The Man-Nurse Diaries

My Son vs. His Toe

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Tue, 13 Sep 2011 09:23:00 +0000

This story might be gross. Just warning you.

My son broke his big toe. Yes, it was that son, the four-year-old who's always hurting himself, the one who's always getting into things, the one who got attacked by poison sumac with a vengeance. He flipped off a bench he was crouching on top of, and the bench slammed down on his toe on our tile floor. Ouch. What's worse is that we had just come home, it was 9 o'clock at night, and we were busy putting things away and sorting children and trying to get ready to get ready for bed (an arduous process around here), and I didn't really pay attention when he hurt himself--he's always doing it, right? So he actually had to hobble over to me before I noticed that he was crying a little more than usual and there was blood all over the floor. That's probably when I earned my dad of the year award.

I carried him to the bathroom and realized we probably had to go the emergency room. The nail was loose and already reddish-black, he had a big laceration down the front of the toe, and he was crying so hard he was almost dry-heaving. I felt so bad for him. I tried to gently wrap it and put ice on it. We arranged for a "babysitter" (my wife's brother...in other words, just an adult body to remain in the house, and most likely the kids would be up eating candy and watching movies all night) and I carried him to the van. He stopped crying so much and became more concerned why we were going to see a doctor about it. Poor guy. Then we drive to the hospital with a crying baby and a crying kid with a bleeding toe.

Luckily the hospital is so close. I carry him into the emergency room and he stops crying. The registration person at the desk asked me his name and birthdate. I can never remember his birth year. This happened a while back with my insurance company, too. She tried to calculate it with me -- let's see, he's four, this is 2011, his birthday is X, so... Then my wife walks in after parking the car. It turns out, ironically, that our registration lady is the same person who registered us at a different hospital's emergency department a few years ago (with the same kid, I believe) and once or twice over the years has seen us at church. So she recognized my wife! Which is nice, though it doesn't seem like a generally good thing for ER registration people to start recognizing you. At any rate, she and my wife are discussing on our new family events (new births, etc) while I'm wheeling him down the hall to triage.

The triage nurse unwraps his foot and his toe is still bleeding pretty hard and looks awful. She asks him how it feels and he, trying to look unconcerned, says "It's fine."

She gave him some ibuprofen and sent us for an x-ray of the toe, which I figured was just a formality. I assumed he just needed some sutures.

Eventually we get to a room in the pediatric ED, and we wait. And wait. Eventually we're seen and the doctor informs us that the distal phalanx was fractured. He doesn't know if this will require pinning or not so he'll send us for a consult first thing in the morning for a plastic surgeon or a podiatrist (it's now 11pm or midnight). He shoots the toe with some lidocaine and sends the ED tech in to irrigate and clean the toe.

Do you see it?

The tech was very nice but very busy with lots of kids, being the only tech in the pediatric wing of the ED. At that point I felt like telling them I'm a nurse and volunteering to do whatever they need done--I had the impression the doc could work on the toe now, but had to wait for the irrigation to be done, so he had moved on to other kids.

During the clean-up the hard-working tech told me all about how he was a single dad of a few kids, since his kids had flatly insisted on staying with him after the divorce. He pulled a lot of hours as a paramedic and ER tech to put them through school and now college, spent the rest of his free time with them being a dad, and said he was going to vomit if another woman told him what a nice guy he was (since he's developed the theory that women say they like nice guys but really they like total scumbags.) I hope he didn't mind me as a fellow hard-working dad telling him what a nice guy he was. Readers--high-five that guy.

Anyway, back to the toe. After another long wait the doctor wants to suture the toe and see what he can do about the nail. The nurse has the foresight to have me hold a towel up so my boy doesn't have to watch it (why don't physicians ever think of these things?). But it's still not numb. Apparently big toes (and thumbs) are hard to anesthetize. He has to inject and re-inject the toe probably a dozen times to try to get to the nerve root. And this is what really hurt him the most, after the initial injury. He was crying but he tried so hard to hold still, and when the towel I held up slipped a bit he grabbed it and threw it over his own head. Still, as much as he squirmed, he held that leg totally still.

The doctor left to wait for the toe to numb up. My son tells me "I wish I was made out of metal."

The toe was sutured up but the nail was a loss. Removing the nail took forever. My son fell asleep during it (thank God for lidocaine). My wife had to leave the room to avoid passing out. I was a little grossed out myself. That's the irony of blood and guts, by the way. If I was in charge of the toe, I would've been fine. As it was I still had a job to do, so I was okay watching it but a little queasy. If I just had to stand around watching it, or if I had to hear about it, I'd want to barf. (Yeah, I know. I'm making you hear about it. Sorry!)

The doc asked me if I want to save the toenail. I was surprised but he said they could possibly clean it up and try to suture it back on. That sounded like more of a hassle (trying to keep it from getting caught on things, trying to keep it clean). It got forgotten about and tossed with the trash, however, so it's a moot point.

The tech redresses the toe. The physician assumed I'd see a doctor first thing, so he thought one dressing was enough, but the tech had the foresight to stuff a bag full of dressing changing supplies. Which was great, because we couldn't see somebody first thing.

We go home around 1AM, go to sleep, and call the consultant in the morning. It's Monday morning at 8:30 and I'm calling the office as soon as it opens. It turns out he's a hand plastic surgeon, and doesn't do feet. His secretary also said this was the second injured toe call they had since they opened, and somebody in the ER needs to stop referring toes to him. I call back to the pediatric emergency department and talk to a nurse who gives me the number of their pediatric orthopedic surgeons' group. With this unofficial (yet obviously accurate) referral, I went there the following day.

We waited in the waiting room forever. We watched Phineas & Ferb for the first time, which is a grand show. Finally we see the physicians--the orthopedist, his resident, and a pediatric resident--and they say there's no surgery to be done, keep it clean, he can walk on it all he wants, but--get this--try not to let him run or jump on it too much. Ha. Ha. Ha.

For the next week we keep him from jumping on the trampoline and riding his bike. Which was sort of like trying to tell him not to eat and breathe.

We're supposed to follow up with an appointment with the orthopods, not for an x-ray or anything about the bone, but so they can look at the nailbed. The nailbed is healing great and, for a gross-looking ex-toenail, is looking fine. So of course, me being a nurse, and a nurse with a high deductible health plan, I haven't bothered to set that appointment yet. I probably still should. Especially since he's gotten in fights with his siblings, kicked things, and had his toe stepped on I don't know how many times.

Do I sign my kid's birth certificate? Do you know any lawyers?

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Thu, 11 Aug 2011 06:08:00 +0000

In the past, I've signed my children's birth certificates as the "attendant". This is not something I really ever planned to do. I think it originally just sorta happened. You go downtown and find the vital statistics people in the basement of the courthouse where they create these arcane documents, and when you say that you didn't have a licensed medical attendant, and there's an empty line to be signed, somehow you end up signing as the father and as the attendant.

I also vaguely recollect a midwife claimed once that whoever cuts the cord (this being, she also claimed, the only 'medical' act that occurs in many home births) is the attendant. But that's probably false—on both counts. It still probably reinforced my mental justification for signing.

Now I'm not sure that's a wise thing to do. It might have been fine when I was an unlicensed nobody, but now that I'm subject to the Nurse Practice Act I'm afraid I could be accused of practicing nursing outside of a licensed facility. Or practicing medicine, that old standby. it just seems I shouldn't have my name on a public record in the capacity of a birth attendent. I've never had a felony. I've heard those things stay on your permanent record.

This could be a viable alternative.

But wouldn't family be exempt? I would assume it would keep me exempt just like before. Assuming I was ever exempt. Did I say I signed anything? I meant hypothetically. My, uh, friend signed it.

I'm just not sure what the alternative is. Would my wife sign as attendant? Should it just be left blank?

IT A GRIL

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sun, 07 Aug 2011 02:36:00 +0000

Go to Cakewrecks. It's funny.

We totally had a baby yesterday. It went like this. A couple days of false labors starting and stopping. Then yesterday morning she's going into what seems like real labor, in the bathroom, while I'm going about the house cleaning up and getting the kids ready to go off with Grandma. Then the midwife arrives and I pop into the bathroom to see how the wife is doing. I'm sorta surprised to see that she's having these really long powerful contractions pretty close together! Glad I was paying attention.

The next few hours develop as labor tends to do, getting harder and stronger and more intense. This one seemed more painful than the rest. The baby was originally posterior and we weren't sure if she had turned. (Posterior labor = badness.) At one point she had my hand in a death grip, crunching my finger bones against my ring. It's just kinda funny because it's not like I can complain, right? Another time she had her face on my knee while I was sitting next to her, and I thought...I don't know what I'm going to do if she bites me.

At one point the midwife said there was a 'lip', where the cervix or some other woman innard gets caught under the descending head, so my wife had to stop pushing. She almost couldn't handle that, and I thought we were in for a day of misery. But after a bit the midwife determined she could start pushing again. And then things started moving fast. Really fast.

I don't know if you're squeamish, but at some point after that the midwife calls my attention to the posterior region. The baby's head is already totally out—but still in the bag of waters. Imagine a baby's head in a water balloon, sticking out of somebody. A WATER BALLOON. Despite four other home births I've never seen that before. In fact, we had one other baby 'in the caul' before, but that midwife broke those waters before I saw. The midwife didn't have to break these; her arm was half-up and in a show of baby might she shoved it out of the bag herself.

She popped right out and was in mom's arms. After a little while she was nursing like a champ.

Right away I could tell she wasn't as big as the last baby (11 lb 6 oz). We guessed weights with the midwife, and we all agreed she was probably in the 9 to 10 pound range. Ironically I'm getting handy at gauging babies in the upper bodyweight divisions. Actually she looked small. And she still does. A pound makes an enormous difference in a baby. And despite the 'lip' and the pain, my wife said it was a much easier labor than last time—understandable right? Actual weight: 10 pounds 4 ounces.

She's a doll. She's cute and easy to please. Well, all babies kinda look like chubby old men, but as far as miniature chubby old men, she's cuter than most!

Uniform policy time.

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Thu, 28 Jul 2011 10:37:00 +0000

Pregnancy update: which is that, um, we're still pregnant. We're past due day three now, I believe. This baby is low. Everyone applaud my wife for going to the gym yesterday! Everyone boo for that not instigating labor, however. Though I would've felt kinda bad for her class instructor if she went into labor then.

-----------------------------

There's a semi-confirmed rumor at work that we're going to adopt uniforms for nurses. This will be house-wide—every RN in the hospital will wear the same thing. The argument is that patients have complained that they don't know who the nurses are. I've heard this argument elsewhere, and I frankly don't believe it. If someone comes at you wearing a stethoscope and carrying a needle, you can kinda figure they're not the housekeeping staff. (If they're are, at least you'll be on the news.) It takes about three milliseconds for a nurse to introduce themselves and establish a professional rapport with the patient they'll be caring for over the next 8 to 12 hours. Do patients forget in that timeframe? Probably not.

I think in all truth it's the physicians who are complaining. We're a huge teaching hospital, so there are literally thousands of physicians. Outside the circle of residents and specialists you always see, I don't know most of these doctors from Adam (or Eve). And they're lost wherever they go, especially the poor primary care physicians trying to find their patients. I'm sure they've complained that they can't readily identify the nurse for their patient, standing at attention and waiting for orders. Heck, they usually can't even find or recognize their patients, but at least they have gowns on.

But on the other hand, I do have to agree that we nurses are a bit, shall we say, casual. At least where I work. The hospital and individual units have frequently issued t-shirts. They bear hospital or unit insignia with varying levels of discernability. They were made back when they were trying to achieve Magnet (big nursing award) status and instill unit pride and all that. Probably more than half of us wear them to work. But I have to admit that a t-shirt and scrub pants feels like working in pajamas.

In fact this was about to be my next scrub purchase. Including the pipe and slippers.

Half the time my stethoscope has been flung somewhere and my ID badge is flipped over or hanging off my waistline or hiding, so I can understand that you probably can't figure out who I am if you don't know me. Of course, like I said, my patients know me; but random physicians appearing at random times who are already frustrated at not being able to navigate the unit and find charts? Not so much.

To make matters worse, some people *shifty eyes* have gone on to just wearing plain t-shirts when they're running out of work shirts. Or we sometimes wear the hospital-issued green scrubs, so we look like residents.

So I know I'll feel more professional if I'm forced to actually wear scrubs. But in the meantime, I'm going to keep looking like I'm at a pajama party because that's what's allowed and it works for us. If I thought that patients were really misidentifying me, I'd worry about it. But you know what? People will still think I'm a doctor even if I'm wearing a white dress, white tights, and a red cross on my hat.

I HAVE NOT POSTED SINCE MARCH OMG.

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Wed, 22 Jun 2011 12:11:00 +0000

What a busy couple of months. So we bought this foreclosure house which has occupied pretty much every waking hour aside from work. It's structurally sound but a combination of neglect and a former owner who thought he could DIY a lot of this stuff equaled a lot of work for us. We had to fix the plumbing, yank out old wiring and satellite cables, rewire a bedroom and a bathroom, repair the drywall in almost every room (and ceiling), paint every everlovin' surface of the house, play some more plumbing "where is this leak coming from?" games, clean out the gutters (organic sediment since 1994, probably disposed of some good fossils), rehabilitate the lawn and kill some grubs, install some appliances purchased on Craigslist, fix said appliances purchased on Craigslist, and I don't even remember what else. It culminated in having electricians discover exposed live wires (thx former owner) all over our attic. My favorite part was when my wife's aunt came over and, looking over the ladders and tarps and paint cans and dust, asked who was doing all this work for us - who our contractor was. I am my contractor. And I'm a pretty unsatisfyingly slow one.

It's been a learning experience for sure. I had no idea how to do 90% of these jobs, but thanks to the internet and a couple of how-to books—that sounds safe, right? :-) Makes ya want to live here. Anyway, I have tools for everything now. I'm mostly impressed by the fact that I can fix walls. Got a hole in a wall? I can make it disappear.

For all this work we're getting a nice brick home on a beautiful lot that's double or triple the average lot around here in the city. The kids love it. It's close to family and my job. It's good.

Now we have to unpack and settle in.

In other news, baby number 5 is slated to emerge in August. My wife is feeling okay, taking a lot of naps. It's hard to schedule midwife appointments in with all the other work and house stuff going on.

In work news, I am forgoing the BSN program. I'm a bit busy, no? I am thinking about doing a little CCRN preparation. The coworkers were listening to the Laura Gasparis review CDs (well, mp3s these days) and she was hilarious.

Thanks for the well-wishes and the concerned comments and emails. We're doing well. Just really busy!

The Bachelor's of Nursing. Tell me again why I should get it.

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Mon, 07 Mar 2011 16:17:00 +0000

Some days ago I was assigned a nursing student from a university to follow me in the care of one of my ICU patients and give certain meds under supervision. I've done this before and I'm always surprised at how easy they have it. The instructors, when they come by, are very nice, helpful, and never expect them to know anything. For instance, she was asked how many units of insulin the patient should get, and she hesitated a second and then seemed to venture a guess. The instructor teasingly called her out on it. A guess? In my day, if I hadn't been prepared with an answer, let alone tried to guess on a medication as important as insulin, I would've had my head stuck on a pike in front of my school as a warning to students forever.

Like 57% of nurses in the US, I was prepared by a community college and received an associate's degree in nursing. So tell me: do you think I will learn anything more about taking care of sick human beings by completing a bachelor's degree in nursing with her university? Because I could. The school is associated with my hospital and will get paid by my hospital if I go there.

No one in nursing acadème or nursing administration comes out and says that an associate's degree is not enough to be a nurse. But they do fixate on the idea that it's not enough to be considered a professional. Not enough to be considered independent or autonomous. Not enough, in other words, to compete with physicians. Going back at least to the 1980s, nurses have been trying to get out from under the paternalism of physician-led healthcare. The general public thinks we're just order-followers, med-passers, and scalpel-hander-overs, and we're still trying to shake that image. For some reason, we think the only way to shake it is with academics. So there are countless RN-to-BSN programs out there, and our hospital system will gladly pay for us to go through them—so I can't really complain that they want us to do it.

Okay, yes I can.

It's kind of silly. My degree is a two-year degree. The four years at a university school are typically divided between two years of general education and two years of formal nursing. In other words, it's a two year degree. But, they say, a university program also includes coursework on research, community health, ethics, and nursing theories. So did mine. So what's the formal difference? A formal degree. Something that academics and administrators can point to. But probably not anything that's going to help you in the care of sick human beings—in bedside care.

The irony is that at the same time we ADN nurses are encouraged to get our BSN, we're also told we don't need a BSN to be good nurses, and that the BSN program is not going to teach us very much we don't already know. They might as well say: it's basically pointless, or it only helps a little, but more importantly it achieves some ulterior goal aside from improving you as a nurse. Goals like being able to say you have more BSN-prepared nurses for your Magnet award application.

The reality is that a nurse doesn't need a higher-level liberal arts education in order to be a nurse. That doesn't make us unprofessional. There's a science to nursing, but there's also an art; there's a logic to nursing, but there's also a knack. We don't like to admit that we're basically like car mechanics, but we are. We know can interpret pulmonary measurements and blood gases, but we can also just eyeball a patient and have a good idea if they'll fly or crash when taken off the ventilator. How different is that from a mechanic who knows how a catalytic converter works but also knows whether a knocking sound is benign or bad? The idea that an academically-prepared professional must fix your body but mere 'skilled labor' can fix your car is absurd. The difference is the degree of knowledge, not the category. Whether you're a car mechanic, a nurse, or a neurosurgeon, you're basically exercising your knowledge as you do tasks. This includes physicians. Physicians are not artists or philosophers. They're task-oriented like everyone else.

What does this have to do with my BSN? Well, since physicians are in the same ballgame as the rest of us, and not an elite group of Ph.D.s, I don't see the need to compete with them academically as long as I can achieve my goals in patient care. I've never met a resident or physician who cares what degree I have. They care about my license and expertise.

But I'll go for it. I'm open to learning new things. It's a stepping-stone to advanced practice, and I don't have to pay for it. But I still kinda worry about the efficiency and efficacy of this: in five years, will it matter than I spent this much time and effort away from my family to do this? Will I think I wasted my time? Most likely there's no increase in pay or status. Am I just submitting to some outdated dream of nurses who abandoned patient care for academic politicizing? I don't know. I just hope this effort helps me more than it helps them.

That's no excuse!!

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sat, 19 Feb 2011 19:44:00 +0000

Sorry for the dearth of posts. We're trying to buy a house, for real this time.

Also...we are pregnant.

I'm not going to say how many kids this makes.

Surviving the Blizzard

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sat, 05 Feb 2011 13:37:00 +0000

We were shortstaffed, had no nurse's aides, our supply of linen was cut off, doctors weren't calling us back...in other words, it was a typical night shift.

My normal commute to work

Our blizzard shifts really weren't that bad. Getting to and from them was an issue. Some nurses drove four hours to get to work. But within the confines of the hospital we were sheltered from the weather, got free food, had the ability to sleep over if we wanted, etc. Several stayed for 16 hour shifts or even slept over and stayed inside the hospital the entire three days. Other than that, things were pretty normal. I know, it's disappointing that I don't have any heroic stories of saving people who were half-frozen and stranded on the highway, or buried up to their armpits in snow. But I think most of the populace was pretty sensible and stayed indoors. An ER nurse did tell me about a few heart attacks from shoveling snow (lesson: stay in good cardiovascular shape the rest of the year!). And that some people came in completely covered head-to-toe with snow. So did I. But at least I didn't have to walk or dig my car out. Luckily, I got rides to work.

Yeah....no.

I think we were all subconsciously affected by the constant news reporting of how everything in the world had shut down - so everyone within the hospital was moving slower. Things were relatively quiet. It seemed like we shouldn't do anything non-essential.

The kids loved it, of course.

The only thing better than a trampoline is a SNOW-COVERED TRAMPOLINE!!

I took more photos, but they're your typical deluge-of-snow images you can find everywhere. My favorite photographic article so far is at the Daily Mail UK, including a satellite composite image showing most of the Northern Hemisphere under ice and snow and many amazing pictures of how completely the snow shut our city down.

Breastfeeding and SIDS prevention - and sleep apnea? and orthodontics?

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sun, 30 Jan 2011 11:20:00 +0000

Brian Palmer is quite an interesting dentist. He has an entire website (albiet in premodern html) devoted to the importance of breastfeeding. He maintains that infant feeding techniques have an enormous impact on the human oral cavity and airway, which in turn has an effect on infant problems such as SIDS and ear infections, adolescent problems such as overbites, and even adult disorders such as obstructive sleep apnea.

I won't get into all of his hypotheses here, but I was interested in what he says about SIDS. Human babies have unique mouths and airways. Their epiglottis, or the flap that covers the airway when you swallow, is high up in the back of the mouth. It comes into contact with the soft palate, or the soft back of the roof of the mouth. The soft human nipple encourages the tongue and lower jaw to come forward in the mouth, and pulls the epiglottis up, reinforcing its position.

The epiglottis is that thin white thing clamping onto the back of the roof of the mouth, preserving airflow from the nose to the lungs. From a slide by Palmer.

This is the position all other mammals have as well. It lets them hork down food more safely while still breathing. Eventually, however, your baby's epiglottis will adopt a position lower in the throat. This is weird and complicated and unlike other mammals, but it does two things: it enables human speech, and it enables the tongue to drop back and block the entire airway (which is what happens with obstructive sleep apnea). But you were breastfeeding, so your kid's tongue and lower jaw will be anatomically correct position: forward and away from the nose-to-lung airway path. Human nipple feeding also molded your baby's hard palate (the bony roof of the mouth), making it wider, which enhances airflow around the tongue.

Note the gap between the epiglottis and the roof of the mouth, allowing the tongue to nearly block the airway. Also note the lower jaw is pushed back. Palmer notes this adult probably had sleep apnea. In an infant this may cause SIDS.

Using a hard preshaped plastic nipple pushes the tongue and jaw back and the epiglottis down. It also mis-molds the hard palate into a more narrow shape. Excessive pacifier use does these things as well. Significantly, the epiglottis drop normally happens after the age of SIDS prevalence (5-6 months or so), presumably when the baby can stir itself to reposition and breathe should the airway become blocked. Forcing this to occur early may be a contributing cause of SIDS, allowing the tongue to fall back and block the entire airway.

You can read his presentations (in PDF format) on SIDS and breastfeeding here. They're a bit anatomy-heavy but have fun slides like this:

Those are some nice teeth.

He also theorizes that this same process of bad mouth molding due to poor infant feeding practices contributes to obstructive sleep apnea in children and adults, otitis media in children, of course there are the dental and orthodontic implications of having your bite messed up by plastic nipples and pacifiers. I haven't even begun to dig through his three-part text The Importance of Breastfeeding to Total Health which may cover all these topics more generally.

Maybe this doesn't seem interesting to everyone, but to me, SIDS is a perplexing event that requires explanation. Also weird is the occurrence of "difficult airways" at work: people who are just really difficult to intubate. Sometimes it's due to overweight, or biting, but I wonder how often it's due to misshapen palates, jaws, and oropharynxes. A difficult intubation in an emergency can be absolutely fatal. Breastfeeding might help in more ways than we have previously imagined.

The Illinois Home Birth Safety Act did not pass

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sat, 22 Jan 2011 19:06:00 +0000

Get 15% off a scrubs jacket with promo code "jackets_t3c"

So SB 3712, the Illinois Home Birth Safety Act, did not pass. Despite passing the Senate it failed to pass the House by a larger margin than any of us thought it would, mostly because the Illinois State Medical Society went completely apes**t about it.

The good news is that they really paid attention to this bill. You can see on their website that the ISMS is still freaking out about the midwife bill:

Seriously? Seriously.

The bad news is that the ISMS and the American Medical Society (which is centered in Chicago) have a lot more money and lobbying power to defend their market. It's amazing to what extent the Illinois State Medical Society was willing to jump to conclusions about midwives to scare people about this bill, neglecting to mention that more than half of the United States can safely use legal certified professional midwives. But despite the ISMS's "action alerts," nobody I know in real life was concerned about this bill, and most people didn't even know it existed. I don't think their campaign reached that many voters. Maybe it wasn't intended to. But apparently enough State Representatives were concerned about this bill -- representatives who probably don't have to answer to too many home birthing families at fundraising dinners. Physicians and physician lobbies are another financial matter altogether, and probably explains why a disproportionate number of reps were concerned when the general public and the news media were not. This is what the ISMS means by "physician support" against the bill.

The fact of the matter is that physician groups in this state, notably the ISMS, the American Congress of Ob-Gyns, and the American Medical Association, have a history of refusing to look at new and more efficient models of care, regardless of what the people want. They fought or tried to restrict the very existence of advanced practice nurses, nurse practitioners, nurse anesthetists, and nurse midwives, and they lobbied against and tried to restrict pharmacy clinics. This despite the improved patient safety, patient outcomes, and decreased patient costs that these entities have brought to Illinois. CPMs are another group of practicing professionals who, despite being tested and proven in the rest of the USA, threaten the inflated practice costs and the exclusive domains of practice that physicians are trying to maintain.

The Illinois State Medical Society is right: some form of this bill will be back. It has to. Our society and our market are not going to continue to support the higher expense and poorer outcomes that occur when birth is the exclusive domain of surgeons and hospitals. The only thing holding it back is the money physicians already have, and in this economy that might not last forever.

You can read my summary of SB 3712 The Home Birth Safety Act here. (Be careful, it's soooo scary.)

Gabrielle Giffords and the drama of neuro-intensive care

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Tue, 11 Jan 2011 12:58:00 +0000

US Rep. Gabrielle Giffords

Last night it was interesting watching Anderson Cooper and Sanjay Gupta sort of stumble over trying to describe the medical care someone receives after surviving a gunshot wound to the brain. They were, of course, talking about the assassination attempt on Rep. Gabrielle Giffords. They didn't seem very certain what they were talking about (at least, that's how it seemed, but it was closed captioned and I was running on a treadmill) but the AC360 blog video, "What Helped Giffords Survive Brain Shot", is a lot more clear. It's interesting to see the public news media grappling with the strange concepts that are dealt with in neurointensive critical care on a surprisingly frequent basis. There are also articles trying to answer why Giffords is in a medically induced coma and highlighting the "new" procedure of decompressive craniectomy (I don't think it's that new?), with more or less accuracy.

Of course, the involvement of highly skilled neurointensive care nurses is apparently nil. It's made to sound as if neurosurgeons and doctors are at the bedside watching these patients 24 hours a day. But hey, that's the media.

It is (obviously) possible to survive being shot in the brain, depending on several factors. First, it depends on the round and the trajectory. It doesn't have to be a through-and-through injury, but it probably helps if it's clean through and not explosive.

Secondly, the problem with brain injuries of all types is that even if the initial injury is survivable, the "secondary injury" is what kills or debilitates patients. I've heard war stories of soldiers being shot in the brain and surviving, awake and talking, for days, and then dying--presumably of swelling or sepsis. The brain swells like anything else after injury, but being in the rigid skull, it has nowhere to go. First the intracranial pressure compresses other brain structures (often the other cerebral hemisphere) which will cause neurological changes. Sooner or later the intracranial pressure can exceed the perfusion pressure of blood reaching the brain--we calculate this as a function of the blood pressure and using an intracranial pressure monitor, a thin catheter placed into the brain--and you have no flow. Swelling may also cause the brain to "herniate" through the hole in the bottom of the skull through which the spinal cord and brainstem connect to the brain, which also compresses those blood vessels, killing the brainstem. Spontaneous breathing stops, your most basic reflexes (coughing, gagging, and blinking) will cease, and there will be no response from the patient to painful stimuli. Death is inevitable unless the blood pressure is supported and they're on a ventilator, but a full brainstem herniation is ultimately unsurvivable. Persistent no flow and brain stem death will lead to a clinical diagnosis of brain death.

CT after craniectomy

So rapid transport to a hospital is critical, followed by rapid assessment, intubation to protect the airway, a head CT scan, and a neurosurgery evaluation. If the patient is a surgical option, they'll open the skull (a craniotomy) to remove clots, and may elect to leave the skull flap off (a craniectomy) to decompress the brain and allow it to swell. The skin is sutured back without the skull and we're on strict precautions (obviously) to leave that part of the head alone. The skull flap is preserved for later reattachment, sometimes in the patient's abdomen, sometimes presumably in some fridge somewhere in the hospital (hopefully labelled and dated appropriately, otherwise the secretary will throw it out--or maybe that's just my lunch).

After surgery the patient typically goes to a specialized neurosurgical or trauma critical care unit staffed by experienced nurses who take over the hour-to-hour care. The patient will be kept intubated and breathing by ventilator. The patient is sedated into the "medically induced coma" the media keeps mentioning, mostly to control pain and agitation. The brain injury, the surgery, the breathing tube, and being restrained to the bed by the wrists (which is done to protect the breathing tube, mostly) all lead to agitation, which sharply elevates intracranial pressure, so the nurse will be continuously managing those drips as needed. Usually it's propofol because you can shut it off quickly, but the rapid-acting benzo Versed is also used; and a continuous fentanyl or morphine drip for pain.

The nurses will examine the patient hourly for the first day or more, then every two to four hours as the patient stabilizes. Sometimes this will involve turning off the sedation and seeing what the patient does - do they follow commands, open their eyes and track and focus, etc. Otherwise a significant amount of neurological information can be gained even with the patient out - do they react to pain, move all four extremities equally, still have all their reflexes? It's hard to overstate the importance of these exams; the patient can look the same and be totally stable but have a blown pupil or have a diminished reaction to pain in, say, the left arm - these are huge easily overlooked changes that can occur in an hour. We can also determine if we're sedating the patient too much and reduce the drips as needed. If an intracranial monitor or drain is placed it will be monitored fairly continuously. If anything changes, a stat head CT scan is done and the neurosurgeon and critical care physician are notified. The patient might need more surgeries if there's rebleeding, more swelling, etc. The nurses will also administer antiseizure meds, meds to reduce swelling, and keep track of the rest of your bodily functions--heart, lungs, etc.

If all goes well, the patient can survive. The patient may need a tracheostomy and feeding tube ("trach and peg"). They'll be taken off sedation and the ventilator if they're able to breathe on their own, but only time will tell if and to what degree there will be any disability, personality changes, or decrease in cognitive function. Some patients are unscathed and others are not.

That's the extent of what I see - the patient is usually transferred to rehab and I don't see them after that. But eventually the skull flap will be placed and stay a night or two in the same intensive care they started out in, which is sometimes nice for us to see.

Spread some holiday cheer. Don't shoot anyone!

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Wed, 22 Dec 2010 14:11:00 +0000

15% off spongebob scrubs with promo code "spongebob_sale"

I was told this all summer, but I still can't believe it's really true. All summer we had violent crime victims, mostly GSWs (gunshot wounds) several times a week, sometimes daily. And that was just what came into our ICU; I don't even know the rate for the whole hospital. (At my old hospital, I'm pretty sure if you were shot anywhere we all panicked and you went to the ICU, but at my new workplace, if you're shot in a nonvital manner, you get patched up and go to a regular trauma-medical floor.)

But all the experienced people said the trauma season really slows down in the winter. And it has! I can't get over that.

Violence in the cold winter Midwest.

People are really out less shooting each other because of the cold. I mean, it kinda makes sense - most people can hardly oblige themselves to shovel their sidewalks. It takes me an hour to get the kids ready to go outside. I can hardly imagine trying to motivate your minion gangbangers to go perpetrate crimes in this weather. But honestly, you wouldn't think drug-addled hoodlums would care so much about it. Doesn't alcohol make you feel warmer?

Lest you think this wasn't written in the holiday spirit, it was: anyone braving the shopping malls at this time of the month should take heart that the hideous stress of last-minute Christmas shopping hasn't driven up our admissions - at least for violent crimes, that is. Make sure you don't slip on the ice and come in with a subdural hematoma.

Merry Christmas!

First MRI Images of Live Birth

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Thu, 09 Dec 2010 14:47:00 +0000

Although it's not as cool as x-rays of video game controllers, a hospital in Berlin performed an MRI scan of a live birth.

The exam was done in order to see why labor stalls and why women require c-sections. Of course, we already know that supine labor (pushing a baby out against gravity, on your back with your pelvis up) can stall labor. I would venture a scientific guess that it stalls 55% more often if you're crammed into an MRI machine - even an custom birth scanner.

Source: Daily Mail

I'm curious why every news source has flipped the woman onto her belly. That's her spine and tailbone above the baby there. Conversely, some of the images are oriented vertically. A step in the right direction, perhaps, but I doubt it happened that way! I haven't seen any supine images, which has to be how it really happened.

I'm thinking it won't reveal very much on why labor stalls, if I'm right in my assumption that labor stalls for positional (anti-gravity laboring) and hormonal (stress hormones inhibiting oxytocin, the labor hormone) reasons, as well as poor clinical decision-making like forcing labor (or non-labor) by induction and augmentation. I'd also think the mechanism of labor, the descent, is probably different when you're laboring in the more upright positions humans have naturally tended to labor in over the millenia. Laying flat on your back with no regard for spinal alignment or pelvis positioning or the weight of gravity does not strike me as an accurate way to do an imaging study of birth.

The Daily Mail Online: Doctors produce first-ever MRI scan of baby at the moment of birth
Medgadget: MRI Used to Visualize Live Birth
The Unnecesarean: Woman Gives Birth in an MRI Machine

X-Rays of video game controllers and other random things

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Wed, 01 Dec 2010 20:04:00 +0000

Flickr user Reintji is a radiology technician who apparently has the spare time and the films to take x-ray images of video game controllers, coconuts, beer bottles, telephones, iPods...

You know, I got accepted to radiology tech school and I turned it down to go into nursing.

A few minutes in the life of a nurse.

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sat, 27 Nov 2010 22:41:00 +0000

I can't believe how many things my brain has to deal with at work. For instance, in my way to work I walked past my own patient being emergently transported with the paramedics from an outside hospital - not that I knew it was my patient yet. They were arriving at the change of shift, so within five minutes I was getting report from the day nurse while simultaneously helping the paramedics slide the patient into bed, assessing the patient (are they breathing right? vitals stable? pupils working? talking? oriented? following commands? moving all extremities equally?) and holding a pan and towels while they vomited all over the place. Meanwhile I'm trying to make a list of things in my head that I needed immediately: oxygen, blood draws, drugs, do I have IV access?, doctors to be paged, etc. I trusted, by faith alone, that the neurosurgeon had already seen the scan by computer and that the intensivist had got some kind of report from the other hospital. But I was the only one (besides the day nurse, who was trying to go home) who was actually seeing the patient. Getting the patient semi-settled for two seconds, the day nurse and I go to the desk to give a decent report, but in the middle of that the doc calls, so I have to grab the phone while I can and get all the orders I'll need (otherwise I'll have to page in the middle of the night) - IV fluids, labs, electrolyte replacement, insulin, DVT prophylaxis, pain meds, antinausea meds, are we doing another CT scan?, consults, and by the way we're not going to surgery emergently, right?, give a quick run-down of my assessment in twenty words or less, try to rifle through the paperwork from the outside hospital to see if this patient had gotten fresh frozen plasma to reverse their bleeding (they hadn't, so that meant I had to stat draw a type and crossmatch and send for the blood products ASAP), all while the day nurse still talking in my other ear with suggestions for what else I might need from the doctor (which I actually appreciated a lot). Getting off the phone, I had to still get a report on my other patient, including a rundown of the issues I'd have to take care of related to them being an agitated, neurologically compromised patient on a ventilator and titrating cardiac drips.

This was the first five minutes of my shift. The day nurse said "Wow, you're a good multitasker." I'm like...um, not really. This is just me panicking.

But I felt kinda good about myself and my pace....until the family came in while I was trying to figure out my next step, and asked what the plan is, and my brain froze for several milliseconds while I tried to formulate and distill everything that was currently happening and would happen in the next several hours - without using medical jargon. NOT EASY.

Why Veganism Doesn't Work (mostly)

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Wed, 24 Nov 2010 03:51:00 +0000

A few days ago Tasha, the blogger at Voracious Vegan, wrote an epically long post about why she abandoned veganism - "Vegan No More". It basically comes down to her health: after going to the doctor and finding out she had a severe vitamin B12 deficiency, with the typical anemia that results, and realizing that her tiredness, lack of stamina during exercise, and depression were all symptoms of B12-deficient anemia, she realized (after many rounds of denial) she had to start moderately eating meat products, or she'd harm herself. Logically, she says, a harmful diet cannot be a natural diet. Therefore humans are not naturally meant to be vegan.

She dramatically writes about the energy she started to feel from eating a normal diet:

At 5 weeks I noticed a steady, permanent buzz of energy that carried me throughout the day. I started being able to run errands, work out, and do my writing ... Joy and the most indescribable sense of relief and tranquility were now just a given when I woke up in the morning. And now, after 2 full months of non-veganism, I can honestly say that I feel reborn.

To put it in clinical terms, she reversed her anemia and probably bolstered her B-vitamin-deprived neurological health immensely.

Vitamin B12 deficiency is very common with a vegan diet. (Don't believe me? Google it; countless vegan nutrition websites acknowledge it.) This is because the only things capable of making B12 are certain microorganisms, and these microorganisms (for our purposes) only live in animals. Plants and animals cannot make B12. Animals, however, depend on it to make blood and DNA and other seemingly necessary things. Therefore, if you are an animal, you must either perform cool feats of digestion like hindgut fermentation (moving food through the colon to generate B12, then regurgitating it back for digestion)...

Bovine digestion is way vegan.

...or you have to eat animals. I can't do hindgut fermentation. Therefore I have to eat animals, or their eggs, or their milk. It's not my fault; it's my ecosystem.

If you're a vegan, you have to take B12 supplements made in factories; since that's a luxury our ancestors didn't have, I'm assuming it's not 'natural'.

Vegans try to manipulate their diet into something resembling a complete human diet, but it doesn't really work. As Tasha said:

I was baffled by the suggestions to eat imported goji berries, use maca powder in my smoothies, or eat more spirulina. All these exotic recommendations were supposedly needed to make me healthy on a diet that is heralded as natural and ideal; it absolutely did not make sense.

But even in simple nutritional terms, veganism fails. All you can eat is beans, veggies, and grains, right? Carbohydrates, indigestible fiber, and incomplete proteins. From what I've seen of oh, probably ten years of hanging around vegans and seeing them eat, it's mostly carbs. Tons and tons of carbs.

Vegan reuben sandwich? Don't shudder, I've eaten one. It's all carbs. Their only protein source is beans and grains. That still maxes you out on carbs, and the protein is incomplete anyway. You need all the amino acids to survive. Plants don't give them. You can, enlisting the help of the last 100 years of food scientists, try to compile a diet of vegetarian sources of most the amino acids and essential nutrients you can normally only get in animal products, but this doesn't seem very 'natural' either.

I only chose to write about this because I've seen more than a few people deteriorate through veganism, becoming unhealthily skinny, almost cachetic, like cancer victims.

Incidentally, it's meat loaf night.

Not this guy.

A Summary of the Illinois Home Birth Safety Act

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Tue, 16 Nov 2010 18:29:00 +0000

Here's a summary of the Home Birth Safety Act (Illinois SB 3712). I meant to write this ages ago; I hope it's not too late for people who want to be informed about this bill! You can read the full text of SB 3712 here.

It legalizes CPMs but establishes the title of Licensed Midwife (LM). You can also call yourself "LM, CPM" if you hold CPM certification. However, see below; it sounds like CPM certification is a requirement for licensure.

Licensure requirements (pp.27-28):

An Associate's degree, either a general degree or nursing or midwifery, including life sciences, biology, and pharmacology.
Complete a 3-5 year midwifery education program approved by the North American Registry of Midwives including "clinical internship"
Pass a written and practical exam
Hold a valid CPM credential

It sounds like existing CPMs could be "grandfathered in" before August 2010, but since the bill didn't pass before then, would that date be moved? Interestingly, no evidence of practice submitted for licensure can be used against midwives if it occurred before the Act legalized such practice (p. 28 lines 9-13) though don't trust me on that, I'd figure it out for yourself before endangering yourself!

Midwives would be enabled / required to (pp.6-7):

give prenatal care and testing according to ACOG guidelines
provide 24 hour on-call availability
provide labor support and supervise delivery
provide postpartum observations until mother and baby are stable, for no less than 2 hours
complete birth certificates
offer metabolic blood screening of the newborn
offer vitamin K injections
offer administration of antibiotic eye ointments (gonorrhea prophylaxis

Medications midwives would be enabled to use, with strict dosing limits written into the bill (pp.8-12):

Oxygen for fetal distress
The aforementioned eye antibiotics (tetracycline and erythromycin)
Oxytocin or Pitocin for postpartum hemorrhage prevention or treatment
Methergine for postpartum hemorrhage
Cytotec for postpartum hemorrhage
Vitamin K
Rhogam
Intravenous fluids (lactated Ringer's solution, which is water with electrolytes) for "maternal stabilization"
Lidocaine injection for local anesthesia for repairing perineal tears
Sterile water injections to the lower back for nonpharmacological pain relief (?? I don't know anything about this!)

Midwives must have a formal relationship with an obstetrician or certified nurse midwife (p.21), including quarterly reviews of client records, but not requiring their presence for clinical care, and must consult with them when needed, such as (pp.13-20):

Pregnancy-induced high blood pressure or persistent severe headaches
Persistent urinary tract infections
Significant vaginal bleeding, not associated with labor or uncomplicated spontaneous abortion
Rupture of membranes before 37 weeks
Notable decrease in fetal movement, or no fetal movement
Anemia (low hemoglobin) that doesn't respond to supplements (i.e. iron, B vitamins?)
Fever > 102 degrees for more than 24 hours, or > 100.6 at delivery
Nonvertex presentation (i.e. not head down) after 38 weeks
Persistent vomiting or dehydration (hyperemesis)
Rh negative sensitization
Elevated blood sugar levels resistant to dietary changes
Positive HIV or genital herpes
Malnutrition
Suspected blood clots (deep vein thrombosis)
Low-lying placenta after 28 weeks
Labor before 37 weeks
Gestation longer than 42 weeks "by reliable confirmed dates" (remember the Day 14 myth!)
Multiple gestation
Prior uterine incisions. Home midwives may attend not attend first-time VBACs but may attend subsequent VBACs. In other words no initial HBAC, home birth after cesarean.
Abnormal ultrasound findings (low fluid, restricted growth, etc)
Failure to void the bladder 6 hours postpartum
Signs of significant maternal depression
Dozens of findings related to the infant, including Apgar < 6 at five minutes, respiratory distress, low birth weight, failure to pass meconium by 48 hours, jaundice, etc.

Consultation does not precluding the possibility of out-of-hospital birth.

Guidelines for emergency transfer to hospital include the emergencies you'd expect, but explicitly delineated (pp. 19-20).

Midwives may NOT (pp. 22-23):

Give prescription medications to induce or augment labor
Use vacuum extractors or forceps
Perform "major surgical procedures" including "abortions, cesarean sections, and circumcision"
Accept primary care for a woman with significant organ system disease, cancer, insulin dependent diabetes, confirmed Rh disease, alcoholism, drug abuse, current serious psychiatric illness, and several other conditions

The seven-member Illinois Midwifery Board will consist of (pp.23-24):

Four CPMs with three years out-of-hospital birth practice
One obstetrician or family practice physician with at least two years out-of-hospital birth practice
One certified nurse midwife with at least two years out-of-hospital practice
One "knowledgeable public member" who has given birth with the assistance of a CPM at home (interesting)

After three years of the passage of this Act, no one may act as or give themselves out to be a home birth midwife without being licensed under this Act. Midwives who are unlicensed but still practice are subject to a civil penalty up to $5,000 in addition to any other penalties under law.

The rest of the bill has to do with administrative issues, how Board membership is managed, and disciplinary actions and license suspection/revokation (nothing seemed out of the ordinary here, basically revolving around people who violate the Act).

The Illinois Home Birth Safety Act - vote tomorrow?

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Tue, 16 Nov 2010 17:16:00 +0000

Thanks to the Unnecessarean for pointing out that the Illinois Home Birth Safety Act (SB 3712) is most likely being called to the floor Wednesday - tomorrow! This bill establishes the recognition of certified professional midwives. 27 US states have CPMs.

Midwives are illegal in states in red.
Image credit: Surachit.

We've had four home births here in Illinois, and we may (believe it or not) have more children someday, so this bill directly affects us. Here's what I think.

I generally support this bill because I think it makes sense. The home is a safe place to have a normal, non-high-risk birth. Normal women can give birth without a physician's manipulation; so it makes sense to allow an educated, informed woman to choose to do so. Hospitals have been repeatedly shown to be not very safe or accomodating places to give birth. On the other hand, these midwives already practice and do good for the community. They've been through extensive training and are often already registered, but they cannot legally perform these services in Illinois (though they can in neighboring states!). By legalizing the practice of home midwives, you're helping women make the legitimate choice to birth at home (which is already their right!) and enabling them to hire a compassionate, knowledgeable birth expert to assist them.

On the other hand, these same midwives are now going to be subject to possibly unnecessary restrictions. For instance, this decade's obstetric community (and the insurance companies who write their paychecks) have swung back to a more paranoid view of breech births and vaginal births after cesareans, with little evidence to do so and while other countries are progressively moving forward on allowing these births to proceed nonsurgically. This law would not allow midwives to attend first-time VBACs, though they can attend subsequent VBACs - so women must try to find a VBAC-friendly obstetrician (good luck with that). Midwives would also have to refer breech presentations to an obstetrician for "consultation" - and what obstetrician is going to approve a home breech birth, when he or she knows that no insurance company would allow them to attend one in the hospital? Home midwives already attend HBACs (home birth after cesarean) and breech births successfully; but they would be disallowed under this new law.

There are other issues, like the fact that your very good (albiet illegal) midwife might not be registered how the state wants them to be; they might not have a general Associate's degree (a relatively arbitrary requirement in addition to all their midwifery training); they might be subject to more stringent reprimands and actions by the midwifery board than an obstetrician would be by the medical board (i.e. women complain all the time about obstetricians and nothing happens to them, but the first complaint by a woman against a CPM would probably be handled severely.)

But generally, I think that the bill is a good one, or at least a step in the right direction.

See also my summary of the Illinois Home Birth Safety Act.

Why You Should Lift Weights (no, really)

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sat, 13 Nov 2010 22:26:00 +0000

Get 15% off nursing shoes with code "shoes_fg"

I've posted previously about how my cholesterol was super high - in the 300's - back in January of 2010. Since I worked in a cardiovascular ICU at the time, I was, shall we say, greatly inspired to get that cholesterol down. I didn't want to be one of our thirty-year-old open heart cases. The main way I could see to do it was to lose some weight and get fit. So my wife and I joined a gym, something the highly unathletic pair of us had never done before (though she at least was an Irish dancer, which certainly burns calories!).

By cardio and diet change alone, I managed to get the weight of my 5'9" frame down from 185 lbs to 174-176 lbs, and my BMI (if you believe in that) from overweight to borderline okay. That was probably over about three or four months of hitting a treadmill 4-5 times a week. I ran a 5k run without even requiring chest compressions on the pavement. I also decreased my caloric intake, sorta counting calories but mostly just eyeballing it. Remember, your weight is directly increased or decreased by calories eaten minus calories burned. That's why the Twinkie diet worked for that nutrition professor; it was a simple trick of restricting ingested calories.

But I feel the real gains (or losses) came with strength training. I felt I had lost a fair amount of fat around my neck, arms, etc, but had plateaued around 175 with a fair chunk of abdominal fat. Adding some basic strength training using only free weights and body weight exercises, I managed (to my surprise) to pretty rapidly drop my weight to 161 lbs. Probably in less than two months. I guided myself using the UC Berkeley Wellness Letter's guide to Building Muscle and Bone - At Home, On Your Own. It's one of the rare internet guides not intended for gullible guys who don't care about health but just want big biceps to pick up chicks. You can "follow" it at home or at the gym. It's not really a program, but a simple guide to some exercises you could do in 20-30 minute intervals 2-3 times a week.

So why does it work? Muscle tissue uses more calories than (inert) fat tissue. So you not only burn some calories during the workout, but you burn more calories on a daily basis. There's less of a need to burn 300-400 calories in 30 hard minutes on a treadmill (which you can then ingest in a burger - or a couple Twinkies!). In fact, I generally find weight training much easier than cardio. Cardio requires significant amounts of stamina and endurance over what is for most people (like me) a long period of time - 20 or 30 minutes at a time or more if you really want to see a change. Weight training is so easy compared to that because it's in short intervals. You can rest whenever you want. There's no time limit - you could do it for 15 minutes and not be wasting your time. There's no strict rules or exercise requirements - you could do a single-exercise program like One Hundred Pushups and start seeing results.

What did you expect? Some dude with ripped abs?

Keep in mind - this isn't bodybuilding, which is (as I understand it) all about aesthetics. Guys who want big arms are essentially bodybuilders, focusing on single areas of the body and worrying about appearances. Men and women of any age who want to increase their overall body strength, or lose weight, or gain healthy weight, or increase bone density, or have less back pain, do strength training and are not bodybuilders. Granted this puts me in the same class as grandmothers doing pool exercises, rather than the dudes doing infinite bicep curls...but at least what the grandmas are doing makes sense!

In a later post I'll talk about the whole-body strength training program I'm using now - stronglifts 5x5. I feel like it's the best one out there. It's really simple, it's logical, I've been able to reduce my cardio time, and best of all it's free.

The Day 14 Myth

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Tue, 02 Nov 2010 15:17:00 +0000

Natural family planning seems to be one of those things many people have heard of, but practically nobody understands except the people who use it. My wife and I have used it, and it hasn't failed us. It's a pretty simple system of fertility awareness. You use simple observations to tell where you are in the menstrual cycle. In fact, once you get the hang of it, it becomes easier to think of the menstrual cycle as what it really is: the ovulation cycle. At least that term makes more sense to me, since it describes the process that's really happening in women's bodies, rather than just the most obvious outward sign of it.

Because it's fertility awareness, it can be used both to avoid and to achieve pregnancy. Or it can be used simply to know what's going on. In fact, both the simplicity and the many practical uses of it make one wonder why nobody uses it in modern healthcare.

Consider the woman who has an "abnormally" long cycle, longer than the textbook 28 days. If she's concerned about this and mentions it to her doctor, she'll likely get put on birth control pills. But birth control pills just produce a fake cycle; it stops everything your body is doing, and once a month you take fake pills which let you bleed something like a menstruation. Why is the doctor so concerned with a 28 day rigidity? There's nothing wrong with the woman. The only benefit I can see is the assurance you won't "randomly" get pregnant or have your period, which you can tell without pharmaceuticals by using fertility awareness. That's because, "irregularity" aside, nobody has a random cycle.

Or say she wants to get pregnant. She'll be referred to a fertility specialist who will also, bizarrely, presume a 28 day cycle. Her hormone levels and other factors will be checked around when she's supposed to be ovulating, to see if everything is working correctly. Unfortunately, to most doctors, she's supposed to be ovulating on Day 14 after her last period. Since this might be nowhere near when she's really ovulating, her results be inaccurate, and further medical decisions will be made based on wrong information.

Or say she does get pregnant. She'll go to an obstetrician and be asked about her last menstrual period. Then her due date will be calculated using a simple wheel device, tacking on an extra two weeks to account for the two weeks between textbook period and ovulation. Except what if she ovulated three or four weeks after her period? Her due date could be set weeks early, leading to unnecessary tests, or induced labor for being "late," and a premature underweight baby. In fact, if you use fertility awareness and know when you conceived, some people advise "fooling" your standard-issue obstetrician by making up your own LMP date two weeks before you conceived just so you have an accurate due date!

All of these misguided medical judgments (can I say medical errors?) are based on a bizarre myth: that the standard woman ovulates on Day 14 of her cycle. There's no scientific basis for this. Even if it is common, it's not nearly common enough to be applied to all women.

Even though these physicians all studied and can presumably remember how the whole female reproductive cycle works, how follicle-stimulating hormone and luteinizing hormone are produced by a woman's pituitary gland, how estrogen and progestin shift, how the uterine lining depends on these hormones to grow and shed, how cellular miosis occurs and how a woman's haploid gametes form, how an egg is produced and travels and is fertilized, how the corpus luteum and early placenta produce hormones to sustain a pregnancy; even though they know all this, they presume a Day 14 ovulation and take a chance at throwing all their real-world clinical judgments off. Little of that textbook knowledge matters if you base your real clinical decision-making on a myth.

Guess the unscientific portion of this menstrual cycle diagram.

I suspect that part of the problem with using fertility awareness in modern medicine is that it requires significant time devoted to teaching and answering questions (prescribing the Pill is much quicker, and I doubt physicians are reimbursed for teaching fertility awareness), and that it depends on the woman observing and tracking herself, and not the physician or the labs.

If you've experienced this, please comment and share your story. And if you've seen the opposite, doctors and other clinicians who don't presume a Day 14 ovulation or who know anything at all about fertility awareness, please share their stories as well. It would certainly be heartening.

Don't worry, I won't be wearing this costume.

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sun, 31 Oct 2010 12:20:00 +0000

Happy Halloween!!

OMGWTFBBQFDA!!1! Hyland's Teething Tablets R Poison!!

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Wed, 27 Oct 2010 01:06:00 +0000

Three days ago the Food and Drug Administration issued a warning to parents to stop using a benign over the counter product which we've used with our kids a dozen times at least: Hyland's Teething Tablets. The same day Hyland's issued a voluntary recall. The tiny dissolve-in-your-mouth pills contain minute amounts of belladonna, a plant that's been used medicinally for centuries for its antiinflammatory and antispasmodic effects. It is a natural product, but in reality it does contain drugs used in Real Modern Western Medicine^TM, chiefly atropine and scopalamine.

Both of these drugs are used in varying amounts in real medicine because they are potent anticholinergics. Indeed atropine is the typical drug of this class, and the WHO lists it as one of the few basic necessary medicines needed for an adequate healthcare system. Millions of people are prescribed atropine to control bladder or gastrointestinal spasms; we use it in mega high concentrations in resuscitation efforts because it makes your heart beat faster. So you can see they are serious drugs - when purified and used in concentrations more than a thousand times that used in Hyland's Teething Tablets. It is very possible to give yourself belladonna poisoning, but I would imagine most children would have to eat at least a bottle or several bottles to achieve even the milder adverse effects.

Ironically the dose is low enough that if Hyland's was advertising that their product contained atropine, the FDA and normal medical practitioners would probably be claiming that they're nothing more than sugar pills.

Despite the well-established nature of atropine, and the fact that the "homeopathic" dose is something like a thousand times less than any medicinal use, this is how the FDA chose to inform the public about the drug:

Belladonna is commonly known as Deadly Nightshade. It is a plant whose leaves and berries are extremely toxic. Belladonna has been used as both a poison and a medicine throughout history.

Acting more like it's a medieval poison than a modern medicine.

The FDA isn't saying what symptoms they received reports of, or how many occurrences. On the other hand, you can readily find dozens of real-parent reviews of Hyland's Teething Tablets, or look over the Facebook fan page for more accolades. No reports of adverse effects are easily found online; let me know if you come across any.

It's just dumb. Dumb, dumb, dumb. This product is so benign it's not even funny. I'm sure this is chiefly based on the fact that belladonna, used as a plant-based ingredient, contains recognized drugs, but is not a purified or easily measurable form of the molecular drug compounds. The FDA would probably happily recognize and study Hyland's Teething Tablets if they were purified prescription drugs manufactured by Big Pharma. But they're not, nor do they need to be, and Hyland's probably doesn't have the resources to begin processing like a big pharmaceutical company. So the FDA will just wear them away.

Ironically the FDA action and recall led to the product selling out on Amazon.com. My wife knows someone who just ran around town and purchased 25 bottles.

"The Fading Art of The Physical Exam"

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sun, 24 Oct 2010 13:58:00 +0000

NPR just ran a piece on how physicians aren't examining patients anymore. It's true, even in an environment like the intensive care unit where small details can make or break you. When a physician follows a patient in the ICU, or even on the general floors, they typically don't do daily evaluations. It's even rare to see them use their stethoscope. Rather, they depend on the nursing assessments. They assume that the nurses would tell them if anything is amiss.

Of course, the piece centers on how diagnostic testing is replacing physical examination. Diagnostic testing is a little more glamorous and newsworthy - it's expensive, technological, and sexy.

"We're now often doing expensive tests, where in the past a physical exam would have given you the same information," says Jason Wasfy, a cardiologist-in-training at Massachusetts General Hospital in Boston.

As a result, many doctors are abbreviating the time-honored physical exam — or even skipping it altogether.

The missing piece is that patients aren't being taken care of by expensive testing. The radiology department does not follow your patient for you on a daily or hourly basis. The time-honored physical exam is skipped partly because you can just run tests instead, but mostly because nurses are during frequent assessments.
Doctors can't auscultate chests as well as they used to because they can just look at a chest x-ray instead, but also because the nurse is going to report on any problems with their oxygenation status, with their breathing efforts, with how their lungs sound, and with what treatments are working or not working.

In fact, the situation is a little ironic: because nurses can be sued for not telling the doctor pertinent information, and because doctors can (and do) defend against lawsuits by claiming nurses did not tell them what they needed to know, doctors can safely assume that nurses are evaluating their patients for them.
I know, that's just more physician-bashing. Well, not really. I actually don't mind that they trust our assessment skills and our judgment. We're with the patient all day long, and they have forty patients to see that day, so they need to listen to us.

What about when the doctors sees you directly in the office? The article goes on to claim that "Even when doctors go through the motions of doing a physical, their diagnostic skills aren't what they used to be" and refers to a test where doctors missed a large number of defective heart sounds. I think this is because physicians receive their training in the hospital, where they can, as I said, rely with the nurse's assessments and diagnostic tests to do their evaluations for them. It still goes back to the hospital nurses.

Like I said, I like the autonomy and authority this gives to the RN. And if the news isn't aware of it, that's fine. But I have to admit it's a little worrisome. If you don't have a thorough nurse, and your physician just glances in at you and reviews the chart, then something could be missed until it causes such a big problem nobody can overlook it.

The fact that your healthcare system can't "waste" the expensive time of physicians on general physical exams for everybody means that it needs really, really good nurses.

An Ode to Certified Nurse's Aides

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sun, 17 Oct 2010 14:15:00 +0000

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When I worked at a nursing home as a nurse's aide, I realized something that seemed so obvious yet I've never heard anyone talk about it. I realized that the basic functional unit of a nursing home is the nurse's aide, the certified nursing assistant. CNAs are why they build nursing homes. Sure, there are nurses, but their main job is med passing--being in charge of, say, thirty patients at once. That makes them more like ancillary staff, like the occupational therapists. The reason people go to (or, er, are put into) nursing homes to help with their activities of daily living, when they can't bathe, eat, or toilet themselves. It's not a glamorous job, but people in the United States typically don't want to do this themselves. Whatever. The point is, the basic unit of the nursing home is the certified nursing assistant. And your CNAs will, for better or worse (and trust me, there are worse!), have the most impact on your nursing home experience. I don't think people realize that, or care. That's probably a function of the throw-away nature of the nursing home: in general, people get disposed of there until they die.

I always wanted to write a book about my nursing home experiences. First of all, it's sort of like a prison. Some people go to stay as permanent inmates, and others (the post-hospital rehabilitation patients, if your nursing home has them) will get discharged. People are there for all sorts of reasons: permanent debilitation, temporary rehab, even simple reasons like IV medications. On the same day, in the same hallway, there would be some people sitting in wheelchairs, screaming and talking gibberish, and a young guy getting treatment for AIDS walking among them. The same room (two beds to a room, of course) would have a old long-term resident in Bed 1 who can't walk and needs two people to get him into the wheelchair or onto the commode, and a young construction worker with broken legs in Bed 2 who needs the same exact assistance.

I remember an older woman who loved seeing pictures of my baby (wow, I just said "baby" singular - I only had one at the time!). She was so friendly and perpetually sat in her wheelchair by the front door to greet people. Never saw her family...until she died, when they came out and filled the room and spilled out into the hallway. She was completely comatose and breathing agonally and some young kid was playing guitar for her. I'm like...she probably would've liked this back when, you know, she was conscious.

There are so many other stories. Someday I'll dig around in my brain and come up with all of them.

Also, Dirty Jobs with Mike Rowe should visit a nursing home. But somehow I don't think even that show could go that far.

Gimme your assessment in five words or less!

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Fri, 01 Oct 2010 19:02:00 +0000

I do a thorough neurological assessment on this very sick but awake and responsive patient who just suddenly stopped answering my questions, stopped following commands, stopped showing any cognition of their environment at all. No response to shouting, shaking, or sternal rub. No eye focusing or tracking. Still had their reflexes intact (pupils, cough, gag, corneals), still responded to painful stimuli (i.e. withdrew hands and feet to light nailbed pressure) but kind of an absent stare and a shaky hand - absent seizures maybe? They were pooping out on the ventilator, too - is it respiratory? A metabolic condition? What's going on?

I think this is a pretty decent assessment. I tell all this to the night shift resident. They walk in, gently prod the patient and try to converse with them and fail, and call the intensivist at home, and all my assessment work gets distilled down to: "Yeah, um, the nurse thinks this patient is kinda more out of it than they usually are...what do you think?"

Thanks, I coulda done that!! "More out of it than they usually are." I had to laugh. I know the intensivist is an intelligent person who knows this patient well, so they can put the pieces together even with scant info, but I did want to pull the phone away and talk to the doctor for real. I hope when the docs get these calls from residents they don't think we're the ones not using our brains.

Not that I'm mad at this resident! I'll take a resident who listens and isn't afraid to ask their higher-ups over the ones who just shrug everything off when they don't know what to do!

Anyway, we drew a blood gas analysis and adjusted the vent settings, and the patient eventually perked up and started responding again.