Mondays

Monday in a rural health clinic is, well, interesting. As in the old Chinese curse “May you live in interesting times”. I am sitting in my little office cubby at the back of the building tackling the teetering pile of charts that have messages or lab and test results to be read, when I hear a panicked voice yelling “We need you NOW!”. Dashing out, I am directed to the waiting area where a young man is laying on the floor and the other patients who were waiting to be seen are backing out the door, wide-eyed.

The man was unconscious, not responding and his breath whistled whheep, whheeeep, wheeep, like a kid with epiglotitis. Oh, crap, he probably has something lodged in his throat. I turn him around to check his airway, and check his mouth and he coughs a little, mucous tinged with blood dribbles out. I put him back on his side. Panicked staff crowd around, “What do we do?” one yelled. “Call 911, get me oxygen and the ambubag!” I replied.

He is still not responding, though the wheeping is slowing down a little, and suddenly stops. “Shit, he stoppped breathing!”, I have a sinking feeling in my chest, this guy is going to die on me. I grab him by the shoulders and shake him. “Don’t you DARE stop breathing!” I yell into his ear. He suddenly gasps a little, with a more normal sound, and starts to come round, his eyes open. He whispers “Anxiety attack”. The 911 crew arrives, just as he is starting to sit up. They ask the story and I tell them what happened. At the mention of the words “anxiety attack”, their interest cools considerably. A staff member hands me the patient’s chart, as they now know who it is. He has esophageal ulcers, asthma and GERD listed in his problem list. I pass this information along to the now bored EMTs. I mention they might want to check his lungs as possibly he may have aspirated some stomach acid, they say “thanks, sure” and out they go.

Two days later, the guy shows up for an office visit with his mom. She thanks me profusely for saving his life. When I asked him what precipitated his anxiety attack, he said “Nothing. I was just driving along and started coughing, I couldn’t catch my breath and then the panic started.” I see on his med list he is supposed to be taking Advair for asthma, and Nexium for acid reflux and the esophageal ulcers. He admits to not taking his medicine, that he didn’t feel it was necessary. I explained that a combination of refluxed stomach acid and bronchial spasms from the asthma had probably led to his coughing and panic attack. His mother gave him the stink-eye and said “I TOLD you to take your medicines!” The guy sheepishly promised to take all of his meds in the future.

Later, a guy walks in with a hospital gown on over his jeans and a hard neck brace on his neck. He hands me a pile of papers which are hospital records from an ED visit last night. The records show he has a transverse C4 fracture, nondisplaced. The story of how he got the broken neck was colorful and included beer, motorcycles and police officers and a total lack of memory about how it happened. There were multiple scrapes, bruises and marks on him, one of which looked like a boot print. Quite a night.

“I was supposed to see a spinal surgeon today,” he tells me. “But, the one I was told to see doesn’t take Medicaid. He said I had to get a referral from my primary.” That would be us. The nearest spinal surgeon that accepts Medicaid is at Shands, which is over an hour away. The patient would have to drive himself. When our scheduler called Shands, they told us they would call back to set an appointment after noon tomorrow. Our scheduler “suggested” that she would fax the referral and the pertinent information from the hospital records now and she would call them first thing in the morning to see what time the patient should show up tomorrow. We’ll see how well that goes. I pointedly reminded him to keep the brace on and not try to turn his head until seen by the spine doctor.

The sad part is, if the hospital had admitted him, he could have been seen by the local spine surgeon in the hospital, had his surgery and it would have been covered by Medicaid.

What is wrong with this picture?

 

 

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Awesome things

So, this morning I wake up with some weird pressure in my head, I am dizzy and listing to the right, the nausea center in my brain vestibule fully activated. What the heck. Of, course what if’s are running through my head: brain tumor, stroke and numerous other nefarious conditions. I stagger around waiting for the feeling to pass, but it seems to not want to subside so fast. So, of course I resort to surfing on the computer so as to keep my head still.

I find a blog called “1000 Awesome Things”. Okay, I am immediately contrite. What a whiner I have been. Focused on how I don’t feel like studying CHF and PVD and CAD, and definitely don’t feel like taking a test, which is due today. People are writing in to comment on the blog entries in “Awesome Things” telling their stories of cancer and loss and seeing the good stuff in life in the middle of terrible adversities. My problem is just tiredness.

What is an awesome thing I can come up with right now as I sit here in my spinning room? Well, it has to be my husband. He has done the housework and cooking I don’t have time to do, cheered me up when things seemed insurmountable, made do with massively decreased time with his wife in the name of studying, was always there for me and brags about me to everyone he meets. What an awesome husband he is, and an awesome friend. I really couldn’t do this without his support.

This morning he made me coffee and said “It has to be pressure from your sinuses, take your antihistamine”. He’s right of course. Summer has officially hit Florida and you need a snorkle to breathe the pollen-enriched steam we call air. Antihistamines are essential for survival. I just realized I forgot to fill my little vitamin/anti-allergy pill box for the week, and went without for two days. I’m a dummy. So, one antihistamine coming up (second-generation non-drowsy formula, of course) and I will hit the books and take my test. Wish me luck, I heard it was tough.

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Wow, unbelievable! Re: Nurses masquerading as doctors

Dr. Keith Ablow, a psychiatrist on Fox news, has posted on his blog the worst diatribe I have read in a long time. Read it here: http://health.blogs.foxnews.com/2010/04/15/nurses-masquerading-as-doctors/

Okay, here is my response. I will do my best to keep it civil. Paragraph by paragraph.

First of all, we will see what is in the future regarding the health care reform, but there is, and has been, a shortage of primary care physicians, especially in poor or rural areas. Patients all over America and many other countries have long received primary care from Nurse Practitioners (NPs) who worked independently, or in collaboration with a physician, depending on the state in which the NP has her license and where they choose to work. This is nothing new. Many studies on the effectiveness, safety and patient satisfaction with NP care point to equal or better outcomes than physician care (I have the references if anyone wants them) in the specialities that the NPs practice in: pediatrics, family practice, adult, and geriatric, to name a few. NPs can and do provide excellent primary and specialized care.

The education includes pharmacotherapeutics, and have completed the requisite hours in order to be able to prescribe safely, and have the same CEU requirements as physicians. Each state has their own laws regarding  NP prescriptive privileges, but NPs write prescriptions in all states. Only 2 states do not allow NPs to prescribe controlled drugs such as cough medication, certain anti-diarrheals and pain medication. I, unfortunately live in one of them, Florida. Sixteen times a bill has been introduced and sixteen times shot down through the machinations of Florida Medical Association lobbyists, in spite of documented proof that NPs prescribe safely.  

As to the right to be called “Doctor”. Doctor is an honorific for someone who has reached a doctorate level of education in any field, Dr. Ablow confuses this with the role of physician. But to answer his objection, NPs don’t generally want to be called doctor, even if they have the Doctor of Nursing Practice degree (DNP). When I get it, I will still introduce myself by my name and title of Nurse Practitioner. In 2015, DNP will be the entry-level degree for nurse practitioner certification, and physicians will have to stop being so touchy about it, we are all there for the patients. It isn’t about ego trips, or shouldn’t be.  The minimum degree now is Master in Science of Nursing (MSN).

Obama care is an unknown entity so far, so calling it two-tiered care is just silly. I see no requirements that “poor” people can only see NPs and “rich” people get a “real” doctor. NPs are a resource for good primary care in a time of shortage of primary care MDs, and a great adjunct in the health care team as a whole. Many patients prefer the NP so money is not the issue. NPs are not trying to replace MDs.

Yes, medical school is rigorous and academically challenging, but so is nursing school. Getting into nursing school is tough, many schools have waiting lists of over two years. The average NP has had many years of education to get to where they are. I myself started as an EMT, then got a Nursing Diploma (3 years with many, many clinical hours), then  got a BSN, (3 years with more clinical), now I am enrolled in a MSN-FNP program (3 more years and 700 hours of clinical time). All in all, I will  have spent 10 years in school, and have 20 years of hands-on experience in nursing. I have worked in hospitals, home health, hospice and case management. I was top of my class every time I went to school, and have a 4.0 right now (and it was not easy!) I suspect most nurses who go the extra time and effort to be NPs are intelligent, hard-working, and driven to help patients. As to physicians having more “raw intellect” than the average nurse – aren’t we a tad arrogant, Dr. Ablow? I’ll match my IQ to yours any day and blow you out of the water.

What you are saying isn’t unpopular, it is untruthful in its insinuations. Suggesting nurse anesthetists (and advanced practice nurses in genreral) are second-rate is out-and-out ridiculous. Many rural hospitals don’t have anesthesiologists available, and would not be able to provide surgical and anesthesia services without CRNAs. Besides, anyone who works in the ER wears a mask and gown “just like the surgeon”, they aren’t hiding or masquerading, just doing their job, you moron. (Oops, sorry, not civil. Will be good…) You pay for anesthesia that is safe, and you get it. It is not relevant whether the one doing it is a nurse anesthetist or an anesthesiologist, they are both credentialed, licensed, and able to do the job equally well.

Also, please differentiate between nurses. I wouldn’t want a psychiatrist to decide if I had pneumonia or the flu, but I sure as hell would place myself in the capable hands of an NP. LPNs and RNs can’t do what you describe, but NPs can and do, and do it well.

• “How come no one in Congress would be able to tell you a story about that incredible nurse who diagnosed the rare condition in his or her child?” Because the idiots in Congress only listen to the lobbyists who give them lots of money, i.e. the AMA (which only represents 25% of physicians, by the way).
• ” How come nurses either failed to be admitted to medical school or didn’t try? ” Because they wanted to be nurses. Nurses are closer to patients (in general, there are always exceptions to the rule,  my own MD is a good example), see them as whole people and not just a disease . I was working in the ER and was given D/C instructions for a patient after being seen by the medical person for hematemesis (bloody vomiting). The instructions consisted of a script for a PPI and a referral to a gastroenterologist. When I went in to discharge the patient, I saw he had fresh surgical scars on his wrists. I asked him about them and he explained he had carpal tunnel surgery three months ago. On questioning, it turns out he had been taking Motrin four times a day ever since. “The doctor didn’t tell me not to.” Further questioning of this 20 year-old determined he binge drank every weekend. The medical person never asked.  This situation wasn’t even rare or unusual and he didn’t catch it. In this case we needed to know the cause to be able to treat the problem and prevent reoccurrence, this is where NPs shine because of being a nurse.
• “You think it’s because they thought nursing school would train them better to take care of patients? C’mon. It’s because nursing school is easier–as in, 10 times easier.” Since you never went to nursing school, you wouldn’t know, would  you? Don’t make assumptions about things you know nothing about. Nursing school is difficult, maybe not as crazy as medical school, but that does not make it less valuable. We go to nursing school because we like the nursing model of health care. We are advanced practice nurses, not mini-doctors.

Nurses don’t impersonate doctors (oops, physicians), they are their own entity; complimentary to physicians, not replacements.

Now a word to Dr. Ablow: Do you feel  threatened by NPs? What makes you so hostile? You are supposed to be a healer of the mind and emotional difficulties, yet you seem  beset by your own insecurities to lash out so. Perhaps you need a consultation with a psychiatric nurse practitioner, they are well-known for their good listening skills, understanding and compassion. 

Okay, I was fairly civil, for a Viking…Sigh, I hate it when I get mad, it never feels good afterwards.

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Wrinkles

Okay, so here I am 50+, looking at the lovely “senile lentigines” on the back of my wrinkly old hand. A commercial on TV says their cream will fix my old skin and make me look like a teenager again. Could this be true?

First I had to see exactly how the skin breaks down and gets all saggy: UV radiation causes the generation of free radicals (I thought they were all in Washington, DC). Free radicals, otherwise known as ROS, cause increased levels of AP-1  a transcription factor that inhibits collagen production; and decreased levels of transformative growth factor ( TGF). (Transformative growth factor, wow, that sounds really nice! I want a LOT of that stuff!) Skin is constantly being remodeled. The body really doesn’t like stasis, only homeostasis. So it constantly tears things down and builds them back up. I guess when we get older, the body gets a little lazy, and forgets to build up so much.The  UV-caused ROS messes up the balance, more collagen being broken down than built up causes an invisible “solar scar”. Repeated UV damage eventually causes a deep scar, otherwise known as a wrinkle, and the skin is less elastic because of insufficient collagen.

Back to the creams: can any of them fix the problem and repair the damage? Maybe a little. It turns out that some studies have shown that creams with antioxidants in them actually do reverse the damage a little. Idebedone, a type of Coenzyme Q 10, and Vitamin C 5% topical actually help to stimulate collagen production, though it can take six months to show an effect. Do you think a paste made up of a Vitamin C tablet would work? Maybe I should go to the store and start peering at cream labels with my dollar store reading glasses and see if any have one of those magic ingredients. It can’t hurt, maybe in six months I’ll look 48 again.

Can you tell we are studying “the integument” this week?

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