Document pmMypzjvE4EVR07Vx64nOXmo7

Industrial Nursing Section Executive Committee 1944-1945 General Chairman--Joanna M. Johnson, R.N., Employers Mutuals, Milwaukee, Wis. Vice-Chairman & Program Chairman--Hazel Leebke, R.N., Thilmany Palp & Paper' Co., Kankatma, Wis. Mews Letter Editor--Victoria Stkalxo, R.N., Foote Bros. Gear & Machine Cotjl, Chicago, 111. - Publicity Committee--Rispah Pobxeb, R.N. (Chairman), Chain Belt Col, Milwaukee, Wis.' Jeannette Bartholomew, RJtf., The Texas Co., Houston, Texas. Roth Habdy, R.N., Hughes Tool Co., Houston, Texas. Secretary--Jane S. Web, ICN., National Safety Council, Inc, Chicago, IIL Part General Chairman--Pauline Koehler, RN, Standard Oil Co. of Indiana, Whiting, Ind. 261 262 33rd National Safety Congress, 1944 WEDNESDAY AFTERNOON SESSION October 4, 1944 Presiding: Pauline Kuehlee, R.N., Standard Oil Co. of Indiana, Whiting, Ind. Teamwork of Industrial Physician and Nurse Gets Results W. G. HAZARD Acting Chief, Bureau of Industrial Health, New Jersey Department of Health Teamwork in the plant medical depart ment--as in all other activities of industry --is essential to success, Once teamwork prevails, results are bound to follow. We have been enabled for several years to watch good teamwork and bad teamwork in a variety of industrial concerns. Repeat edly we have been impressed how lack of teamwork leads to far more than profes sional inefficiency. It leads to misunder standings among the workers, waste to the management, and even personal loss to the individual For the company, poor team work is just bad business. Medical policies of a plant depend on the type of medical supervision : whether there is a physician full-time, part-time or on call. The full-time plant physician gives written and verbal instructions and assist ance to the nurse much the same as in hos pital or private-duty nursing. It is by far the most desirable form of medical super vision. Our remarks here are directed mostly towards the plants that have parttime or on-call physicians. These plants make up the bulk of industry. A part-time physician is one who is paid a regular retainer fee month in and month out, in return for which he visits the plant periodically to supervise, diagnose, treat and examine. An on-call physician is one whose fee depends on the number of cases treated, on the number of physical examina tions given, and on the number of other special services performed. Unfortunately, he may not even know the occupational hazards of the plant with which he is asso ciated, and it is often surprising how many on-call physicians there are who never visit the plant For the'nurse and for the cor poration this is the least desirable form of physician arrangement, because it affords the least medical supervision. In industry, as in the military forces, or ganization is basic. For the plant nurse. lack of a clean-cut organization line often obstructs her best efforts, without her re alizing it. A nurse is accustomed by her professional training to report to a phy sician or to a supervisor of nursing. When she gets in a plant, she may find a confus ing picture. A recent bulletin found this about supervision of industrial nurses in some 868 establishments: When the phy sician was part-time, nurses reported to him in one out of every three (34%) establish ments, but when he was on call, nurses re ported to him in only one cut of every 25 (4%) establishments. In the other estab lishments with on-call doctors, two out of five (39%) had their nurses report to the personnel manager; and the remainder of the establishments, more than half (57%), had their nurses reporting to the superin tendent or to some other plant official "A number of nurses interviewed," the bulletin stated, "were not certain to whom they were responsible." Teamwork in those plants where the nurse is responsible to a minor department head, or where she actu ally does not know to whom she reports, must certainly be difficult. The greatest need today perhaps in in dustrial medical departments is for closer medical supervision--and the nurse should constantly try to "sell" her management on this. For example, she should have fre quent conferences with her supervisor, pointing out new services her department can render, emphasizing her own limita tions in giving any medical care but firstaid, explaining how a good medical depart ment can cut operating costs even in a small plant, and educating him gently but persist ently in industrial health. She should route magazine articles to him that support her current projects. She should not only send him statistical reports at least monthly on her work, but she should interpret these in a sentence or two, using the records as in dicators of needed, improvements in her de- 1 Q Industrial Nursing Section 263 ' partment. She should prepare an annual re port on the health of the plant, just as the treasurer prepares a careful report on the finances of the corporation. Her report, however, should not be merely a maze of figures, but a guide to a better health pro gram for the next year. Should Know Plant Next to knowing her boss, an industrial nurse should know the plant and the indus try to which it belongs. Whatever the method used-- the important result is to have the nurse regularly visit the work rooms, familiarize herself with the opera tions, and get to know--and be known by-- die employees. arose. She should visualize what happened in the plant--for example, how heavy the article was that the man lifted, whether he was accustomed to lift that weight whether it was a part of his job, whether there was mechanical handling equipment available, and many other important though small phrases that make up the complete, story. To construct such a history, which subse quently may be worth thousands of dollars to the company, she must know well--as already mentioned--the plant lay-out and operations. The write-up of all cases should be complete--but especially so in those in volving a worker's back, or in cases where there are symptoms of rheumatism, lum bago, arthritis, or neuritis. |ust as a nurse should send marked copies of medical journals to her supervisor, she should get on the routing list for trade journals which today devote more and more space to plant health activities. In giving any treatment the nurse should work under written procedures, when she has a full-time physician in charge, or under written standing orders when she has a part-time or on-call .physician. If there In addition to the mechanical side of her are nonprofessional workers at the plant, plant, a nurse who is not under full-time they also should have written standing medical supervision must help her part- orders. Standing orders protect the nurse, time or on-call consultant in dealing with the worker, and the management. The nurse other departments in the plant She should is responsible for procuring them. know all department heads. She should In handling non-industrial cases, the nurse know the business procedures of the plant should be provided with a definite policy to that affect her work; how to requisition follow in deciding when anything more than supplies, how big a budget the medical de simple first-aid--which is always permissible partment has; how work orders are processed --should be given. to the maintenance department Above all, ' she should know and consult frequently Maintain Standard with those persons handling safety and When a plant has no full-time medical workmen's compensation. She should, in service, the nurse is usually in charge of short know "her way around" the plant the rooms that make up the medical depart and know how to get tilings done. ment She can promote good relationships Professional Do's and Don'ts The above suggestions are made to help the new.nurse feel more at home in the in dustrial atmosphere. In the daily handling of her cases, there are many ways of a pro fessional nature by which she can build teamwork between the physician and her self. The nurse should always regard the per son she is treating as a patient She is not there to determine liability for the injury or illness. That is the job of someone else in the plant She must never get into an argument with the worker as to whether with tiie part-time or on-call doctor by maintaining a standard of environmental and personal cleanliness that would be demanded in a good hospital Most nurses are-affiliated with the American Nurses Association, but probably more should take advantage of the State and local sections of their industrial nursing organiza tions and public health nursing organizations. To keep current on industrial health news, many nurses regularly read such magazines as the National Safety News, Industrial .Hygiene Foundation publications, and In dustrial Medicine. she is permitted to treat a case or not "Selling" the Plant Health Program Her job, in addition to first-aid treat ment is to take a complete history of what the symptoms are and how the ailment The industrial nurse is in a better- posi tion to get her plant adequate medical serv ice than anyone else. From her intimate f jrsM ; ''pip j. n 264 33rd National Safety Congress, 1944 knowledge of the workers, and of the occu pational hazards to which they are exposed, she can aid the part-time or on-call physician immeasurably. From her experience and study of industrial nursing she can recom mend improvements to her management According to the survey of industrial nursing already mentioned, there are right recognized activities of nurses. All the plants surveyed that had ihirses were found to practice two of them: (1) maintenance of plant dispensary (supplies, records, re ports), and (2) care of occupational ail ments and emergency care of non-occupa tional ailments. Generally less than half of the plants surveyed, however, had their nurses engaged in the other six activities. These are: Per cent of plants (3) Participation in physical ex amination program............. 50% (4) Participation in health education program............... 15 (5) Assistance in safety education and accident control............. 42 (6) Assistance with environmental sanitation.... 39 (7) Participation in plant welfare program ................. 75 (8) Home nursing sendee........... 25 It is safe to say that scarcely a plant ex ists in the part-time or on-call medical serv ice group that cannot expand its medical and nursing programs to the advantage of the worker, the management and the com munity. These plants look to their nurse as their resident "health expert," and she is thus well situated to feed ideas to manage ment for plant health improvement, for more nearly adequate medical service, and for the safer handling of employee disabilities. Nursing Ethics in Industry By CATHERINE R. DEMPSEY, R.N. Simplex Wire & Cable Co., Cambridge, Mass., and President of A. A. I. N. We expect the graduate nurse to under stand `the results of each step in an intri cate medical treatment; to expedite these procedures with expert manual and mental skill and fortitude; and to straighten out her patient's emotional reactions. Instead, we often find this -graduate bewildered, struggling to combine with her highly pro fessional duties those of the house-keeper, personal maid, interior decorator, personnel director; safety engineer, clerical worker. Perhaps some of this so-called bewilder ment regarding professional duties may be the reason we bear so much discussion to day about a code of nursing ethics in in dustry. What do we mean by nursing ethics in in dustry? Webster gives one definition of ethics as "broadly, the science of ideal human character." Charlotte Aikens in Ethics for Nurses states, "as.relating to nursing, ethics has to do with the ideals, customs and habits which the members of the profession are, by degrees, accumulat ing around the name and general charac teristics of the woman known as the trained or professional nurse." In discussing nursing ethics in industry, what is tiie first and most important point for us to consider ? Does management dearly understand nursing ethics in indus try? Does the physician dearly under stand nursing ethics in industry? What about the-labor organizations? How many workers have any appreciation of the sub ject? Last but not least, does the indus trial nurse hersdf fully realize the impor tance of a code of ethics? From the staff muses of one nation-wide company we received the following: "World War II has again brought to the fore ground the importance of industrial nurs ing in helping to maintain in industry all workers physically and mentally fit, in or der to speed production. As rite has a specialized piece of work to do, ethics re quire trust in the industrial nurse. To bring about this trust, she must have, among other qualifications, tact, adaptabil ity, order, promptness and memory. She must also be an adviser in essentials of good health and hygiene, and to be able to see the viewpoints of others and be a real friend to the employee without bring inti mate.*' Ethics Always Count The ^same rules of ethics taught us in oar training are just as applicable in indus trial nursing as they are in institutional Industrial Nursing Section 265 nursing. However, in industrial nursing 'more responsibility is relegated to the nurse so die must be ever mindful of these roles and regulations. Usually her imme diate supervisors and associates are doctors and nurses, and her behavior as concerns them should be respectful and above cen sure; Between the industrial physician and the industrial nurse lies a profound under standing of the nurse's capability and limitations. From this profound understand ing has arisen a marked degree of con fidence bestowed by the physician in the in dustrial nurse and an awareness on his part of her true value in the profession. How ever, the management of (he plant and the patient often are not aware that such ethics do exist and at times will expect the industrial nurse to overstep her bounds. Especially is this true in the small plant where only a part time physician or no physician at all is employed. With tact, the nurse must explain to the managing personnel or to the patient that she is lim ited in what she can and cannot do. Once her limitations are understood by all, she experiences great satisfaction in her work as nurse, counselor and confidant It is invaluable for industrial nurses wherever possible to maintain an active part in their alumnae, state, and national nursing associations. In tins way contact is main tained with ethical problems of other nurses. Nurses in the office of the medical di rector of an entirely different company say: "It has been the custom for some nurses in industry to follow a hospital code of ethics for reference in the industrial clinic. This did not work as well as they expected; so from there they went to the old school of trial and error, which is a help only when it is too late. "There is a basic code for all nurses, embracing personality, professional man ner, loyalty, executive ability, appearance, but the nurse in industry may be judged in three other ways: "(1) The nurse who is too severe. This nurse is never very popular. She is called snooty, cold, uninterested, mercenary and a host of other names. She may cooperate with management and personnel in an ap proved manner, but her lack of sympathy with the worker, whom she was employed to benefit, will jeopardize her popularity. "(2) The nurse who ts too familiar. This nurse shows favoritism and talks about a worker to anyone who has time to listen. She shatters the confidence of. dll workers, without which her chances in industry are limited. Counselling can only be done by gaining the worker's confidence. "(3) , The nurse who has reached the happy medium. This nurse is admired for her fairness and her loyalty to management and worker. She respects authority, ob serves rules, is progressive, mixes well with all workers, takes an interest in all plant activities. She is the nurse who loiows that workers are not machines, and a monthly servicing will not make them run smoother." From another section of the country we receive tins quotation: ."The successful, in dustrial nurse must be first, a good nurse; second, she must like people; and third, she must have a strong sense of Ethics. "One of the most important qualities for a nurse In industry to have (or develop) is the ability to see the entire industry ob jectively and understand clearly the rela tionship of her department to the whole. Even though she is expected to be a tower of strength and a fount of wisdom, she is wise not to expect or accept special priv ileges or consideration. She will do a better job by being a good company employee. "The nurse in industry is in a position of guiding and teaching all workers. Her own mental control and emotional stability are her first concern. Without them, she can do only .a routine job. With an under standing heart and a level head, the nurse in industry can do an inspired job. Her op portunities for educational health work are unlimited,. as are the ramifications- of her job and her usefulness to her company. "A doctor once described an industrial nurse as a 'diplomat at large.' Her pa tients are her fellow employees. A patient is usually only such for a few moments at a time. This creates a different relationship from that existing in any other type of nursing. She must be in the position of re specting the confidence of the patient, yet not keeping from management or safety any information "vital to the well-being of this individual or other employee. "We all know how a department head will sometimes ask, "What's the matter with him?' when told that one of his workers is iO and should go home. It is a natural and, in most cases, genuinely interested 266 33rd National Safety Congress, 1944 question. However, it is one that the nurse interview to determine the applicant's emo must answer most carefully. The boss is tional stability; whether or not she is quick not a member of the patient's family. tempered; is she congenial; can she take "It is not ethical for any nurse in any orders; does noise affect her; does she position to assume responsibility which is favor some patients and not others; does not rightfully a nurse's work. If we have she sincerely like nursing and why Iras she less supervision, then our responsibility to applied for the position. The answers our own nursing profession, the medical greatly determine the adjustability of a profession, and to our management--not nurse to industrial work. to overstep the bounds--is greater than in "If a nurse is emotionally unstable, she other lines of nursing. cannot be depended upon to teach a con Must Know Hazards vincing health program. Quick tempers can and will destroy a feeling of confidence "It is, of course, necessary for a nurse between lay and medical personnel. A nurse to be intelligent about general conditions who cannot harmoniously work with other in her plant, to know the hazards, to serve nurses is demonstrating her incapacity to on committees, to advise about conditions make adjustments which are frequently re of cleanliness, etc. A nurse can understand quired in emergency work. Inability to take a surgical operation so well that she knows orders creates a friction between the super each move that is to be made and each visory and staff of both factory and medi instrument to be used. However, this does cal personnel. Favoritism among patients not qualify her to perform the operation, dirides employees into two camps: those but makes her an able assistant The same who like the nurse and those who do not, rule applies to her cooperation with the sometimes to the extent of passing up Safety Engineer. She must understand necessary treatment how to do so intelligently. Suggestions and "A nurse's reason for entering the in recommendations can be made and condi dustrial field must be based on a sincere tions reported." desire to promote health education. She The following opinion comes to us from must believe in her work in order to con the supervising nurse of another nation- vince the employees of the importance of wide corporation: building up and maintaining the maximum "Because of the wide range of industrial of health." jobs, skilled and unskilled, employees are In July, 1943, the Royal College of Nurs attracted to industry from all sections of ing in England issued a pamphlet on a the United States. As a consequence, great "Code of Ethics Governing the Professional numbers of people are grouped together Conduct and Procedures of the Industrial whose modes of living, attitudes and reac Nurse." Following are a few of these rules tions are vastly different A nurse, in order as quoted from this pamphlet: to benefit these employees as well as man "The following rules have'been drawn agement must have the qualities of a up as a guide to nurses in the industrial teacher and a broad understanding of hu field of public health nursing, and have man nature!. The average employee who is been endorsed by the Association of In antagonistic to routine medical procedures, dustrial Medical Officers. who disregards safety rules, and jeopardizes "They are intended to govern the pro his health, does so in most instances fessional relationship between the industrial through lack of understanding, rather than nurse and: a desire to hinder the nurse in the per a) industrial medical officers and other formance of her duties. Nurses should be medical men; carefully selected for industrial positions. b) other members of the nursing pro Supervisory personnel should select nurses fession ; , who have a basic academic background: c) management; psychology, sociology, social case work, d) employees^, and Principles of Public Health and In e) other professional workers. dustrial Nursing. Three years' training in "The nurse employed in industry shall an accredited school does not necessarily conform to the accepted professional prin qualify the nurse for industrial work. ciples and instruct auxiliary nursing per "Time should be spent during the first sonnel accordingly. Industrial Nursing Section 267 "1. The nurse shall hold in confidence all personal matters imparted to her and all family affairs aiming to her knowledge. "2. Anything relating to the health of the employee, of which the nurse gains knowledge in her professional capacity, shall be treated as confidential, unless the law requires otherwise, and disclosed only to the industrial medical officers, her nurse colleagues, or the employee's own medical attendant "3. The nurse shall not influence the re ligious or political opinions of employees or members of their families. "4. The industrial nurse shall not influ ence the employee in the choice of any particular doctor. "5. The nurse shall maintain a strict neutrality in any political issue involving differences between management and em ployees. She shall not allow herself to be involved, by statement of opinion or other wise, in differences between the manage ment and employees. "6. Medical records concerning the em ployees kept by the industrial medical officer are confidential documents. As these may be placed in the custody of the nurse during the doctor's absence, she shall not allow any other person to have access to them except with the approval of the responsible medical officer." The basic ethics of, the nursing profes sion as outlined in the Florence Nightingale Pledge, which was formulated by a com mittee in the year 1893, are just as ap plicable to nurses in industry as they are to nurses in any other branch of the pro fession. The nurse in industry must often assume or carry more responsibility than the nurse in other fields, especially if she has only a part time physician or no physician at all. Therefore, she most be ever alert to maintain these basic ethics in order to up hold the highest traditions of the profession. THURSDAY AFTERNOON SESSION October S, 1944 Presiding: Pauline Kuehleb, R.N., Standard Oil Co. of Indiana, Whiting, Ind. Industrial Nurse's Application oi Psychiatry LYDIA G. GIBERSON, MJD. Industrial Psychiatrist, Metropolitan Life Insurance Company, New York You nurses are among the true pioneers of industrial medicine. You blazed the trail (as far back as 1895 when workers were jnst something you hired), did the initial job we are all talking about today. Yon retain within yourselves the greatest contact with the workers of whom yon are one. It is through your sympathy and un derstanding of all phases of the industrial medical problem, flat the proper under standing can reach those empowered to deal with the worker. In that sense your field is almost limitless. It readies into every facet of tiie worker's life His life on the job, off the job, physical and mental. And it is about the mental side I would like to speak today. Upon your accurate report and understanding, must rest, in large degree, the benefits which industrial medicine can furnish. Workers will talk to you in the course of your duties. Don't be bored just because you are busy. What they have to tell you can have a definite psychiatric benefit and bear ing. Make mental or even written notes, and transmit them to your medical depart ment. They may be of immense benefit to the patient under a proper medical setup. You have all heard, I am sure^ the many adjurations concerning accidents, and safety in general. No one knows more piognantly than you the results of industrial careless ness. Your` job to preach that gospd is pretty plain. Describes Emotional Stress But there rides beside every man at the bench, die intangible ghost, which no amount of training can remove--his other life--his emotional life--his life in the process of 268 33rd National Safety Congress, 1944 living. And that takes in his twenty-four hours a day living. His financial worries, his family cares. In feet, the sum total of his emotional life.. It is beside him every waking hour. At the bench, at home and, if you believe the Freudians, in his sleep. You have a twentyfour hour man to deal with. His troubles should not be a bore. They are important They bear directly on his work and there fore on your job of keeping him healthy. I don't mean to suggest by this, that all he's got to tell you is pertinent There are some chronic beUyachers, a few malingerers, and a few who are just there for the paycheck. But there are others, and many of them, who have various physical and truly mental burdens, and these should be care fully listened to and helped Yours is not the job of sorting out the sheep from the goats, but a medical observa tion post from which can flow a current of immensely valuable data, whereby your medical organization, and, in turn, your per sonnel management can function to infi nitely greater advantage. Let me illustrate: Mary X readies you. She can't concentrate. She's jittery. She's making many mistakes. This is unusual for Mary. There is apparently nothing organi cally wrong. You find out she has a flyer brother. He's been reported missing. With great effort she has controlled herself and carried on. Suddenly in her Section, there is much talk about the war. Her mind wanders. Errors creep in. Production goes down. At home Maty has had to present a brave front A side mother cannot be un duly upset Maty pours out her story to you. She gets relief. She can steady herself now. You can also help with some wise suggestions to the Section Head Thought less remarks and unnecessary gruesome tales of war and war prisoners can well be dis pensed with on the job. There's probably no one who looms as large on our national or industrial scene as G.I. Joe, who's coming back to us some time, and the sooner the better, say we. Undoubtedly, you've-read a great deal about this gent About what he'll think, about the way he'll act, about the way we should act, etc I personally resent the idea, that when he comes bade, he's going to be some sort of stranger we can't talk to or deal with as we've always dealt with him. Loves GX Joe He's the man we've always known and loved He's GX Joe--American, who has been away iron us for a time, doing a dirty job he won't talk about if you don't first. He's coming back to the one country he knows and loves. He wants only to resume the life and work he's left--to work, hold his head up, support his family and find out how the Dodgers are doing. That's why we like him. So it seems only a matter of common gratitude and humanity to smooth his path, to act as though he were only one more applicant for a job (let personnel policy take any further steps necessary). There will, of course, be many, seeking jobs, physically or mentally disabled But again their American pride has earned its right to be recognized Help 'em, but above all, don't pity 'em. There will be certain medical regulations laid down for you, in the course of time, dealing with these men. As your duties demand it, you will have to administer them. But--as many of you must have some G.I. in mind, don't pity him and don't ask him unnecessary questions... He has been confronted with questions probably for years and the greatest kindness you.xsan do him is to keep your official con tact with him to a minimum. Try to ac quaint yourselves, as closely as you can, with:the conditions of Ins reemployment and assist him within these limits to meet a situ ation, which, at best, will be complicated. His medical history in the army should be a matter for your careful scrutiny. No matter what steps are taken by per sonnel or management for meeting this situ ation, yours is one of the most important liaison jobs that can be done for the returning Service man. He needs your understand ing but not your sympathy. * t t i i) t i l l t s f s c t l d v f it s t t a 0 .f 1 P \ a V 0 c 0 I< V tl c V n ii v ii ii b fi a c Industrial Nursing Section 269 New Trends in Treatment of Industrial Injuries By DR EDWARD C. HOLMBLAD, M.D. Managing Director of American Association of Industrial Physicians and Surgeon* Chicago, 11L There has been during the past few years again take full advantage of preventing the greatest advancement in the primary spread of the infection.1 Cellulitis, follow treatment of injuries. Prompt, efficient and ing injury, yields well to massive internal intelligent treatment of minor and serious sulfonamide therapy, although the local injuries has now been supplemented by the application of sulfa drugs or sulfa oint use of sulfonamide therapy directly into ments is of- almost negligible value after the original wounds. Dirty wounds of die the' infection has started. In addition, we hands or feet come into our clinics with use all the well recognized principles of lacerations and bleeding, sometimes injuries treatment of infection: rest, localization of to bon* nerves,' tendons and muscles. The infection by hot packs, incision and drain serious injuries you refer to the hospital age of abscesses, etc. Most infections lo for deansing,local sulfonamide therapy, calize much faster and in. some instances suture or other indicated treatment. In abscess formation is prevented by internal many flap lacerations of.the scalp, face and snlfa therapy. I 'prefer. sulfadiazine' in- hands,'the bleeding is controlled, flaps lifted ternally, giving with it an equal amount of bade with forceps and sterile sulphanilamid soda bicarb to eliminate gastric irritation. A dusted and sprinkled directly into the wound. This sulphanilamid or other sul fonamide should be sterile. It can be placed in liberal quantities without hazard, but should. not interfere with the closure of the wound. Be careful not to get it in the eyes, as it Is painful and may set up a conjunctivitis. A much higher percentage of primary wounds so treated within die .first hour or two after injnry go on to primary healing. A very much smaller percentage than formerly become infected. Ninety per cent of .the spontaneous cases of osteomyelitis occur as complications from superficial skin infections such as boils; therefor* boils and skin infections must be cleaned up and healed as quickly as possible. In some cases of repeated staphylococcic infections, sadi as boils, styes, axillary abscesses, nose infections, I have had satisfactory benefits, from a course of staphylococcus toxoid (digest-modified) In jection therapy. We can now immobilize with bandages Penicillin treatment, still a hospital pro and even plaster pans splintage, and dose cedure, has saved many lives and. reduced wounds by suture that formerly we dared the -complications and severity of many in not dose. Wounds that had to be under fections. Its value is mainly in strepto constant observation for \ infection that cocci* staphylococci* meningococci* gano- might be developing are now observed fpr cocric and similar infections. It is life sav localized swelling or temperature changes ing to those -patients who cannot take the ft without removal of dressings. snlfa drugs internally without severe re Many surgeons are taking advantage of actions. --... __ . > -K'/hi- the preventive value of sulfonamides in More X-Rays Used cases of injuries. In the army and navy wounded men are instructed to take sulphanilamide or other sulfa drugs internally immediately after injury. In industry, then, when we have injuries of a severe enough magnitude, most of which are hospitalized, it is good treatment to prevent infection by giving the sulfa drugs internally for the first five or ten day* thereafter in gradu ally decreasing doses. In the treatment of. fractures and dislo cations, there is a trend to much earlier and more frequent x-rays of injured hand* feet, elbows, knees, shoulders, etc, espe cially when there is an adequate history of sufficient'trauma.. We are well satisfied if SO per cent of the cases we x-ray have fractures. It is much better to take a few more x-rays than to pass up one or two fractures. Nothing brings more discredit i tr- When the patient does not come to us 'on a plant medical department than to have until he already has, an infection, we can the family physician pick np a fractured i'.-.U -i 270 33rd National Safety Congress, 1944 ffs 'e s s tfe crurn t t s u sih .m e. b o foot, toe, hand or finger that was missed at the plant simply because an x-ray was not taken. Another reason for early x-ray of more cases, and one of the most valu able, is to establish medico-legally the pres ence or absence of fracture and the presence of old fractures and old pathology that can definitely be established if x-rays are taken in the first two or three weeks. Let the case go six months or a year and then it is not so easy to prove that the old path ology antedated the injury. One other im portant fact is that by taking the x-ray early, after adequate trauma, you gain the confidence of the patient You can tell him positively that there is no bone injury nor fracture, and he usually appreciates your thoughtfulness and interest in his injury. In cases of dislocations it is imperative that x-rays be made before the dislocation is reduced. X-rays rule out complicating bone fractures and establish by the best evi dence the existence of an actual disloca tion. The scarcity of x-ray films showing dislocated fingers is usually due to the fact that most of these dislocated fingers are reduced before the x-ray is taken, many times by the patient or one of his friends pulling on the finger. Many an interne or young doctor's diagnosis of dislocation has been doubted simply because he (fid not have an x-ray of the condition before he reduced it Why do we splint and immobilize frac tures without much displacement? That means that the bone fragments have not moved out of their normal place, or even that in some cases there has been very little displacement If the original injury was not sufficient to cause the bones to move out of place, certainly your subsequent treat ment and the patient's conduct are not go ing to displace the fragments.' There are some exceptions. Fractures of both bones of the forearm or weight bearing on the bones of the legs or metatarsals of the foot are such examples. We immobilize or sup port such fractures by splints only long enough to relieve pain. I have seen many fractured fingers and toes that were relieved of great pain by simply removing tongue depressor, adhesive tape or even plaster pans splints. In most instances these pa tients are much more comfortable with a. simple gauze or sheet wadding dressing. The patient should use the injured part to the maximum extent of his comfort We get better preservation of muscle, joint, nerve and even bone function and tone if we start easy and early movements of these muscles and joints, passively at first, later actively. The blood and lymphatic circu lation is always much better in cases of early mobilization and usage of the injured part One very striking observation of this point occurs when we compare the edema, swelling and disability of a fractured ankle treated by the old method of immobiliza tion in a cast without weight bearing and using crutches for months, with an ankle fracture treated by weight bearing and a cast with a walking iron or walking heel support The former has a lot of edema after removal of the cast the ankle is stiff and painful, and many weeks are required h> bring about weight bearing. In the case with the walking iron, there is very little edema and swelling after removal of the cast The patient puts on his shoe and starts right out to walk, sometimes even without a cane. From many such observa tions I believe that in cases of fractures without displacement or with very little displacement early movement and early us age within the patient's comfortable tol erance are most effective in reducing dis ability periods and permanent disability end results. Metatarsal bars properly placed on the underside of the instep of a shoe have been most helpful in permitting patients with fractured metatarsals or toes to walk around early. The use of Iong Kirschner wires to im mobilize fractures of long bones, such as the radius, ulna, humerus, tibia, femur and even metacarpal, metatarsal and phalange, is meeting with excellent success. Many problem cases several months old came to me for evaluation of their injuries and suggestions for further treatment In taking the history, too often I found that the doctor saw the patient the first time and started a heat lamp treatment of 20 to 30 minutes* duration, bat that the nurse or some other office attendant gave him the treatment subsequently. In one case re cently the patient went into the room, turned on the lamp, took bis treatment; turned off the lamp and went about bis way with only a fleeting glance from the nurse attendant In several other instances. B' f B S 8. al Si 1 0 **2. J? J> B B?9. *9 Ve nt, i( !St ter m- of :ed lis sa, de sa nd de a td na iff ed se tie he id m a- es it s>1- sld he \ re / ts Ik il ls id iv Id is in it te x> >r te >. t, .is te I 5 Industrial Nursing Section zn I have known of patients with plaster paris treatments. He was sent back to his job body spica casts being placed under heat and told if he wanted to continue running lamp treatments, with the casts on, for 30 ( a racing book in the afternoon he had bet or 40 minutes. Wasn't the cast enough ter get a night job. It is surprising how without adding the discomfort of an in often these patients reveal themselves and effective heat lamp treatment? These pro their motives for continuing disability. One cedures do not deserve in the least part the employee earning $50.00 a week brought in name of physical therapy. enough insurance benefit papers to pay him Each case turned over to receive physical $100.00 a week. Who couldn't afford to therapy should first have a thorough ex remain disabled under such conditions? amination by a physician or surgeon, who All baric sprains are by no means pro should be responsible for improvement and truded intervertebral disc cases. Remem treatment He should examine the patient ber that the disc case usually comes on at least once a week or better twice weekly. from a lifting effort, has some disability A weekly or periodic conference between immediately, and usually greater disability the physio-therapist and the attending sur within 34 to 48 hours. There are almost geon can be made most valuable to the always loss of AchHIe's tendon reflex and patient A trained physio-therapist knows an area of anesthesia. More detailed dif by experience what results are to be ex ferential diagnosis is left to the neurologi pected from each type of physical therapy cal and orthopediesurgeons. treatment When such improvement does not occur, she then looks for conditions or factors that might be modifying or delay ing recovery. In this connection we have learned that abscessed teeth are associated with about 50 per cent of the subdeltoid bursitis shoulders, and even these shoulders with demonstrable calcification in the sub deltoid bursa. Recently we have confirmed Dr. William R. Cubbin's observation that many calcified subdeltoid bursitis cases have a high uric arid blood chemistry, establish ing a common relationship to goat. Some cases not responding to physical therapy treatment are those unfortunate individuals who suffer from a genuine Sudek's atrophy or painful bone atrophy. It is better not to expect too rapid im provement in that type of case and to keep the employer posted on a guarded prognosis. Some traumatic surgeons advise absolute bed rest immediately for the injured or sprained hack. This hospital treatment is excellent and to be recommended where feasible. Jolting and jarring a sprained back is poor treatment; but; in many in stances, bed rest, ambulatory activity such as bring up for meals or going to the toilet, do not appear to retard the patient's recovery. We determine at the time the patient is. seen whether he should be treated in the hospital as a bed case or at home as a semi-ambulatory patient Give him reasonable treatment bed rest support to the bade; rigid bed if necessary, analgesic and sedative medication and palliative re lief measures such as an electric pad, hot water bottle^ hot tub baths, and massage in moderation. If after three to five week^ your back case is not making satisfactoryprogress toward recovery, then it will be Malingerers Are Spotted advisable to make a complete and accurate- Properly administered physical therapy gives information about patients with doubt ful complaints, when the physical findings are not consistent with the complaints. After a ten day or two week therapeutic test treatment period, the surgeon and his physiotherapist can convince themselves that the patient is a malingerer or a gross exaggerator. Recently one such shoulder diagnosis: x-rays of his spine and x-rays of teeth and sinuses to rule out focal in fection, prostatic examination, blood count blood chemistry, basal metabolic test speria! tests for typhoid, uncialant fever, etc, special x-rays for intervertebral disc with contrast media, spinal puncture, neurological and orthopedic examinations and consultations and any further measures that may aid. case was found never to keep afternoon ' Almost 50 per cent of our hernia cases appointments for treatments. In ten days have pain referred to the upper sacral and we had the information that he was run lnmbo sacral region of the back, much the ning a racing book at the track and of same area to which prostatic pathology re cotirse couldn't come in for afternoon fers its pain. So constant a finding is this 'am : i.-' ir.'l .a.* v 1$ .-1 b#i /.? iKiiK! - ; -if! i. I'M i'Mi' IS- m i' I?) M 272 33rd National Safety Congress, 1944 that we believe the converse statement to have avoided that unfortunate situation be tree: many cases of back pain are due where the patient feels you have, ordered to inguinal hernias of which die patient is him back to work even though he was in unaware. For this reason every hernia case' jured and felt he should go home. I know is asked if he has bade pain, and likewise of many patients with simple fractures of every case of back pain is examined very the toes or removal of toe nails who have carefully to rule out inguinal hernia. preferred to go bade, to work. I.frequently First Impressions Count help a patient make the decision by saying, "You don't have .to go back to work; you The first impression that a patient gets can go home. But the nature of this injury of the plant physician, nurse and medical is such that it is perfectly safe for.you to department is sometimes very important go back to work if you want to. We'D Therefore, modern equipment dean sur let yon. If you think you'd like to keep roundings, pleasant kind, understanding going." Then on the release we write for personnel pay excellent dividends in obtain tire patient's benefit, "Allowed, to continue ing the patient's confidence. Show a genu work" How much better that is than to ine interest in the patient's injury problem. take a dominant attitude or on his release To him it is most important and he may to say, "Ordered bade to work" have an anxiety, problem even if you can't The term "light work" has become a bug see objective evidence of traumatic injury. bear to foremen and supervisors. They al- An error of tact is committed when a doc ways suspect the employees of "soldiering" tor or a nurse tries to minimize the extent on the job or using their injuries to get of a patient's injury. It is also unwise to soft jobs. So when we are ready to send make comparisons between this patient and a man back to light work we tdl him to someone else more seriously injured. It is talk to his boss and see if there is some much better, if there is a simple injury, modified work for him. Then when the to make the necessary examination, explain man or his boss tells ns the ldnd of work tactfully in a sincere way that it does not he can do, we release him to. resume modi appear to be serious, and that you have fied work The boss is satisfied, the patient every reason to believe the injury will make happy, and so am L The term "modified a complete recovery in a reasonable tune. work' seems to be a much better phrase Then proceed to render the necessary treat than " light work" ment carefully. Tact is required also when treatment is There are always instances of a hyper to be terminated and the patient wanders critical, antagonistic type of employee that what yon are . going to do with him if he will try the patience of everyone in the has a .permanent injury with specific loss medical department Your first reaction is or disfigurement Treatment should not be to argue with such an employee to prove terminated exactly at the same time you that his criticisms are untrue, incorrect or send him back to work We prefer to carry not founded on fact This simply makes over the treatment period a week or two matters worse. You are playing right into until the patient has proved to himself his his hands, and he makes a mountainous ability to renew work If dressings are issue out of a trivial one. It would scan necessary we have theopportunity of see to me to be a much shrewder procedure to ing the patient after he goes bark to work be overly-nice and if necessary over-treat In cases of serious injuries or disfigure such a patient I know that in many in ment, we tdl the patient when he resumes stances I have won the patient's confidence work that we know there, is going to be and helped him get well, by. simply giving some permanent injury and we also know him a chance to get it off his chest there is going to be farther improvement There is a tactful way to send an in So we aril him back sometime between jured person back to work. In minor in six months to a year after his injury, and juries it works well to say, "You probably then give him an appraisal examination want to keep working?" or "Do you think and report his permanent disability. Some yon can keep at work?" or "Would you patients try to hurry their disability settle like to try to oontinue working?" You ments. If one can reasonably expect any give the patient, an opportunity to decide further improvement, then the permanent that he wants to keep working; and you disability evaluation should be deferred: