All posts by Alyson D

09May/17

Pins and Circumstance

I don’t think there’s been a day where I haven’t thought about graduation this semester. TWO DAYS LEFT! My eyes have pored over page after page of disease processes, treatments and research and my hands have discovered a new dexterity at the bedside. Beyond theory, nursing school has given me a new perspective on people, cultures and a new approach to solve problems and challenges. I’ve gained a new confidence in my identity as a nurse and individual but was also humbled by the realization of my weaknesses and knowing that I’ll never know everything! Nevertheless, knowing that the knowledge and possibilities in this field are boundless is exciting. I’ve been researching a few organizations and I see myself working in the public health sector in the very near future. I don’t know where or when, but that’s part of the fun. I’m grateful for the friends, instructors and even family that I have formed new or renewed relationships with. God has blessed me with so much support! I know that God has plans for me and I don’t want to forget that he has brought me to this point for His glory!

…Goodbye ugly white shoes!

29Apr/17

There’s a certain Slant of Light

There’s a certain Slant of light,

Winter Afternoons –

That oppresses, like the Heft

Of Cathedral Tunes –

 

Heavenly Hurt, it gives us –

We can find no scar,

But internal difference –

Where the Meanings, are –

 

None may teach it – Any –

‘Tis the seal Despair –

An imperial affliction

Sent us of the Air –

 

When it comes, the Landscape listens –

Shadows – hold their breath –

When it goes, ’tis like the Distance

On the look of Death –

There’s a certain Slant of light, (320)

BY EMILY DICKINSON

Image from http://images6.fanpop.com/image/photos/36000000/Emily-Dickinson-image-emily-dickinson-36077093-900-727.jpg

Bring up end-of-life care to a family and you’ll be needing a knife to cut through the tension when you return to the room. As I’ve witnessed in the clinical setting, death is a sensitive subject but one mostly surrounded by ambiguity. People just don’t know what to do with it. It’s become a casual subject in my family. My mother has made it clear that she wants a DNR and her remains cremated after organ donation (assuming she’s a candidate) so that her ashes can be scattered on the hillside behind our house. There may be a few barriers to the latter part of her will… Sometimes these conversations turn into a joke. We don’t think death is trivial, but we also don’t think we have to fear it. My parents organized the logistics to prepare me and my siblings financially, emotionally and spiritually for the day they would leave this earth to be with Jesus. I think starting this conversation early can help reduce the discomfort of this difficult reality.

According to Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families A Multicenter Survey of Clinicians, nurses, residents and staff physicians identified the following as the greatest barriers to end-of-life goals and discussions: 1) family members’ or patients’ difficulty accepting a poor prognosis, 2) family members’ or patients’ difficulty understanding the limitations and complications of life-sustaining treatments, 3) disagreement among family members about goals of care, and 4) patients’ incapacity to make goals of care decisions (You et al., 2015). In addition, all three clinician groups perceived that it was part of their professional responsibility to participate in end-of-life discussions and goal setting (You et al., 2015). However, “staff physicians and residents were more willing than nurses, and staff physicians more willing than residents, to engage in communication and decision making about goals of care” (You et al., 2015). This study suggests an emphasis on helping clinicians improve communication about end-of-life care through training and classes, however, there were also reports of “discomfort in responding to the emotional reactions of patients” (You et al., 2015). Perhaps, it would also be beneficial to emphasize the psychological components related to these discussions to anticipate associated repercussions such as stress, guilt and emphatic fatigue. Early preparation is key in successfully and effectively achieving end-of-life goals and increasing quality of life as the patient transitions out of this life.

References

Dickinson, E. (1999). There’s a certain Slant of light, (320). Retrieved April 29, 2017, from https://www.poetryfoundation.org/poems-and-poets/poems/detail/45723
You JJ, Downar J, Fowler RA, Lamontagne F, Ma IWY, Jayaraman D, Kryworuchko J, Strachan PH, Ilan R, Nijjar AP, Neary J, Shik J, Brazil K, Patel A, Wiebe K, Albert M, Palepu A, Nouvet E, des Ordons AR, Sharma N, Abdul-Razzak A, Jiang X, Day A, Heyland DK, for the Canadian Researchers at the End of Life Network (CARENET). Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their FamiliesA Multicenter Survey of Clinicians. JAMA Intern Med. 2015;175(4):549-556. doi:10.1001/jamainternmed.2014.7732

 

13Apr/17

Pray for Paris

Image from http://www.cnn.com/2015/11/13/europe/paris-attacks-at-a-glance/

On November 13th between 9:20pm to 12:20am November 14th suicide bombers and men armed with assault rifles attacked 6 different locations in Paris: a soccer stadium, a concert auditorium and various cafes crowded with locals and tourists during a Friday evening. Paris was well prepared for this disaster. The Assistance Publique-Hôpitaux de Paris (APHP) mobilized the “White Plan” which resulted in the rapid response of emergency medical services and the APHP crisis unit. The APHP crisis unit is the largest of its kind in Europe with a collaboration between 40 hospitals, 100,000 health professionals, a capacity of 22,000 beds, and 200 operating rooms (Hirsch, 2015). To address the possibility of a large influx of wounded, 2 additional hospitals in the crisis unit would serve as extensions. However, there was no need to utilize the 2 extension hospitals. The APHP also recognized the need for psychological care and had a team of psychiatrists, psychologists, nurses, and volunteers to provide support at Hôtel Dieu in central Paris (Hirsch, 2015).

The types of trauma care that would have been provided were gunshot wounds, lacerations and penetration from debris, hemodynamic shock, skeletal fractures and blunt trauma. An “injury” I did not realize would be a problem was heart attack (Hirsch, 2015). Care would also have needed to address psychological trauma, anxiety and stress. As a healthcare provider during that event, triage skills would be crucial in recognizing which people were the most injured and who had the highest chance of survival. In addition, a healthcare provider would need to initiate the ABCDE assessment and intervention strategy, recognizing that prehospital care and the “Golden Hour” are important in achieving good patient outcomes. Socioeconomics and environment made a positive impact on outcome. Paris is a city in a well-developed country which had the benefit of access to multiple resources, well-trained professionals and updated technology. Paris is also a large city, generally a location that would contain a greater concentration of healthcare resources, first responders and law enforcement. The APHP was able to maximize the capabilities of these agencies.

Image from http://www.cnn.com/2015/11/13/europe/paris-attacks-at-a-glance/

Although the “White Plan” was largely successful, it was not perfect. Some of the disaster sites experienced problems such as a shortage of stretchers and not enough tactical [on-site] physicians for the number of casualties. The “exclusion zone” was also a barrier to care; the danger zone in which explosives are a threat to those within (Service, 2015). Access to the “exclusion zone” was given to the French police counter-terrorism team and tactical physicians but not conventional prehospital health workers. Although this policy made the safety of healthcare workers a priority, it would delay the treatment of victims to some extent.

Image from http://www.cnn.com/2015/12/08/europe/2015-paris-terror-attacks-fast-facts/

Although it was the pilot execution, Paris seemed to be well prepared for this disaster with the successful execution of the “White Plan.” The “Plan” was developed 20 years prior and during the time of the terrorist attacks, the healthcare workers who responded had completed recent education and updating on emergency response and planning. These healthcare workers were experienced with crisis situations and were long-time colleagues. This highlights the importance of teamwork and collaboration. As a result of the current political climate of the globe and the prevalence of terror attacks worldwide, Paris, an iconic and densely populated city, anticipated the possibility of experiencing terror attacks. It can be assured that future disasters will be handled with efficiency, organization and speed. In the U.S., terrorism is addressed by agencies such as Metropolitan Medical Response System (MMRS), the Public Health Emergency Preparedness (PHEP) program, managed by CDC, and Hospital Preparedness Program (HPP), managed by the United States Department of Health and Human Services (HHS) (U., 2017).

References
2015 Paris Terror Attacks Fast Facts. (2016, November 30). Retrieved April 12, 2017, from http://www.cnn.com/2015/12/08/europe/2015-paris-terror-attacks-fast-facts/
Hirsch, M., Carli, P., Nizard, R., Riou, B., Baroudjian, B., Baubet, T., . . . Lafont, A. (2015). The medical response to multisite terrorist attacks in Paris. The Lancet,386(10012), 2535-2538. doi:10.1016/s0140-6736(15)01063-6
Service Médical du RAID. (2015). Tactical emergency medicine: lessons from Paris marauding terrorist attack. Critical Care20, 37. http://doi.org/10.1186/s13054-016-1202-z
U.(2017). Metropolitan Medical Response System. Retrieved April 13, 2017, from http://www.homelandsecuritygrants.info/GrantDetails.aspx?gid=17164

 

30Mar/17

The Road Map to a Healthy Brain

The Alzheimer’s Association and the CDC have worked together to develop a road map that utilizes the strengths of public health and government to promote cognitive health. Officially, it was named The Healthy Brain Initiative for 2013-2018 and its action components are based on the Essential Services of public health.

  1. Monitor and evaluate – surveillance data to inform public, identify disparities and needs of caregivers and those with dementia
  2. Develop policies and mobilize partnerships – collaboration between state and local government, incorporate Healthy People 2020 objectives
  3. Assure a competent workforce – continuing education
  4. Educate and empower the nation – disseminate evidenced-based messages, strategies to promote availability of services

Aging is something we cannot prevent and it is the greatest risk factor in developing Alzheimer’s disease (Alzheimer’s, 2013). The trend in healthcare is prevention, and this includes the aging population who are already affected by chronic diseases such as dementia and Alzheimer’s. We can anticipate needs for long term care of these individuals and concerns arise in providing support for their caregivers and family. Another concern is quality of life and the end-of-life wishes of the individual with dementia or Alzheimer’s.

Read it here: The Healthy Brain Initiative

Alzheimer’s Association and Centers for Disease Control and Prevention. The Healthy Brain Initiative: The Public Health Road Map for State and National Partnerships, 2013–2018: Chicago, IL: Alzheimer’s Association; 2013.

07Mar/17

Medication Knowledge

After interviewing family, friends and coworkers this is what they know about the medications they take:

TriNessa

Informant 1: Does birth control count?

Me: Yes!

Informant 1: I take birth control called TriNessa. The side effects can be weight gain, sore breasts and nausea. The same amount is taken, one pill every day, and if it is missed the next day you can take two pills but never more than two pills a day. I don’t really know anything about herbal medication.

Me: Good! Now let me see if I can educate you…

Informat 1: Okay, would be good to be more educated on what I take every day.

Me: TriNessa prevents your ovaries from firing eggs. May alter cervical mucus and uterus lining to prevent sperm penetration and egg attachment (so thick mucus and bad farming season). Not only prevents pregnancy but decreases acne, menstrual bleed and symptoms of PMS and menopause. It increases folate levels as well, preventing brain defects in your baby. Biggest side effects: Risk for dislodged blood clots and inflamed pancreas. May decrease effects of Tylenol. If you take it with St. John’s Wort herbal medicine, TriNessa will be less effective. Grapefruit juice may increase its effects and risk of toxicity.

Informant 1: Huh, very interesting. I feel like I like my birth control even better now. Thanks!

Me: Missed dose: Take as soon as remembered or if it’s already the next day…you’re correct, take 2 pills. If you miss 2 days in a row, take 2 pills a day for the next 2 days then go back to your regular routine and use another birth ontrol method for the rest of the cycle. You’re welcome!

Informant 1: I didn’t know about taking 2 pills for the next 2 days. That’s good to know!

Employees of a Clinical Lab

Informant 2: My coworkers said they liked to read about the side effects of the medications that they are prescribed. Although not very familiar with generic names, they know some of the more common generic names of over the counter meds like Tylenol (acetaminophen) and other cold meds. Most of them have experienced homeopathic or herbal medications during their lifetime.

This is my opinion. I think common people who have no medical or paramedical background will research and ask more questions about the meds that they are taking. Most people from older generations are more likely to have more experience with homeopathic medicine than younger generations.

Employees of a Pharmaceutical Company (most are not pharmacists or pharmacy technicians)

Informant 3: One of them used to work as a pharmacist tech and always asks questions and Googles information on her medications. She has not tried herbal medicine. Out of my six officemates, only one said they tried herbals. Overall, all of us agree that we always want to know more information about the meds that are prescribed to us and we look for it.

01Mar/17

Sedation Vacation

I have not yet observed the use of sedation vacation. So far, I have witnessed the use of sedation medication on an as-needed basis on the medical surgical, surgery, progressive care and emergency units. The most common sedative I have seen used is Lorazepam/Ativan. However, I have also seen phenergen/promethazine, sublimaze/fentanyl, precedex, Nembutal sodium. These medication were usually administered intravenously using an IV pump but sometimes IV push or orally in pill form. Teamwork between nurses and respiratory therapists is essential to patient care, however, I feel that it is underemphasized. Yes, I see nurses and respiratory therapists working together to relieve a patient’s symptoms, nurses calling respiratory for assistance and respiratory therapists taking the responsibility of managing respiratory medications and equipment. However, active teamwork between the two disciplines seems to be limited to acute care. I cannot say that I have seen a nurse and respiratory therapist take the time to discuss the plan of care for their mutual patient. In addition, I spoke to a respiratory therapist who shared that many nurses are not familiar enough with respiratory equipment. Perhaps, this is an opportunity where nurses and respiratory therapists can train together?

24Feb/17

4 Pearls

Josh Farkas offers four “pearls” in treating DKA: 1) Avoid normal saline for initial treatment. 2) Use bicarbonate to treat hyperchloremic, non-anion-gap acidosis. 3) Avoid intubation if possible. 4) Continue long-acting basal insulin throughout the DKA resuscitation. Management and treatment of DKA is a difficult balancing game. However, this article highlights how changes and treatments to one aspect of the disease process will have consequences in another aspect. I’m curious to find out how this original protocol was standardized in the first place with normal saline producing such a profound negative effect on chlorine. The use of bicarbonate also has a double function, treating the hypochloremia and supplementing the patient’s low levels of bicarbonate. The fragility of the patient in ketoacidosis is another reason to practice conservative implementation of intubation. The last recommendation to continue using long-acting basal insulin works well with the body’s already conditioned response to the medication regimen. It makes more sense to continue rather than recondition the body to insulin and risk rebound hyperglycemia. This alternative protocol seems to be a more efficient way of treating diabetic ketoacidosis. With such a promising alternative treatment to DKA, it is hoped that research is invested into making these recommendations a standard protocol.

PulmCrit – Four DKA Pearls

 

12Feb/17

Cardio- what?

Most anyone will tell you that they have heard of “CPR” (cardiopulmonary resuscitation). Granted, their knowledge of it may involve pushing on someone’s chest and mouth-to-mouth contact, which may have been learned through a television program. I was surprised when I read that “less than 3 percent of the U.S. public receives CPR training annually” (McCoy, 2015). The general public would be unprepared if they witnessed the event of a cardiac arrest. The knowledge of what it is, how to perform it and when to provide it are essential skills. You never know when an emergency demanding it will arise. I interviewed several individuals who had varying degrees of knowledge about CPR.

Informant #1 – Carpenter (not currently CPR certified)

Informant #2 – business/administrative employee at AmerisourceBergen Pharmaceuticals (not currently CPR certified)

Informant # 3 – Fire Technology student (currently CPR certified)

What does “Cardiopulmonary Arrest” mean to you?

Informant #1

  • “Failure of your heart.”

Informant #2

  • “You stop breathing.”

Informant # 3

  • Could not explain.

Do you know what “MI” means?

Informant #1

  • “No.”
  • After brief education he mentioned that he has a history of hypertension and takes 10mg of amlodipine. Since his diagnosis, he “eats less salt and fat,” however, he still has a large intake of sugar.

Informant #2

  • “No…Your heart doesn’t have oxygen.”

Informant # 3

  • “It’s a block in your heart.”

Do you know how to perform CPR? Do you know when someone would need CPR? What do you perceive happens during “CPR”?

Informant #1

  • “Yes, I was CPR certified 8 years ago. It’s required when you apply to be a foster parent. About 2 years ago, I performed CPR on a woman at church. I was sweating; it’s hard. I was glad when the paramedics came. It’s scary to do CPR on someone.”
  • “Another time was at a lady’s house I was painting. I think she was about to faint. I got her monitor and it showed a high blood pressure. She was too panicked, she couldn’t tell me where her medicine was. I crushed and gave her a whole head of garlic to swallow. It’s what I learned in the Philippines. It went down after 20-30 min.”

Informant #2

  • “I was certified a long time ago through work. When asked what she would do if someone had a cardiac arrest and dropped to the ground, she said she would start calling 911 and wait for someone to get there.”

Informant # 3

  • “I’m certified. You have to assess the person. Check their breathing and pulse. Check if they’re unresponsive. Call 911 and start CPR. You have to breathe for them. What is it, 20 compressions for every 2 breaths?”

These interviews taught me that occupational and educational background do not necessarily determine an individual’s knowledge of CPR or their ability to perform CPR. I myself did not feel comfortable with the skill until my third certification renewal class! During these interviews I was able to educate about cardiopulmonary arrest and MI. Explaining meaning, etiology and factors for prevention (diet, genetics, exercise, weight). I also mentioned that compressions are better than no compressions at all. As with any skill, it take practice and exercise of the knowledge to use it confidently. It’s easy, get certified at the American Heart Association.

References

McCoy, M., Liverman, C., & Domnitz, S. (2015). Strategies to Improve Cardiac Arrest Survival A Time to Act. Institute of Medicine, 3-4. Retrieved February 11, 2017, from file:///C:/Users/alysond/Documents/Critical%20Care/Lecture/Unit%201/Week%203/StrategiestoimproveCardiacArrestReportBrief.pdf.

 

03Feb/17

#BreakUpWithSalt

According to the World Health Organization, heart disease is the number one cause of death in the U.S. and the number one cause of death worldwide. However, there are factors that we can control to avoid and stop this epidemic. A healthy heart has its start early. Together, children and their parents can take steps to prevent future complications with simple lifestyle changes, one of these is reducing sodium and fat intake.

Dr. Hannans challenged the class to evaluate our sodium and fat intake for one day. Cardiac patients are restricted of salt and fat for a “Heart Healthy” diet. Could I easily adjust? I used the American Heart Association’s handy Salt Tracker (and modified it to include fat).

Perhaps, I could adjust more easily than most. The American Heart Association (AHA) recommends no more than 2,300 milligrams (mgs) a day and an ideal limit of no more than 1,500 mg per day for most adults. I cook the majority of my meals and I avoid using salt to flavor my cooking, preferring different ways of seasoning. However, keeping track of my sodium and fat intake was tedious and inevitably made me more aware of my intake. Seeing the numbers add up, I made conscious exchanges for foods with lower sodium and fat content. Reducing these nutrients in a person’s diet can be relatively “easy” if they eat fresh fruit, vegetables and unprocessed meat, substituting or omitting salt in their cooking. However, global culture is in love with processed and packaged food. These foods have a long shelf life but they also have high-salt content. As part of their Sodium Reduction Initiative, the AHA have challenged us to #BreakUpWithSalt. Take the pledge with me here!

You can and (should) still enjoy fat and salty food but moderation is key. Our bodies still need these nutrients them. Watch the salt and Know Your Fats!

31Jan/17

Urban Health

Cities have the largest concentration of health services and resources yet they have the largest concentration of individuals who suffer from disease (communicable and non-communicable) and healthcare inequities. The World Health Organization published a 2016 report shedding light on the important link between the environment and health and the link between urban planning and public health.

Global report on urban health: equitable, healthier cities for sustainable development, 2016