Thinking outside the box: Fighting Fire with Fire- using HIV to fight Cancer.

Why are American health care costs so high?

Games: for your health

This video by Jane McGonigal is fantastic. It talks about the value of playing as adults, but also about this woman's struggle with illness and how creative play gave her a tool to help her help herself through the healing process of a traumatic brain injury.

I found her discussion on post traumatic growth to be insightful because some people do persevere and recover from a traumatic event and those people are thought to be 'lucky' or 'resilient.' Rather this shows that they are simply using a different set of tools. The nice thing is tools can be shared, like McGonigal talks about here.

here is a link to here to her website as well: https://www.superbetter.com/

A rattling tail of a story

On my hiking adventure this week I was in the lead of our small hiking group with Roxie on her leash and following me and my coworker a few paces behind. The path at the time was gravel and we were down in a small ravine with a mix of wildflowers and sagebrush on the left (the uphill side of us) and lush grasses and choke cherry trees to the right (the downhill side of us) next to a creek. 

Beautiful, wildflowery day

My coworker and I were talking as we hiked, mostly about how the hike was going since we had completely misread the map and were somehow on mile 6 of what was supposed to be a 3.5 mile hike. My left foot was coming down next to a sage brush bush and out of the corner of my eye I saw the ground below it move and then I heard the infamous warning rattle like a "tsh-tsh-tsh-tsh-tsh." 

My body and it's primal fight-or-flight instinct reacted eons before my mind was able to catch up and process what was going on. Instead of putting my left foot down on what was a coil of a snake's body, I pushed off my right foot and leaped in an Olympic style fashion probably a good 4 feet ahead all the while dragging Roxie with me.

I hollered for my coworker to stop and from the sagebrush bush we heard the rattle again and a rattlesnake's head pop out from below the bush to peer at us. I generally have no problems with snakes, but this was my first encounter with a poisonous one. Thankfully the snake and I had mutually scared the pants off each other that Monday afternoon and both reacted by running/slithering in opposite directions. The snake looked at us for probably about a minute deciding which way to go, and then turned up hill while shaking it's rattler at us as it headed up the hill. I am so incredibly thankful I did not get bitten!

Not my photo---but about the right size

Things that I learned from this heart thumping experience:

1. Always pay attention to where your feet are
2. I will never hike alone and whoever is with me better have a medical degree of some sort
3. I have no clue how to treat a rattlesnake bite in the field-so now I've looked it up

The do's and don'ts of treating a rattlesnake bite according to Backpacker Magazine:

• DON'T
• slice the bite mark to try to suck out venom: you are creating a wound site for infection
• suction the area: you aren't going to get any venom out anyway since the it has already started pumping through your system since your heart rate accelerated from the situation
• apply a tourniquet: it will concentrate the venom in one area and accelerate cell death in that one place. It's actually better to let it get diluted through your system.
• apply an ice pack (who is carrying one of these while back packing anyway?): the cold will slow the circulation to the area (much like a tourniquet) and concentrate the cell damage
• DO
• Get medical attention as soon as possible
• An antivenom will be needed to treat the patient. 
• Interesting fact: rattlesnake antivenom is made from the serum globulins from horses that are immunized against many different species of snakes
• Remove tight fitting clothes/jewelry: this in preparation for swelling
• Clean the bite area: with soap and water or an antiseptic from a first aid kit
• Carry the victim (or yourself) out slowly: Ditch the backpack, you don't need to make your body work any harder
• If you have a pen: mark the swelling area every 15 minutes. This helps doctors guess the amount of venom in the bite
• Interesting fact: about 20% of bites don't have venom injected by poisonous snakes and are considered "dry" bites

Body language: a good lesson for new nurses and old nurses alike

In an earlier post I had mentioned the power of body language to influence our behavior and feelings. We have known for a long time that forcing our selves to smile makes us sound nicer on the telephone and can cheer us up. As a dog owner, I learned the equivalent of this with my dogs that you can hold their tail up when they are scared and that this cheers them up too. Our moods are incredibly responsive to our body's actions. It is counter intuitive in many ways, but biology often drives behavior.

I stumbled across this TED video and it made me think about how hard it is to teach communication to new nurses. I felt that I learned next to nothing in my nursing communication course except for how to prepare an SBAR (that will be for another post). I don't think the communication and confidence "thing" clicked until I started my job and realized I had other people's well being in my hands. I emulated my coworkers and quickly learned what did and didn't work.

There is very little, apart from life experiences, that can prepare you for the occasional dose of crazy patients, aggressive doctors, or bullying coworker nurses. I thought this video was a great reminder to how to not read only others, but to read ourselves in the great game of communication. Enjoy!

Pulmonary embolism & deep vein thrombosis

In recent weeks I've had new encounters with pulmonary embolisms (PEs). So, this post is to explore the origin of this condition and what it looks like.

First off, deep vein thrombosis (DVT) refers to clots that form in the veins of the legs. DVTs are often the cause of the pulmonary embolisms. Normally, the blood in the veins is pumped back to the heart by the leg muscles that 'milk' the veins through contraction. However, clot formation occurs when a person is on bed rest or is inactive (like mentioned above - long car trips or long hours at a desk). In the hospital a lot of attention is paid to preventing DVTs; patients that are in the hospital post surgery or are on bed rest for more than 24 hours are automatically given heparin, an anticoagulant, that prevents clotting.

These clots when they do happen can break off from where they have built up within the leg veins. The clots then travel to the heart and get pumped out to the lungs - getting lodged and causing a pulmonary embolism.

Again, pictures are worth much more than my words so here is a quick video that illustrates the phenomena of DVTs and PEs:

It's also worth noting, this can occur in any age group. In March 2011, the athlete Serena Williams had a foot surgery in New York and then traveled to Los Angeles, where shortly afterward she had to be rushed to the hospital for a PE (Serena William Hospitalized for Pulmonary Embolism). 

So remember to get up and move around to keep your legs and lungs lively!

Kidneys: the water treatment plant of your body

It seems some things come in waves. A few weeks ago every time I got an admit it was a GI bleed, in the last 2 weeks it's been kidney/renal problems. 

For some reason I find kidneys to be mysterious organs - maybe it's because it seems like they are hiding back behind the rest of the organs like they have a secret? Or the fact that you have 2 of them, but can live with 1? Anyway, I thought it was a great opportunity to review the basics. 

First, this short 45 second video is a great big overview of the kidney (plus the English accent is funny- especially the word for capillaries):

All right, so we know the kidneys produce urine. But that's not the only thing you kidneys do!

Here are some of the other very important and necessary functions of kidneys:

Excretion of waste:

Kidneys remove waste produced by your body's metabolism. Major waste products would be urea (that makes up uric acid) and nitrogenous wastes. To much of either of these waste products does intense damage to the body and brain. Often times in renal failure people will present with altered mental statuses because of the build up of waste products that starts to affect their level of consciousness or even personality.

Acid/base balance:

Our body tries to maintain a neutral pH. Carbon dioxide (CO2) and hydrogen ions (H-) are both acidic substance in our bodies. Bicarbonate (HCO3) is a basic substance in our bodies. Our lungs regulate the CO2 through breathing. Our kidneys can regulate HCO3 by not filtering it out of the blood and into the urine. The kidneys can also regulate acid by filtering out H- from our blood and into the urine.

Fluid volume regulation:

The entire goal of the human body is to reach homeostasis. With everything. Really, your body is like Goldilocks, it doesn't want things too hot or too cold, too acidic or too basic, too full or too empty. Fluid volume is another one of these markers. 

The body- more specifically the hypothalamus in the brain-  is constantly monitoring your fluid volume and telling the kidneys through hormones messages - "okay - we are too full, take more fluid off " or "we haven't had a drink of water all day - get rid of waste, but hang on to the water!!!"

Blood pressure:

This is related to fluid volume, but also to your body's needs. If you go for a run, your blood pressure is going to go up because your heart is pumping and your muscles are demanding more oxygen and want to get rid of waste. Blood pressure at the kidney level has to do with the retention of sodium. When we need our blood pressure to increase, the kidneys get a signal to retain sodium, because water follows salt. When you keep your sodium, you keep your fluids and your blood pressure increases. 

In cases where someone has high blood pressure because they are unhealthy or sick, one medication that is often prescribed is a diuretic. These medications often cause the kidneys to release the sodium into the urine. Again- water follows salt - the salt leaves, so does the extra fluid, and voila - your high blood pressure patient's blood pressure decreases and they have to urinate fairly frequently.

Production of red blood cells:

So far we have talked about hormonal messages traveling to the kidneys to activate a response. However, kidneys are responsible for releasing their own messenger called  erythropoietin. When the kidneys sense they are not getting adequate perfusion (meaning their own red blood cell/oxygen supply is not sufficient) this hormone is released and sent to the bone marrow to stimulate the production of more red blood cells. In patients with renal damage, they tend to be anemic because this function is damaged and the bone marrow never gets the message to make more red blood cells.

Now go drink some water and appreciate everything your 2 kidneys do!

Types of strokes and some neat new facts

This week's new nurse forum was all about stokes. I previously touched upon tPA, a clot busting drug given to stroke patients in my posting Week 4: one month of nursing!!!. This post I want to focus briefly on the 2 types of strokes, the parts of the brain, and some neat information I learned from our stroke nurse education.

First off: ischemic versus hemorrhagic stroke. My conceptualization of blood vessels that I always return to is thinking of blood vessels as gardens hoses. It's not a perfect simile, but it works for me.

In ischemic stroke a blood vessel in the brain gets blocked, something essentially is stuck in the garden hose preventing it from flowing. Things that can cause blockages: blood clots, cancer cells, clumps of bacteria, and even clumps of fat cells can get lodged inside one of the brain's blood vessels. Everything downstream of that clot is not receiving blood/oxygen/nutrients and the tissue becomes ischemic (ischemic is a fancy pants way of saying the tissue is not getting adequate blood supply and is starting to die). Ischemic strokes are candidates for tPA because the goal is to break up the clot and restart blood flow to that tissue.

Hemorrhagic strokes are more like a garden hose that springs a leak. Instead of a clot that stops blood flow to brain tissue, instead the blood vessels is leaking or bursts such as in an aneurysm (a blood vessel with a weak pouched out wall that eventually breaks). Blood is kept inside blood vessels for a reason: it is a great transporter of nutrients/waste/oxygen/and carbon dioxide, but it is caustic on tissue. As one of my nursing instructors would always say, "Too much of a good thing is always bad." When the blood gets out of the vessels and into the tissue it causes swelling, cell death, and everything downstream of that leak (much like ischemic stroke) is also not getting adequate blood supply.

Again, I think a video does a better job providing a visualization to these different strokes. The first stroke is ischemic and the second is hemorrhagic.

One of our speakers this week is our stroke nurse educator who is spear heading our transition to becoming a certified stroke center. She recently attended an international convention on strokes where some really interesting research is going on.

Some of the preliminary findings she shared were pretty neat including:

• Strokes seem to occur more frequently when there is a change to cold weather. Something about the body vasoconstricting (making the garden hoses smaller) to conserve heat may increase the occurrence of strokes in these transitional weather periods.
• The majority of strokes occur from 6am to noon. This is when the body's cortisol level is the highest (unless you are a night shift worker). Cortisol is produced by the adrenal glands and helps manage metabolism, blood glucose levels, and is the hormone that helps the body manage stress. Additionally, it increases the coagulation of the blood, thereby making the chance of blood clots to the brain a higher risk. 
• One problematic group of patients has been those that wake up from sleep with a stroke. The clot busting drug tPA has a four and a half hour window that it can be given from a patient's last known well time. The previous bullet helps narrow down when a possible stroke start time could have occurred. Research is also showing that is seems patients are waking up on average about an hour or so after the stroke has started (I wish I had the paper this was from because I would like to know how they determined this). This allows physicians to be more aggressive with tPA and this segment of patients are now having better outcomes.

I will try to post more educational information over the next month as I will be working weekends for the month of March, but still have Wednesday classes. 

All about: PCIs and CEAs

I worked Tuesday night and had class Wednesday morning this week. What an experiment in sleep deprivation and an ode to the powers of caffeine! I had a busy beginning of shift with an immediate transfer of a patient upstairs (a real character and one of those you are always sad to transfer off your floor). My other 2 patients were a carotid endarectomy (CEA) surgery patient and a percutaneous coronary intervention (PCI) patient. So, today I'm going to elaborate on those 2 procedures!

The patients that have CEAs usually have this procedure because they have a high risk of stroke from stenosis (narrowing) of their carotid artery. They may even have had transient ischemic attacks (TIA) which is like a tiny stroke that has self corrected. The CEA patients, when they come from a certain doctor, have the most specific notes I have yet to see. It is very clear about how often neuro checks will be completed (every 15 minutes for 3 hours, every 30 minutes for 3 hours, every 1 hour for 6 hours is usually standard), when to initiate certain drugs if they have certain high or low blood pressure levels, what time to discontinue the antiplatelet IV drugs they are on post surgery, and what time their urinary catheter will come out, even if it's 0300 and the patient is sleeping. Here is a really great video on what occurs during a CEA surgery. In our hospital we use bovine pericardium (the exterior envelope of a cow's heart) to provide a patch.

PCI is very common on our floor. Patients go the the cardiac cath lab, have this procedure where they may or may not have an intervention, like a stent placed. They return to our unit where we check their labs and once their ACT (activated clotting time) is below a certain number we remove the sheath from the femoral artery. Removing a sheath is literally like holding someone's life in your hands. The bandage over the sheath is removed. The suture holding in the sheath is clipped. The arterial pulse is palpated. You attach a syringe to the sheath and withdraw about 5ml of blood. I keep my left hand on the artery just about the sheath entry point, have patient exhale, and then remove the sheath, promptly stacking my right hand on top of my left hand. If everything goes well, you sit there for 20 minutes holding pressure on the site and it coagulates just fine. You clean it and put a transparent bandage over it. Then you patient gets to lie on their back for 4 hours extremely bored so as to make sure the puncture site has plenty of time to start healing. The things that could go wrong with a sheath pull and require you to holler for help:

1. your patient has a vaso-vagal maneuver where their heart rate drops to less than 40 beats per minute and an emergency medication has to be pushed to speed up their heart rate
2. your patient doesn't stop bleeding. You keep holding pressure, you get more people in the room, and you grab a femoral stop device and call the MD
3. the patient has really high blood pressure that's 'fighting' you. In this case some morphine is a great idea because it decreases blood pressure and reduces your patient's discomfort of you pushing on them.

Now here is a great video all about PCI

Triple A, AAA, Abdominal Aortic Aneurysm

Known by many short hand names- AAA, triple A- an abdominal aortic aneurysm is a very serious medical complication. In the last few weeks I've seen a handful of them along with the 2 primary methods of fixing them- open or endovascular method. This video was really helpful for visualizing what the medical problem is and the two procedures.