What in fact does a nurse use a stethoscope for?

Daytime television isn’t historically the best place to educate thyself, but isn’t this “The View” moment a great opportunity to explain to our patients what we do as nurses?

So far as I can tell, a lot of everything pretty much everywhere. “Nurse” covers a heap of credentials, too. It may be the CNA or Certified Nursing Assistant who takes your vitals (may use stethoscope!) and assists you in getting fed and staying clean and comfortable in the hospital. It could be the RN or Registered Nurse who dresses your wounds, asks about your pain, listens to your lungs, and behind the scenes communicates how you’re doing to the doctor– including a recommendation for action–and, god love him or her, gets you that pain med you desperately need. And you know what? It may be that the RN who asks about your pain is communicating with an APRN or Advanced Practice Registered Nurse instead of a doctor to get you the proper medicine (Nurse Practitioners, Certified Registered Nurse Anesthetists, and Certified Nurse Midwives fall under the APRN heading and may prescribe medication).

The funny thing about a nurse is that no matter what their title/education/credentials, if it’s within scope of practice, they will take care of patient needs. I’ve seen APRNs change soiled beds. I get care from an NP who has spent hours corralling my records from various specialists in various health systems. (She waited on hold with patient records for me. I love her.) Does the patient need it to receive quality care? Is anyone else taking care of it? Nurses are get it done people.The pros and cons of weakly defined roles and challenges of delegation are a topic for another day. One with less post-surgical morphine, perhaps.

I actually got a cardiologist’s stethoscope for graduation. I’m fancy. When I planned on working in a Neuro Intensive Care Unit I knew it would be useful for my newbie ears when it came to hearing bruits in patients’ carotid arteries. When I start work as a community nurse visiting homes of pregnant women, one thing I’ll use it for is getting an accurate blood pressure to check for signs of preeclampsia. Early detection of high blood pressure in a pregnant woman can save her life and the life of her baby, so I best show up with my tools. She depends on me. Her doctor or midwife does too.

I use a stethoscope since it’s a valuable part of the medical trade. Just like me. Simple as that, really.

Poetry Monday

Saturday I had the pleasure of listening to Margaret Mohrmann give the keynote at the UVA’s End-of-Life conference. Blow. Me. Back. The weight of the subject matter and her nimble language. The stories steeped in years of experience ecclesiastical and medical. Is frank compassion a thing? I think it may be her thing. One of the two times she made me well up (for my patients, for my loved ones, for me, for my fellow RNs & MDs, for humanity):

A Blessing for a Friend on the Arrival of Illness
by John O’Donohue

Now is the time of dark invitation
beyond a frontier that you did not expect.
Abruptly your old life seems distant.
You barely noticed how each day opened
a path through fields never questioned
yet expected deep down to hold treasure.

Now your time on earth becomes full of threat.
Before your eyes your future shrinks.
You lived absorbed in the day to day so continuous
with everything around you that you could forget
you were separate.

Now this dark companion has come between you.
Distances have opened in your eyes.
You feel that against your will
A stranger has married your heart.
Nothing before has made you feel so isolated
and lost.

When the reverberations of shock subside in you,
may grace come to restore you to balance.
May it shape a new space in your heart
to embrace this illness as a teacher
who has come to open your life to new worlds.
May you find in yourself a courageous hospitality
towards what is difficult, painful and unknown.

May you use this illness as a lantern
to illuminate the new qualities that will emerge in you.
May your fragile harvesting of this slow light help you
release whatever has become false in you.
May you trust this light to clear a path
through all the fog of old unease and anxiety
until you feel a rising within you,
a tranquility profound enough to call the storm to stillness.

May you find the wisdom to listen to your illness,
ask it why it came,
why it chose your friendship,
where it wants to take you,
what it wants you to know,
what quality of space it wants to create in you,
what you need to learn to become more fully yourself,
that your presence may shine in the world.

May you keep faith with your body,
learning to see it as a holy sanctuary
which can bring this night wound
gradually towards the healing and freedom of dawn.

Health Policy Quiz

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So I’m working up the guts to post a statement of benefits that will help show the calculus that goes into medical billing. As I’m finding the courage, take these two super-fun health policy quizzes! It’s like Jeopardy but the only category is health policy! IS THIS HEAVEN?!

International health policy quiz

Medicaid quiz

Final Jeopardy: The Medicare program was signed into law by this president. (Hint: to answer this question you must know the difference between Medicare and Medicaid, study up!).

You are so welcome.

<3

CDC Recommends Antiviral Drugs For At-Risk Patients : NPR

CDC Recommends Antiviral Drugs For At-Risk Patients : NPR.

The flu is awful this year. I’m in the bathroom washing my child’s hands all Lady Macbeth the second he gets home from school. In this interview Tom Freiden, Director of the CDC, explains plainly why the flu is so bad right now and why people who have gotten the flu shot are still getting sick. He also talks about antiviral use in flu patients.

I’m concerned for public health and the future success of flu shot campaigns. The strain that is infecting people despite vaccination was chosen for the vaccine, but between it’s selection and the beginning of our flu season it mutated. ARGH. This wasn’t a failure on the part of the CDC but it will lose them good faith in a year where we already had our eyes set to roll at their very next press release. So now add to the giant list of reasons people won’t get their flu shot “they messed it up last year.” Which is bad for community immunity.

Below, data for health districts reporting in VA (two weeks old). The red is the sub-type of flu the vaccine does not cover.

flu data
http://www.vdh.virginia.gov/Epidemiology/flu/WklyPhysReport.pdf

Knowledge cures ignorance so here is the back story of the flu vaccine and why this year was a one-off to convince you to please get your flu shot next year, too:

How are the viruses selected to make flu vaccine?

The influenza (flu) viruses selected for inclusion in the seasonal flu vaccines are updated each year based on which influenza virus strains are circulating, how they are spreading, and how well current vaccine strains protect against newly identified strains. Currently, 141 national influenza centers in 111 countries conduct year-round surveillance for influenza and study influenza disease trends. These laboratories also send influenza viruses to the five World Health Organization (WHO) Collaborating Centers for Reference and Research on Influenza located in Atlanta, Georgia, USA (Centers for Disease Control and Prevention, CDC); London, United Kingdom (National Institute for Medical Research); Melbourne, Australia (Victoria Infectious Diseases Reference Laboratory); Tokyo, Japan (National Institute for Infectious Diseases); and Beijing, China (National Institute for Viral Disease Control and Prevention) for additional analyses.

The influenza viruses in the seasonal flu vaccine are selected each year based on surveillance-based forecasts about what viruses are most likely to cause illness in the coming season. WHO recommends specific vaccine viruses for inclusion in influenza vaccines, but then each individual country makes their own decision for which strains should be included in influenza vaccines licensed in their country. In the United States, the U.S. Food and Drug Administration (FDA) determines which vaccine viruses will be used in U.S.—licensed vaccines.

BBC Radio 4 The Future of Medicine – Dr Atul Gawande – 2014 Reith Lectures

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BBC Radio 4 – The Reith Lectures, Dr Atul Gawande: The Future of Medicine – Dr Atul Gawande – 2014 Reith Lectures.

Gleaned from these lectures, questions IMO we should ask all patients. At least once a day for those in the hospital:

“What is your understanding of where you are with your condition or your illness at this time?” “What are your fears and worries…”…“What outcomes would be unacceptable to you?”And with that, they’ve told you their priorities and what they care about and then that tells you both where the bright lines are that you do not cross and what you might actually be aiming for.

I enjoyed so much being stuck in traffic listening to these lectures this week. Gawande, my mentor who doesn’t know he is my mentor, pulls from previous works and his most recent book “Being Mortal,” which covers the medicalization of dying and offers suggestions to bend the system to favor better communication between providers and patients, supporting meaningful living through old age and, hopefully later rather than sooner, an end to life that is most agreeable to the dying person.

I recommend this book people who have parents and loved ones moving into their later 60s, as it kindles the kind of conversations that are much better had over a beer or some tea and biscuits (my dad and mom respectively) than in a hospital room. I promise you it is worth the work now to know what your loved ones want. When they are incapacitated the weight of decision making will fall to you.

I had a loving adult son, flown in from Florida, standing with me in the doorway of his critically ill father’s ICU room the other week. He told me his dad had never been sick a day in his life. He said they knew something would happen some day, but they just didn’t want to think about it.

In truth though enjoy the lectures. Gawande is uplifting and so so logical, a great story teller to boot. One day I will grab the podium and sound like that. Right now it would come out LISTEN TO ME AND FIX IT FIX IT FIX IT. Lacks maturity.

Big Hero 6, starring a nurse, tears of sad and tears of happy.

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I don’t advise anyone to have children (period, cause that’s none of my business) but if I did my first pro argument would be the super children’s movies out there. This week we took my son to see Big Hero 6. It was the greatest. Baymax the robot, main character, IS A NURSE and the best thing to happen to nursing since Flo hit the Crimea. That might be an exaggeration. Baymax assesses his patient, provides excellent pain control, recommends evidence based treatment, does education, and is unable to deactivate until his patient states that they are satisfied with their care. He also wields the defibrillator with his own two stubs (no hands), a tip off that it’s your RN and not your MD who is most likely to analyze your cardiac arrest and defibrillate.

The writers make Baymax a nurse and not a doctor. Not what we’re used to seeing, right? The movie takes place in futuristic San Fransokyo where there is a melding of American and Pan-Asian culture (similar to Joss Whedon’s Firefly and Gary Shteyngart’s Super Sad True Love Story). Over the years I’ve heard of the looming caregiver shortage in Japan. I dug up this 2009 NPR piece about robot caregivers for the elderly. So, naturally, I’m thinking this movie with it Manga-ish style about robot caregivers has got to have roots in Japan. This is the best I could come up with on my internet search: the movie is “loosely based” on a Japanese comic strip of the same name. By way of Marvel, by way of Disney. I looked into Japanese nursing to see what they might be doing differently to achieve a public image that is more congruent with the work we do than anything we see in American media. From my cursory glance it appears the title of nurse requires more education (for RN min two years in America, min 3-4 in Japan). Also, public health nurses and midwives have much more defined roles and are a feature of the daily lives of citizens. Nurses are decoupled from the elbows of doctors–true in American practice as well, but not as visible.

If we want to be Eeyores about it, we can see this movie as another in a long line where jobs of less value are relegated to robots (WALL-E, Star Wars, help me out nerds…). Okay, maybe. BUT in his last act which I will not spoil because if you have a heart in your chest it will make you cry, I would argue that Baymax is sentient, nulling that sad hypothesis. He is a nurse super hero movie star. AND THE PEOPLE (well, just me) IN THE MOVIE THEATER REJOICED!

This was a great movie to see with my kid for 10,000 reasons. So have kids or not but see this movie. Then you better recognize that this nurse right here is an autonomous and patient-centered ass-kicking machine.

Where is my mind?

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I have really enjoyed dropping off the face of the earth for a few days. The academic schedule suits my glutton-for-punishment alternating with complete and total slacker personality. Of course I can be as maniacal at slacking as I am at work. Over the past week I read a 700 page novel in time to have a meeting of the introverts’ book club. You know–two people at a bar who read the same book. Reading a beautiful novel that has nothing to do with health care then going to a bar, an entirely selfish act for a wife and mother, is my best shot at spiritual renewal.

Early in graduate school our class was introduced to a mindfulness curriculum. It intends to create embodied, resilient, and compassionate providers. Man, I thought, this nonsense is going to burn off like so much morning fog. Then came the infamous mindfulness retreat. There was gentle yoga and meditation to the sounds of jungle rain. No wait that was just me crying uncontrollably. Mindfulness:1, Melissa: 0.

fetal-position-550x550

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I was not ready for mindfulness. It is powerful medicine. What was wrong with my foremothers’ ways of coping with life’s ups and downs? Beating carpets, aggressive scrubbing, tea.

Complementary and alternative medicine (CAM) is a booming area of research. What interests me is finding the best way to provide access to the modalities, germane to many folks aren’t hanging out on Maslow’s lowest 2 or 3 spots, to people who are unfamiliar with CAM and have a list as long as my arm of more immediate food-shelter-safety concerns. The people at Common Ground Healing Arts are making some impressive forays, working in public housing projects and a prison, and showing good results in terms of better controlled diabetes and lowered BPs. I came to them last winter with a note from the cancer center and they took care of my penniless self, too. I want to talk to them about their work. I kind of love them.

So to review, meditation/yoga/acupuncture, the whole package, is a significant thing. I buy it okay, I’m on board. I’m just not all the way ready. So practitioners please be aware that efforts to induce mindfulness may create a paradoxical reaction. Also, it’s okay if your way of clinging to mental health like hang in there kitty is reading a big book, drinking three fingers of whiskey, and talking to your friend about this beautiful line of prose, did you catch that leitmotif, and oh the point is that half of love is yearning.

Happy holidays all, do your thing to get restored.

Interlude

Y’all,

I’ve lived nearly all my adult life in rural Virginia. I’ve tried to leave it and do something shinier with my life, to no avail. It calls me back. As I hone in on where I want my practice to go I’m more and more certain that health care access and preventative care issues among rural people, especial rural black people, is my dissertation in waiting.

And as much as I complain about the year round life-size outdoor nativity set down the road and the absurd number of sheds people have and the omnipresent target rounds being fired, I can’t imaging a life without my incomprehensible neighbors (who btw think I’m a space alien. Running at night down my unlit road with a headlamp confirms that suspicion). I’ve got a great post brewing about how my tiny county has managed, by being so indisputably red and according to a poll of bumper stickers having only two political issues (out of my cold dead hands and NOBAMA), to create progressive local educational and health care initiatives. When no one has to prove their redness, a space opens up for common sense arguments.

I am a physical wreck by the end of my semester and trying to get a tree up and make the Christmas magic happen for my lovely kid, so this make take a day or two. In the meantime enjoy this picture of my doc’s patient room. DISCLAIMER: This is the best PCP I’ve ever had. Hands down.

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Now everyone feels bad about the pies.

(Image from CDC)

Happy day after Thanksgiving. Now that we’re all in regret mode, diabetes! This is a slow-motion public health train wreck, amiright? And it’s another marker of race disparity in health… but I’ll save that for another day.

Diagnostic for diabetesHemoglobin A1C>=6.5 OR 8 hour fasting plasma glucose of >= 126 mg/dl OR oral glucose tolerance test of >= 200 mg/dl OR random plasma glucose of >=200 mg/dl.

Super user-friendly.

So diabetes is a clear medical diagnosis to make, but telling someone with a fasting blood sugar of 120 that they do not have diabetes is the wrong message. You either have HIV or you don’t. Diabetes is a disease on a continuum. Even with moderately high sugars the vessels of the fingers and toes and heart are getting damaged. The delicate vasculature of kidneys and eyes is getting all junked up, and pancreas… oh poor pancreas you will never be the same.

So it would make sense to do some intensive nutrition education for people that fall into that pre-diabetic category, you know, maybe keep them from become full-blown diabetic? As it stands, Medicare does not reimburse (pay for) nutrition consults until you have the official diagnosis of diabetes. So we are giving nutrition education to people in the hospital after they have had their toes amputated, between debridements of wounds that won’t heal, and in dialysis while they wait for a kidney transplant. These are miserable, life-limiting procedures. All of which are way pricier than some front-end nutrition education. And the cost of diabetes has increased 41% over the past 5 years.

My mom falls into the pre-diabetes category. I write little lists and send texts and talk to her on the phone about how she is managing a blood sugar that is next door neighbors with diabetes. Based on my very limited knowledge of nutrition (nursing schools could really fortify this part of our education), here are some of tips I’ve given her: First, 5 a day, lots of fiber, and minimal processed foods. Look for added sugar in all all foods, especially processed. If a product is labeled low or non fat, you can assume that they replaced that fat with sugar. Check the label. Also, exercise helps your cells metabolize sugar, bringing down your blood sugar. Even if you don’t lose pounds. What else can I do? I’m genuinely asking.

Open Access. For journals. For everything.

The journals that publish those papers are, in many cases, for-profit institutions — and they prefer charging for access.

via The Gates Foundation pushes to make more academic research free and open to the public – Vox.

The (TAXPAYER FUNDED) National Institutes of Health, which spends about $30 billion yearly on medical research, began in 2008 requiring that research studies it funds be made open access a minimum of one year after publication. The Gates Foundation now requires that publication of the research it funds be openly accessible by the public starting now and for, like, ever–meaning that publishing in big brand name subscription-only journals might be off the table. This puts pressure on those journals to provide open access. HOORAY! Science evolves!

At the moment clinical research is the area of study least likely area to be open access. The community hospital I work at provides its clinicians no scholarly resources. My school bestie and I our putting our thesis where our mouth is by choosing to study and promote access to clinical resources for staff nurses…despite being told by every adviser we have that it’s a bad idea. We may (probably will) go down in flames, but sometimes the amount of push-back you get is proportional to how right you are.

Ethical problems crop up in establishments that sustain themselves by limiting access. Closed institutions embolden those with access to manipulate those without, provide a nice incubated broth for corruption, weaken the rigor of their founding principles, and encourage opacity to protect against anything that might devalue access.

Am I talking about academia? The journal Nature? Fraternities?

If you opt for open access and promote a culture of transparency you’ll get two things: 1.) Diffusion of knowledge making fertile ground for creativity and innovation, 2.) Confronted with the fact that there’s a lot of bad wood underneath the veneer. Which is the first step in getting that rotten stuff out of there.