniversary of the Coronary Care Unit Concept, W. Bruce Fye, Circulation. 2011 Vol 124 (17), 1886-1893. 

The first few of months in the CCU, I supervised the set-up of the physical space, hired nurses and organized the classes to be given by cardiologists. I gave lectures to the hospital staff nurses and administration about this new clinical specialty unit. 

I worked in the CCU for only ten months. Newly married, my husband and I moved to another state because he had a great job opportunity. Over the next few years, we moved five times, had two children and I worked part-time at two other CCUs. When I started school for my bachelors’ degree in 1970, I never went back to the CCU. Cardiology is still my favorite specialty.