Cary, RN

cancer

Sat, 30 Jul 2011 11:10:00 -0400

can a nurse tell you that you could have cancerous cell after an abnormal pap test?

Hi and thank you for the question.

This seems like a very simple question, but like most medical/nursing things, it really isn’t. Typically cancerous cells are identified by a pathology lab. Your sample is sent off, read by the lab, the lab writes a report and sends it back to the physician who sent it in, and the physician “interprets” it. This often means the doc just reads the report and goes with it, but not always.

A nurse can tell you that you have cancer or may have cancer, but typically does not diagnose it. So in an office with physicians and nurses, it is dependent on policy. The doc may get the reports, read them, sign off on them meaning to show they’ve been seen by him or her, and then hand them to the nurse to call or talk to patients. Or the policy may be that only the doc informs patients of this sort of thing. It totally depends on the clinic, the staff, and the policy.

In one line, the answer to your question is yes, but it depends. I hope that helps.

Pulmonary Hypertension and My Friend Christa

Tue, 22 Jun 2010 23:26:00 -0400

A friend of mine was recently diagnosed with pulmonary hypertension (PH). Many of you who follow this blog know Christa as well. We discussed my writing about PH because the statistics can be depressing, and I didn’t want her to feel negatively affected by my writing a very direct, factual post about this illness. Christa and I have discussed more than once that statistics are meaningless until it happens to you. So while this is a rotten illness, our friend’s life is not a statistic. People beat the odds in medicine every day, and Christa has the attitude to persevere.

Pulmonary hypertension is not the same as common hypertension, or high blood pressure. PH is an incurable condition. There are several causes, and sometimes it is idiopathic which means the cause is unknown. In Christa’s case, it was probably caused by fen-phen. Regardless of the cause or type of PH, treatments and prognosis are generally similar.

Fen-phen was a very popular diet drug until it was outlawed. Christa’s doctor prescribed this drug for her because she was overweight. She did nothing wrong, she didn’t take any illegal drugs or abuse her prescription. Many people have died as a result of taking fen-phen; that’s why it was outlawed by the FDA. Christa took this drug 20 years ago, before anyone realized how dangerous it was.

PH occurs when the arteries in the lungs have abnormally high pressure. The vessels narrow and become stiff, increasing pressure as when you put your thumb over the end of a hose. Because the pressure in your lungs is usually low, the right side of the heart easily pushes blood into them to be oxygenated. The blood then travels back into the left side of the heart and is pushed out into the body. ‘Regular’ hypertension is when the left side of the heart has to push harder to pump blood through your body. This is a more common problem.

When the right side of your heart has to pump so hard to push the blood into the arteries of your lungs, it enlarges. Just as any other muscle that is pushed to extremes, the right side of the heart can become very enlarged. The difference is when the heart muscle enlarges, it works less efficiently. The high pulmonary pressure can also cause regurgitation, meaning the blood going into the lungs can backflow a bit back into your heart.

All this pressure, enlarged heart and swirling backflow of blood raise the risk of blood clots significantly. People with PH are often prescribed blood thinners such as Coumadin to decrease the risk of clots.

Symptoms of PH are dizziness, shortness of breath, fatigue, chest pain, dry cough, edema, depression, cardiac arrhythmias, and fainting. Some people also get Raynaud’s phenomenon, which makes fingers white or dusky blue, can be painful, and is sometimes provoked by exposure to cold. Initially the breathlessness occurs with exercise, but as the disease progresses, it is present at rest as well.

Treatment depends partially on the cause, but includes various cardiac medications, supplemental oxygen, diuretics, anticoagulants, and inhalers such as Advair. Over time medications are added and can include portable medication infusion. These therapies are not curative. Eventually if a patient is a good candidate, PH may require a lung or heart/lung transplant, or rarely, heart valve surgery. Due to the complexities of organ donation, transplants are not something you can count on.

Medical treatments have improved a lot over the years, and people with PH live longer than they used to. Over time PH causes right-sided heart failure. The right side of the heart becomes too weak to push the blood against the pressure in the lungs. According to the Centers for Disease Control, prior to 1995 the survival rate for PH patients at diagnosis averaged less than three years. Treatment has improved since 1995, and so have quality of life and survival rates for PH patients.

As you can imagine, treatment for PH is expensive. Christa, like many in the U.S., does not have health insurance. She must pay for oxygen tank rental, and hopefully will be able to get financial help to buy an oxygen concentrator. With the portable concentrator she will not run the risk of running out of oxygen as she does now, because it takes room air and concentrates it to give her the extra oxygen she needs. Medications and doctor visits are costly, and PH treatment requires special doctors who are up to date on current research. An inexperienced treating physician can literally cost a PH patient her life.

PH is a terrible disease with no real cure. It causes disability and early death, but first it bankrupts patients, even when they have health insurance. The diagnosis and initial education is a shock to a person who is already having physical difficulty getting through her day; when you add the emotional toll this diagnosis causes, it is understandable that people with PH need all the support they can get.

Many thanks to Christa for allowing me to mention her in this post. Love you, girl.

References:

American Heart Association: Pulmonary Hypertension

Centers for Disease Control and Prevention: Pulmonary Hypertension Fact Sheet

Cleveland Clinic: Pulmonary Hypertension

Medline Plus: Pulmonary Hypertension

National Heart Lung and Blood Institute: Pulmonary Hypertension

Pulmonary Hypertension Association: About PH

U.S. Food and Drug Administration: Fen-Phen Safety Update

I've never gone to a therapist before, but I think it's time that I start. How do I go about finding someone to call and make an appointment with? I don't feel ready to admit to friends or colleagues that I want therapy, so I don't feel as if I can "ask around" for recommendations? How do I start?

Mon, 21 Jun 2010 13:32:43 -0400

Finding a new therapist can be tricky, and it is not unusual to see one a few times, determine that is not the therapist for you, and then find another. I may need feedback from you to answer this to your satisfaction, so please write again if I don’t get everything you need to know on the first try.

One of the things you need to decide is what do you need to get out of treatment? For instance, if you think you are schizophrenic, bipolar, or seriously clinically depressed, you should probably start with a psychiatrist in case you need medication, and to rule out a medical problem that may cause symptoms of mental illness. A psychiatrist is basically a medical doctor with extra education in mental health and illness.

If you have an issue like OCD you may benefit from medication, but also cognitive behavioral therapy. CBT is sort of a practical and speedy approach, as opposed to traditional psychotherapy. CBT is not about digging through all of your childhood traumas and rehashing everything, it is more about “what can we do now to change your mental and behavioral patterns so you feel better and cope more easily” with life. This is good for almost any mental or emotional issue, and can dovetail very well along with psychiatry for a serious mental illness or mood disorder.

Psychologists cannot prescribe medication. Neither can social workers or the professionals commonly known as counselors. But many of these therapists work with doctors or psychiatrists, so if a patient seems to need medication the counselor can refer to the MD they work with in those situations.

Just like medical doctors who specialize in different parts of medicine like orthopaedics or urology, therapists often specialize. So if you have a history of molestation, child abuse, or another specific issue, you may want to see someone who specializes in that area.

A good way to start looking for someone is to ask your regular health care provider. They may be able to refer you. Many insurance companies (assuming you are in the US) have websites with providers and therapists listed along with their specialties, backgrounds and licensing which can also be helpful. If you have a local hospital that you use for medical things, check their website. They often have a list similar to the insurance company list. This may sound odd, but look at ads, too. I found an excellent woman therapist with a doctorate in psychology when I kept seeing her ads in the local newspaper. The wording in the ads really appealed to me, so I gave her a try.

If you do not have insurance, most areas have mental health clinics you can go to. In the past I have done that. It seems like a crap shoot, but I worked with a couple of excellent people through those low-cost clinics.

In the end, working with a therapist is going to be all about personalities. If you don’t hit it off in some way, you won’t be able to do the work. Once you find someone you think you want to try out, go to the department of professional regulation for your state and check that therapist’s licensing. Most states have this listing online. You do the license lookup, put the name in, and check to see that they truly have the license they say they do, that it is current and that no complaints have been filed against them. In most places, it is not easy to get a complaint put on that site. So if a therapist or other health care professional including nurses have a complaint listed, I’d avoid them.

If you have more questions after reading this, please hit me up again.

Organizations that offer support for the mentally ill and their families, and may also be a resource for finding a therapist:

National Alliance on Mental Illness

Depression and Bipolar Alliance

Schizophrenia.com

BPD Central (borderline personality disorder)

So I’ve got this standing desk, and I’m trying to...

Sat, 15 May 2010 22:14:59 -0400

So I’ve got this standing desk, and I’m trying to find good information on the proper way to adjust it ergonomically.

I have a floor mat that is supposed to reduce foot strain. Someone suggested I also get a footrest, but I’m not sure why.

The footrest is to help prevent fatigue by relieving the weight on your feet intermittently. Standing on your toes and flexing your calves periodically will help with venous return so the blood doesn’t pool in your lower legs and feet, causing swelling and pain.

How high should the monitor be? Should I be looking straight ahead/a little up/a little down? (if “straight ahead” is that to the top/middle/bottom of the monitor).

What about the keyboard? What’s the right height for that? I’ve adjusted it so that my forearms are basically parallel to the floor but the monitor seems a little high. Then again, the whole thing is different, so anything would feel a little weird.

If you look at the diagrams at the top of this post, they explain how high everything should be. I thought these were some pretty great diagrams. I took them from the Canadian Centre for Occupational Health and Safety site.

Going by their information, it sounds like your keyboard is a little high. For those of you who don’t want to search for it, a centimeter is equal to approximately 0.39 inches.

They go on to give a few more tips on the site:

“What can workers do to reduce the discomfort of working in a standing position?

Adjust the height of the work according to body dimensions, using elbow height as a guide.

What should workers avoid while working in a standing position?

Avoid reaching behind the shoulder line. Shifting feet to face the object is the recommended way.
Avoid overreaching beyond the point of comfort.
Avoid reaching above shoulder line.”

It’s been my own experience as a sometimes spastic, twitchy person who probably would have been diagnosed with ADHD as a child if they had done it back then, standing or walking (on a treadmill) while working or studying really does help me concentrate as long as I can do it without falling down or running into anything. It was pretty surprising to me when I first figured it out, and I ended up doing a lot of studying on the treadmill.

Thanks for the question!

Allergy Overview

Tue, 27 Apr 2010 19:25:52 -0400

I have gotten several questions about allergies. Allergies are really complex. That’s why there are entire fields of medicine, research, and drugs devoted solely to this one topic. I’m going to do my best to give a simple overview, and then if I haven’t answered a question to your satisfaction, let me know and I’ll get more detailed.

Allergy symptoms are caused by an immune response to an invader. Colds and flu have similar symptoms, because it is a similar mechanism. Virus, bacteria, pollen or other allergens enter the body, the body says, “Oh, I don’t think so. Get out of here.” The body releases histamine, usually at the entry point, so if you breathe pollen, for example, you develop respiratory symptoms; if it is something you eat, you might have gastrointestinal symptoms or a whole body systemic reaction.

The immune response due to allergies is an overreaction. In most cases, the food, pollen, or other invader is not a serious threat, but your immune system decides it is. No one is 100 percent sure why this happens in some people and not others. It is thought that the problem is partially genetic, and there are some theories about allergies increasing due to fewer immune challenges when we are infants because we live in relatively clean houses and eat and drink cleaner things than we used to as a species. Then if our immune systems encounter any little thing, they freak out.

There are a lot of medications you can take for allergy symptoms, both prescription and over the counter. Many antihistamines cause drowsiness, even the ones that are labeled non-drowsy, so always test them on yourself at home first rather than at work. Decongestants can make some people really hyper, especially kids. Read the labels on both types of drugs carefully, because there are warnings if you have high blood pressure or arrhythmias, as well as glaucoma and a couple of other things.

Antihistamines are the meds that actually help decrease allergy action. Decongestants are more for treating symptoms. Together they can be really helpful if they are safe for you.

Cats. I had a cat allergy question. There are no truly hypoallergenic cats. Some people will tell you this or that hairless cat or cat with less dander is hypoallergenic, but many of the allergies to cats are allergies to a compound in cat saliva. Cats bathe in their saliva, so they’re pretty much covered with it. Weekly cat bathing can help with this, and if you start when they are kittens, they usually don’t mind it that much. However, a lot of bathing can dry out the cat’s skin, so you have to keep that in mind.

If you have allergies to pets in your home, keep them out of the bedroom. Keep things clean, because skin cells and dander can hang around in carpet or dust. Use an electrostatic furnace filter, and run the fan all the time even when the heat or air conditioning is off to help keep the allergens down.

Allergy shots are another treatment for chronic allergies. They help some people a great deal, but they don’t help everyone. They are often given on a weekly basis. Sometimes an allergy is too severe for the shots to be safe.

Allergies can start when you are a kid, and you can grow out of them, or not. They can start any time as an adult. You can be stung by a bee today and not have a reaction, and tomorrow get stung again and have anaphylaxis. The first sting could sensitize you. That goes for any allergen. It is fairly common to develop new allergies in your late 20s or early 30s. Again, no one is really sure why that is.

The best way to know what you are really allergic to is to be tested. There are several ways to do that: the old scratch test, where you have umpteen labeled poke spots with allergens scratched into your skin, the patch test which is less invasive and not always as accurate, and RAST testing which is a blood test that looks for immune reactions to allergens. The fastest, cheapest, and many say the most accurate is the scratch test.

A personal lesson: for years I thought I was allergic to cottonwood trees. When the fluff went flying through the air, I was always miserable. But after testing, we found out I was allergic to something less obvious that blooms at the same time. So sometimes what you think is an obvious connection and a clear allergy really is not.

Allergies can be life threatening. That’s anaphylaxis. This is most commonly heard of related to bee stings, peanuts, and shellfish allergies. People carry epi-pens to self-inject when they’ve been exposed. Sometimes you have to have steroids to settle down a bad allergic reaction as well.

Anaphylaxis usually starts within minutes, with numbness and tingling around your mouth, hives, itching, flushing or paleness, vomiting, diarrhea, a weak and rapid pulse, dizziness or unconsciousness, and your tongue and throat can swell so rapidly you can’t breathe. These symptoms mean you call 911 (or whatever is your emergency number), do not drive yourself to the urgent care or wait to see if it gets better.

Allergies can be mild and annoying or life threatening. When in doubt, always check in with a health care professional.

Some resources:

National Institute of Allergy and Infectious Diseases

Medline Plus

Mayo Clinic

Politics and Health on the Internet

Thu, 22 Apr 2010 20:24:00 -0400

I should start this by saying I may be one of the last people to have figured this out, but I’m saying it anyway.

I have a few questions to answer but I came upon some things this week that frustrated me greatly and I want to make you all aware of them. I’m talking about internet health care politics and trickery.

As many of you know, I’m writing for a couple of websites now, and I’m seeing some things that I have long suspected were happening but now I’m certain about them. The sites I’m writing for are totally on the up and up, don’t get the wrong impression. But there are more dangerous people than your average trolls on health sites, and as someone who is passionate about health education and impartiality and non-judgmental assistance and all that stuff I am a little bent.

Politics figure big into health care. Not just in the US, but everywhere. It’s all about finite resources and who gets what and who will pay for it and who is important enough to have their needs met and who is disposable, etc. We all know that. Nurses are required to learn about the effect of politics on health care, and I was lucky to have a politically active professor teaching my course on that topic. We went down to the state capitol and talked to legislators and drank too much. It was a great learning experience even though I was already in my early 30s.

Part of the politics of health care is information sharing vs. propaganda spewing. This is where the internet comes in. Everyone has an agenda, but some of them are more worthy than others. When I get weird questions about pre-marital sex that are tagged by the questioner with an organization that pretends to have Planned Parenthood type clinics but are actually places to pressure scared girls into decisions without all the facts, I can see the agenda.

I know that people who use disinformation to steer others are legion. They have websites and go on Oprah to bash vaccination while children die of disease we haven’t seen this rampant in 50 years. They have sites that say acai berry cures rheumatoid arthritis and they cater to those who believe their alien overlords mean their children don’t get antibiotics or chemotherapy and instead can suffer and die from treatable disease.

Why am I writing this long editorial whine? I want you to be careful. You may check a reputable health website and find ranting threads about how vaccines killed children with sad, sad stories but no real facts. You may find that when people are allowed to post their thoughts without fact checking, facts are scarce.

The CDC, NIH and WHO have great factual websites. I write for websites that have great factual articles. But beware of comment threads and discussion boards. People insert propaganda into those places even on reputable sites. If something sounds too good or too terrible to be accurate, it probably is. When in doubt, get a second opinion, especially on the internet.

In Memorium

Sun, 18 Apr 2010 14:28:00 -0400

In lieu of a regular post today, I want to send condolences to an amazing family, The Norlings.

Leah lost her husband Bob to cancer today; their children lost a wonderful father. The Norlings are a strong, beautiful family, and Leah has shown strength, grace and humor throughout this awful fight.

If you want to help this beautiful family when they need it most, please send a heartfelt donation to the Norlings. Life goes on, and Leah and her children need all the support they can get. If nothing else, please send your prayers and good wishes.

for those who want to give to Leah/pocketcontents & Bob

sendchocolate:

Here is the zipcode for the BofA in NV where the account is, if you want to do an online transfer:

Account Name: Norling Family
Account #: 501008379041

zipcode: 89423

Or you can just click, if you don’t want to write a check. See how easy? please reblog…

http://www.typepad.com/services/tipjar/confirm?tj_xid=6w00e00998f266883301347fd41b31970c&blog_xid=6a00e00998f266883300e55296bf6d8834

Endometriosis

Sat, 17 Apr 2010 13:39:00 -0400

I promised someone quite a while back I would write a post about endometriosis. I haven’t forgotten. I’ve read up on it over and over to refresh my memory and was wondering to myself why it was taking so long to write about it. I figured it out last night.

Endometriosis is frustrating. Even to read about. So I can’t even imagine how frustrating it is to have. It is another one of those problems that has no definitive cause or cure.

The endometrium is the lining of the uterus. Every month hormones pump out in the natural order of things and the endometrium thickens, preparing for egg implantation and pregnancy. If no egg implants, the lining is shed, known in common parlance as your period, your lady time, your aunt flo, etc. The entire cycle from beginning to end is a menstrual cycle.

In some women, endometrial cells are found outside the uterus. This is not the norm. But no matter where these cells are located, they are still endometrial cells, so they still react to the hormones of the menstrual cycle and thicken and shed. Usually the errant patches of endometrial tissue are in the abdomen, in various areas near the uterus but outside of it instead of inside.

The abdominal cavity is not meant to have these endometrial patches outside the uterus. So they cause pain, sometimes severe. They can cause infertility, because they can attach to the fallopian tubes and interfere with the egg’s trip to the uterus. They can cause adhesions.

Adhesions are scar tissue in the abdominal cavity. The endometrial patches act kind of like when you scrape your knee. You get that scrape and sometimes it keeps oozing a little serous drainage, and if you stick a band-aid on it the band-aid can stick. Then if you try to move that band-aid, it pulls because it is stuck to the scab and that hurts. The endometrial tissue is sort of sticky, and if it is between organs, like between the uterus and bladder, it can make them stick together. That is an adhesion. Then when you move around or your bladder is full or your uterus is swollen it pulls on that attached spot. That is painful.

Endometriosis is sometimes diagnosed by exclusion. If you have all the symptoms, your doctor considers and tests for other things that could be causing them, and if it’s nothing else, it’s endometriosis. The only way to definitively diagnose it is laparoscopy or laparotomy. This means surgery. A little scope is inserted into your abdomen, and the surgeon looks around for endometrial tissue and adhesions in the abdominal cavity in laparoscopy. Laparotomy is the same idea but requires an open incision instead of using a scope. This might be necessary if there is a lot of errant tissue or if the surgeon just can’t see everything with the scope.

When surgery is done for diagnosis, often the surgeon removes any adhesions and endometrial tissue and sends the tissue for biopsy as a precautionary measure. Removing the tissue can relieve symptoms, but it may not be permanent. Just like the example with the scab, when you cut scar tissue, you can create another scar. It isn’t always a great solution, but organs that should not be stuck together can cause complications, so it is important to try and separate them if it is feasible.

There are several theories about how endometrial tissue migrates to the abdomen. These include moving through the lymph system, backwards migration up the fallopian tubes, and congenitally misplaced cells. Some theories call it an autoimmune disorder. No one really knows the answer with any certainty.

Treatment other than surgical intervention is medical. Hormones can be prescribed, including birth control pills. This regulates the menstrual cycle, or sometimes eliminates a period altogether. The treatment depends on whether you want to have children or have already had them. Endometriosis is more common in women who have never had children, and is implicated in 30-50 percent of infertility problems.

There are quite a few websites dedicated to endometriosis education and support. I recommend starting with American Congress of Obstetricians and Gynecologists or ACOG. They have a good page on this topic.

CPT 2 Deficiency Question

Wed, 14 Apr 2010 22:31:57 -0400

We had an infant (approx 9 mos old) that had become restless and the mother was en route to the Dr with it when it became unresponsive. By the time they had got to the nearest hospital it was DOA. This is the first time that any of us at the PD had heard of this, I was just wondering if you have ever had any dealings with it.

I have not personally dealt with this, but I have had adult patients with rare metabolic disorders on occasion. There are a zillion different types of genetic metabolic enzyme deficiency problems, and this is one of them. I read up a little to answer you, including the link that you sent, so this isn’t a medical explanation so much as a translation from medicalese to American English. I’m about to oversimplify, so if you are a medical person reading this, please bear with me.

A baby born with this deficiency cannot process fats properly, including fatty acids created by her own body. Your body uses glucose (sugar) for fuel. Glucose is quick energy and is required for brain function in particular. Because it is quick energy, you also use it up kind of fast, which is why you have to eat often rather than say, once a month.

If you haven’t eaten a meal for a while, your body uses fatty acids as fuel. Your body breaks them down into usable form with enzymes. If you are deficient in the enzyme you need to break the fatty acids down, your body and especially your brain will be starving for energy. An extremely low blood sugar can put you in a coma because your brain stops functioning. It has no fuel. That is what happens when you use up the glucose and can’t use the fatty acids.

Your brain and body don’t want you in a coma, so if there is no glucose and no breakdown of fatty acids, your body will start breaking down muscle tissue. Even on a cellular level you want to survive. So your body says the next thing to try eating is muscle, and basically starts shredding it into bits. This is called rhabdomyolysis. Rhabdo, as we lazy people call it, is not that uncommon as metabolic problems go. It can happen to marathon runners, and is an adverse effect of some cholesterol drugs. (Thus the warning about calling your health care provider if you have severe muscle pain, etc.)

When you start shredding muscle for energy, your body has trouble processing it. In an oversimplified manner of speaking the muscle fibers get stuck in your kidneys like pieces of yarn. Your pee turns red, your muscles are breaking down, and your kidneys start to fail because they are full of shredded muscle. Your brain still isn’t working right because you can’t metabolize all this crap properly and turn it into sugar to keep that brain fed.

The baby may have died from a super low blood sugar, or from kidney failure poisoning the body, or both. You can live a fairly normal life with this CPT 2 if you never have a crisis. But if the baby slept all night or went an extra long while between meals, her brain and/or kidneys may have just shut down and it may have happened too fast for anyone to realize what was happening. Parents don’t even always know if the baby has this deficiency. It can go undetected. It isn’t even known for sure how common the deficiency is, because it is not always diagnosed.

I hope that helped explain it for you. For everyone else, this is your link, and here is another that I found. Thanks for sending me the question! I always like to learn something new.

Grief

Wed, 07 Apr 2010 13:28:21 -0400

Grief is a bitch. There is no way around it. People grieve for many different reasons, and the process is different for each person, but the thing to remember is that grieving is a process. It isn’t an act or an event. It is a process that can take from days to years in a healthy person, and in someone who isn’t healthy emotionally it can last indefinitely.

The best-known “authority” on grieving was Elisabeth Kubler-Ross. (I put authority in quotes because the true authority is the person who is grieving.) She is a minor deity in many circles, including hospice nursing. She was a psychiatrist who was one of the first modern researchers to really look at grieving, how it works, how it affects people, and how we treat the dying. The shocking thing is that while people have been dying as long as humans have existed, this research really only started in the late fifties.

Kubler-Ross came to the US from her native Switzerland and was stunned by how terribly the health care system treated the dying and their families. We are, in all honesty, still pretty bad at it overall. That is why I went to work in hospice, and why so many nurses are huge hospice advocates. It is all about doing the best we can to make every death “a good death” for the patient, family and friends.

Once again, I have wandered off track. Kubler-Ross posited five stages of grief, and this theory has been widely accepted. They make sense as long as you remember they aren’t rules, but general stages the grieving often go through, in no particular order:

1. Denial and Isolation

2. Anger

3. Bargaining

4. Depression

5. Acceptance

Grief doesn’t only happen with death. People grieve many losses. I went through a long, kind of terrible period of grieving when I was formally diagnosed with rheumatoid arthritis. I say terrible because I spent a long time in Anger and I’m sure I was just about the most awful person to be around for a couple of years. When I had to stop working, I went through it again. I wasn’t so angry this time, but I held depression close to my chest in my crooked hands.

You might grieve a job loss, a divorce, your sibling’s mental illness; you may go through a grief process related to any loss. The trigger is often the loss of what you thought would be. If your child is born with health issues, you may grieve the loss of that ideal healthy child. The loss is the death of what could have been along with the fear of figuring out how to deal with what is.

There are many books on death and dying, on grieving actual or perceived loss. There is a website containing some of the ideas and work of Kubler-Ross and her colleague, David Kessler. One of the pages is an excellent guide to helping someone who is grieving. So often we ignore the grieving person because we don’t know what to say or do, or we have our own fears of loss that make it easier to deny what is happening. The page is titled, “The 10 Best and Worst Things to Say to Someone in Grief.” For me, the best part of the page is at the bottom:

Traits of the worst ones

They want to fix the loss

They are about our discomfort

They are directive in nature

They rationalize or try to explain loss

They may be judgmental

Not about griever

May minimize the loss

Put a timeline on loss

Traits of the Best ones

Supportive, but not trying to fix it

About feelings

Non active, not telling anyone what to do

Admitting can’t make it better

Not asking for something or someone to change feelings

Recognize loss

Not time limited

We will all go through the grief process at some point in our lives. We will each have friends or relatives who go through it as we stand by, helplessly flailing in our attempts to be there for them. The most important things I have learned in my nursing career are to listen and validate.

Just listen. Don’t think about what you will say or when lunch is or how you wish she would stop crying or anything else. Quiet your mind down, engage with the grieving person, and just listen. You do not have to fix it. You cannot fix it. Just listen.

Then validate. Everyone needs validation. Validate that you heard the person, you understand what he said, or you don’t understand and ask him to explain. The point of validation is to be there to witness, and express that you are witnessing, and that you care about what another human is going through. You don’t have to understand everything or agree with anything. You are a human being saying, “I hear you. You matter.”

Listening and validating the feelings of someone who is grieving can be very uncomfortable, often agonizing. Most of us fear death or loss or even bad luck. If it can happen to someone else right in front of us, it can happen to us. That’s scary stuff. But however uncomfortable you feel, the person who is grieving feels worse, and it is our duty as human beings to be there for each other, even when we don’t like it. Nothing is more important than supporting your fellow human.

If you are struggling with grief, get professional help. Sometimes grief can be complicated by difficult relationships. Sometimes people feel very hopeless in the face of loss. Do not allow grief to shut down your life. Get help.

I recommend a few books on grief:

The Year of Magical Thinking by Joan Didion

On Death and Dying by Elisabeth Kubler-Ross

the farewell chronicles by Anneli Rufus

Social Phobia/Social Anxiety Disorder

Sun, 04 Apr 2010 12:11:00 -0400

Social Phobia or Social Anxiety Disorder is often a life-long issue, even though it usually waxes and wanes according to what is happening in a person’s life. Estimates say approximately 2-13 percent of the general population struggles with Social Phobia.

Generalized Social Phobia is not the same as a limited fear of public speaking or other limited anxieties. It can be a little tricky to tease out if there are other mental/emotional issues in play, and the main point of doing that is for diagnostic purposes, as many anxieties or phobias related to interacting with others are treated in similar ways. In other words, some of the diagnostic criteria are more academic than necessarily helpful to the sufferer.

That being said, the official diagnostic criteria (edited for space) from the DSM-IV-TR is as follows (sans criteria specifically for children):

A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.

B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.

C. The person recognizes that the fear is excessive or unreasonable.

D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupation (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

F. In individuals under age 18 years, the duration is at least 6 months.

G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder.

H. If a general medical condition or another medical disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.

Mayo Clinic has a simpler list of signs and symptoms of the anxiety disorder:

Intense fear of being in situations in which you don’t know people
Fear of situations in which you may be judged
Worrying about embarrassing or humiliating yourself
Fear that others will notice that you look anxious
Anxiety that disrupts your daily routine, work, school or other activities
Avoiding doing things or speaking to people out of fear of embarrassment
Avoiding situations where you might be the center of attention

So what can you do about all this freaking out? There are medications, mostly SSRIs and anxiolytics/sedatives, as well as a few herbal remedies, Valerian and Kava in particular. The gold standard treatment, at least in the US, is medication along with Cognitive Behavioral Therapy.

Extremely simplified, CBT teaches you how to deal with the fear and cope with the symptoms. It doesn’t say you don’t have them; it doesn’t necessarily try to tease out the origins or blame your mother. CBT says, “Okay. When you do this, that happens. So when that happens, try this.” It is a more practical behavioral approach rather than years lying on a couch looking for clues.

I’m not dissing psychoanalysis at all. It can really help people. I’m merely describing CBT, which is a faster, more concrete behavioral approach to getting yourself under control. It is pretty successful in helping people deal with their fears and feel some ability to cope with them, even if the fears refuse to disappear.

I plan to address anxiety, panic disorders, and go more in-depth into medication for anxiety in upcoming posts.

Sources:

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association

MayoClinic.com, Social Anxiety Disorder (Social Phobia)

Long-Term NSAID Use

Wed, 31 Mar 2010 22:37:14 -0400

What can you tell me about long-term use of NSAIDS for people with osteoarthritis? I take double the normal dose a couple of times a week (with food), when I know I’ll be walking or standing for long periods. Thanks!

Non-steroidal anti-inflammatory drugs (NSAIDS) are ubiquitous but they are like most other drugs in that there are definitely pros and cons to taking them, especially long term.

NSAIDS work pretty well at treating pain related to osteoarthritis. They are sold over the counter, but they can be problematic as well, causing gastrointestinal erosions and ulcerations in some people, particularly the elderly. NSAIDS can worsen reflux, but some studies have shown that they may lower the risk of colon cancer and have a protective effect against Alzheimer’s.

If you take NSAIDS regularly, your health care provider will probably recommend you take a proton-pump inhibiter like omeprazole (Prilosec) along with them to lower your risk of GI issues. But that isn’t always enough. Click here to see Consensus Guidelines For Long-Term NSAID Use.

When you have a problem in a specific area such as an ankle, there are newer topical anti-inflammatory medications that may work just as well for you and spare you GI effects. Voltaren gel is one of the topicals. The drawback to this gel is it must be applied every four hours. But it soaks right in to your skin and goes to work on the spot.

My current personal favorite is the Flector Patch. It is like a big sticker that you stick on the area giving you problems. The great thing about the patch is it works for 12 hours and you can keep applying them to the same spot without any wait time in between. They can be cut into sections and applied to more than one spot. The only drawback to the patch is that it isn’t as convenient for some areas, like a hand. That is where the gel is a better choice.

If you have multiple areas causing you pain, NSAIDS are easier. You can’t apply a topical to every part of your body, even though the gel can go on several spots at once. When you use a topical you should not take an oral NSAID at the same time. The main thing about taking NSAIDS long term is to be careful with your dosage and be sure your provider knows what you are taking and that way you can work together on whether you should be taking prophylactic drugs for your gut as well.

Diet Question

Sat, 27 Mar 2010 20:39:38 -0400

I am probably about 80lbs overweight. Currently I weigh 360, and probably should be somewhere in the 240-280 range. I have a familial history of cartilage degeneration in the knees. Pops is 61 and due for a knee replacement this July. After a bad sprain this winter, I saw an ortho and she said that I’ve got “arthritic changes” in my knee that mean I’m losing the same cartilage.

I know there’s an easy way to prevent this: diet & exercise. But I have an immensely chaotic schedule that prevents me from packing my lunch each day, or settling into a routine at a gym.

Can you help me identify a few ways to pick better foods (the fast food lunch has the benefit of being ubiquitous and quick, but is probably like shooting heroin or something) and find some exercise in my day to day life?

The answer seems so simple. Move more, eat less. But we work too many hours, don’t live close enough to our jobs to walk to them, same with our grocery stores and on and on. Much of America is not conducive to a healthy lifestyle.

Make it easy for yourself, and less overwhelming. Go to the fast food place and get a salad. Or get lunch at a grocery store. They often have prepared salads and sandwiches among other things that are healthier than a burger and fries. Carry fruit or veges with you all the time. For example, apples and carrots are high in fiber and easy to eat on the go. If you eat foods that are higher in fiber, you will not be as hungry.

I have recently talked to several people I know who are healthy, thin, and happy. One of the things they all do is eat some of the same things all the time. Just like fast food is a habit, the apple can be the habit. If you don’t have to think about what to order, like a number 5 at Wendy’s or whatever, you make it easier on yourself. So have a fridge full of pre-made salad and greek yogurt. Carry apples and carrots in your briefcase. That sort of thing will help. At first you might hate it, but my old tastebuds can attest to the fact that your tastes will change. Things you routinely eat now start to taste gross when you get accustomed to eating real food.

As far as activity is concerned, I get the time crunch. So time yourself, and start small so you aren’t overwhelmed and disgusted. We should get an hour a day of activity, but that sounds so hard to fit in, right? Tell yourself five minutes, or two songs on the iPod. I’ll walk/dance/hula hoop for five minutes. If I still feel good, I can always keep going but if I don’t want to I can stop. Every day you can find five minutes for yourself. Go up and down your stairs for five minutes. Do situps and pushups for five minutes. Then after a week of five minutes a day, make it six.

What I’m trying to say is even tiny, incremental steps in the right direction will help you. Thinking about changing your entire crappy diet to all healthy food is great, and totally overwhelming. Going from a chair to an hour a day of jogging is not going to happen in one week. So do one bit at a time. Replace the burger with a salad and the sitting through commercials with pacing in the yard. It will become habit, and you will become healthier.

SparkPeople is a great website when you are ready to look for diet changes or encouragement from others or even just calorie counts. It helps a lot of people because there are all kinds of diet and exercise resources there in one spot, along with lots of encouragement.

A good place to look for how to cook healthier meals without spending hours doing it is Delicious Decisions, by the American Heart Association. The recipes on Delicious Decisions are based on a cardiac diet. This is the diet we should all be eating, whether we have cardiac issues or not. One great thing about this website is you can see what you have in your refrigerator or cabinet, enter it, and a recipe will pop up for you.

There are a lot of tools out there to help you, but basically it comes down to making better choices and giving yourself time. One choice at a time, one minute at a time. You deserve it.

Nursing Differs From Medicine

Thu, 25 Mar 2010 13:17:00 -0400

I want to take a moment to talk about how nursing, nursing advice, and health care education differ from diagnosing disease and practicing medicine.

In a nutshell, a nurse looks at your reaction to an illness or problem, and works to keep you well and coping with what you have going on. A nurse should not tell you that you have cervical spondylosis, that is a medical diagnosis. A nurse can talk about various neck problems and risks for issues and educate you on your neck and explain cervical spondylosis and common treatments for it without prescribing one. A nurse can explain what happens when a nerve is compressed, educate you on any medication you may be prescribed for your spondylosis, but a nurse cannot and should not make a medical diagnosis.

This may sound like splitting hairs, but it is very important. Doctors, nurses, and other health professionals have pretty specific scopes of practice. If I diagnose a medical illness, I can theoretically lose my license, face a malpractice issue, and be shunned by other health care professionals, not to mention it isn’t ethical. A doctor’s main focus is diagnosing and treating disease. That is why sometimes people feel doctors don’t care about them as much as nurses do. That is not the case, though, it has to do with our professional roles and scope of practice, as well as what we are all reimbursed for in a professional setting.

In Illinois, it is illegal to misrepresent yourself as a doctor. It is also illegal to misrepresent yourself as a nurse. If you tell a friend their problem sounds like what you had and suggest they take Motrin, no one is going to sue you. If I tell someone they have cervical spondylosis and tell them to take Motrin, because I am a licensed professional it is a different situation.

I can talk about health issues all day. I have a science degree. I can suggest educational materials for you, or even write them myself. But in the end, if you need a medical diagnosis, you need a medical doctor. If you need in-depth chemical information on your medication, you need a pharmacist. If you need health education, you may need a nurse. That’s why so many companies have telehealth lines staffed by nurses.

I’m so glad you are asking me questions, and I’ll get back to them tomorrow.

I have a pregnancy question. If I'm spotting in the beginning of my pregnancy, can I (and should I) still have sex? Will intercourse exacerbate the whatever's causing the spotting?

Wed, 24 Mar 2010 14:08:00 -0400

The answer to this question depends on the cause of the spotting. I wouldn’t do a thing until you know what is going on in there. For example, bleeding caused by placenta previa can become worse with intercourse.

I’m probably sounding like a broken record here, but it’s a good idea to see your OB or other health care professional (NP, midwife) to determine a cause before risking sex if you are spotting.

If someone has has carpal tunnel for 10+ years, is there any point in doing ergonomic exercises?

Wed, 24 Mar 2010 13:57:57 -0400

After that many years, you probably have some permanent nerve damage. The carpal tunnel/median nerve is only a part of your wrist and hand anatomy, and exercises may continue to stretch and relieve some pressure for the entire area, even if the nerve is damaged. However, some sources, including Mayo Clinic, say that doing the exercises after damaging the nerve could aggravate the pain. My suggestion, as it is so often, is to see a health care provider or occupational therapist before you do any further damage or cause yourself further pain, numbness or dysfunction.

My left thigh is "numb", in that I don't get goosebumps there and when I scratch it, if feels...muffled, if that makes sense. But it also aches intensely sometimes, usually after I'm on my feet for a long time. I've been x-rayed and MRI'ed and apparently it's just a pinched nerve. No one seems too concerned about it; should I? Is there anything that can help?

Mon, 22 Mar 2010 20:04:00 -0400

The problem with saying “just a pinched nerve” is that the nerve often becomes progressively more inflamed and what starts out as an annoying condition that can be handled with some physical therapy or even yoga becomes a permanently damaged nerve that doesn’t fully recover even after surgery.

This problem is similar to what I posted about necks last week. Imagine instead of a nerve, it is your finger. Your finger is smashed in a door and instead of taking it out of the door, you leave it in there or even slam the door on it again every day. If you would have opened the door and pulled your finger out of it the first day, it would recover just fine. But after weeks and months of pressure the damage may be permanent.

I don’t know what type of health care provider you saw or who ordered the MRI, but pinched nerves are nothing to mess with. In addition to the damage the nerve might sustain, the imbalance in your posture or the arthritis or whatever is causing the nerve problem can cause a cascade of issues.

Let’s say you have a little bone spur that is compressing the nerve. The sensation is a little off in your leg, and that causes your gait to be a little off. The funny gait stresses your other hip or knee or the other side of your spine. It sounds a little alarmist, but that is what can happen.

I suggest a second opinion, especially if this has been going on for a while. At the very least you should get a handout with some physical therapy exercises for whatever spinal nerve has the issue. That nerve pain is a symptom, not the cause of your problem.

Look at this link: Dermatomes. Dermatomes indicate the area of your body innervated by a particular nerve. The chart is like a spinal nerve map. Because you have an issue on your thigh, I know the problem is probably in your lumbar spine. I used to have a dermatome chart hanging in my office because in addition to being incredibly useful, it’s just plain neat.

Please go back to your doctor, or get a second opinion from a rehab specialist, ortho or neuro doctor.

So, I was doing a little drunk cooking last night and I burnt my hand (the fleshy bit just under the thumb joint) pretty good on the pasta sauce. I held on to an ice cube for a while, then went to bed. I just woke up and it's come up in a massive blister. What should I do for it? I'd like to bandage it so I don't bang it against anything (it hurts like a mofo), but will that slow the healing process? Should I put any kind of cream or ointment on it? What else should I do (besides put the pizza delivery place on speed dial)?
Thanks in advance, erin

Fri, 19 Mar 2010 18:30:18 -0400

I’m writing this short answer because I know it hurts!

First, I don’t know how big or deep the burn is, but basically you should put something like Neosporin or another antibiotic ointment on it and bandage it. Believe it or not there has been some back and forth about whether you should put cream or ointment on burns. Large or deep burns probably should have something like Silvadene Cream or another topical cream with silver in it (silver retards bacterial and yeast growth), but the main thing is to keep that skin soft, pliable, and protected.

That blister is protection against infection. If it dries up or tears too soon, you have a potential route for infection to enter your wound. So let the blister live for at least a few days, keep it moist and the antibiotic ointment is just another hedge against infection. If it hurts you can put ice or something on it for a bit with a towel in between the ice and your skin. The cool will feel better, but if it is too cold you slow circulation to the area and you don’t want that, either.

You might even have some sort of anesthetic spray like a Bactine or something in your drug stores there. That could help with the pain. Burns hurt like crazy, as you know. I hope this helps, Erin.

Neck Question

Wed, 17 Mar 2010 23:18:42 -0400

How do I tell if my chronic (9 days straight now) neck pain is from tension or because I pulled something? Do I need to visit a doctor or a chiropractor? If so, when?

This could be very long and involved, so I’ll do multiple spine posts. I worked neuro/neurosurgery and then in an ortho/spine clinic, but that doesn’t make this area any less grey. I can say a few things with certainty.

I didn’t post your name, but I know you are young, as in twenties young. This makes it more likely you have a muscle strain or are having some kind of muscle spasms. My first guess would be what I like to call computer neck (this website gives a good explanation of anatomy and muscle groups, but don’t feel like you need to buy anything). When you sit at a desk or computer and you put your head forward a little and round your shoulders, it puts a lot of strain on that entire area from between your shoulder blades on up across your shoulders and into your neck. If you strain this area, not only will you have what can be a really painful neck, but you can also end up with headaches because the muscle spasms can go up the back of your neck, up the back of your head and over the top to your forehead.

You should always go to the doctor ASAP if you have neck pain that is associated with numbness/tingling, burning or jolting electrical sensations in your arms (this is called cervical radiculopathy). This can indicate a pinched nerve, possibly due to a disc problem or vertebral fracture. Another symptom that should send you straight to the doc is neck issues with upper body or full body weakness or new coordination issues. That can mean pressure on your spine (this is called cervical myelopathy).

Any time you have a fall and crack your head or whiplash your neck, you should be seen by a doctor and have some sort of imaging, like xray or MRI. You can have a tiny fracture and not realize it. If it stays in place you might be fine, but if it is unstable, meaning it moves around or if a little piece of bone breaks off and is loose, you put your spine at risk. No one wants to do that.

If you go to an ortho or neurosurgeon and they determine you have spasms or a little disc problem that is not a risk to your spine or spinal nerves, they will most likely prescribe physical therapy. PT can make a huge difference, even if you only go to a few visits. It can help you avoid surgery, teach you better posture to prevent problems in the future, and what to do if you have those spasms again to head them off before nine days go by.

People still argue about chiropractors. They can really help if you have no problems that make it unsafe for you to go. For instance, if you have rheumatoid arthritis, you have to be very careful about allowing a chiropractor to adjust your neck. Go to a chiropractor with a good reputation in your area. Check the license look up to be sure they are licensed and have no complaints. If you have a lot of pain after an adjustment, or if you have visual changes, dizziness or any other symptom of compromised blood flow in your neck after an adjustment, go to the ER. It is not common, but there is a syndrome some people have if a neck adjustment is not done correctly where blood flow is compromised to your brain. That can be dangerous.

Another thing to consider is acupuncture. Acupuncture can be really great for neck pain if it is a strain and not something more serious. Some chiropractors are also certified in acupuncture, and some of them do the acupuncture with electrical stimulation. I have personally been to someone like that, and it did more for my chronic neck pain than anything else I have tried.

Lastly I will say if you are miserable, or if you feel very worried, always go to the doctor. Trust your knowledge of your body. One of the strongest signs that something is very wrong with a person’s health is their feeling that something is seriously wrong, or a feeling of impending doom. So trust your gut unless you are a silly person.

Coffee Question

Mon, 15 Mar 2010 14:00:00 -0400

Question: Why does coffee make me poop?

Coffee!

We love coffee! It is often thought of as a guilty pleasure, or an every day addiction. You don’t need coffee to live, but coffee is a wonder drug. It can also cause adverse reactions in some people.

Scientists still argue about whether coffee is good or bad for us. There are check marks in both columns, but some of the old studies showing how awful caffeine and coffee are for people have been refuted in the last few years. That doesn’t mean it doesn’t have drawbacks. Coffee can raise your bad (LDL) cholesterol levels. It stimulates gastric acid production and can be hard on reflux, ulcers and other gastric issues.

Coffee stimulates peristalsis! That is why it makes you poop. In fact, some people rely on that effect and have to wean off coffee onto other methods to counteract constipation if they have depended on coffee to keep their bowels going. Coffee also has diuretic properties.

Do you have asthma? Caffeine is chemically related to theophylline, which is an asthma drug. People who drink caffeine have better lung function for up to four hours afterward. It is a weak bronchodilator and it reduces fatigue in the muscles you use to breathe (Caffeine For Asthma). This does not mean it can replace your medication, but it can help you on a rough day.

Caffeine may have beneficial effects on liver function. That one is still being studied. In the past, coffee enemas were used to treat liver problems. I’m not saying I recommend coffee enemas. I like to drink mine the old fashioned way. Along the same lines, coffee seems to decrease progression of disease if you have Hepatitis C (Drinking Coffee Daily Linked to Lower Risk for Progression of Chronic Hepatitis C).

Coffee intake of more than four cups daily may decrease your risk of gout (Drinking 4 or More Cups of Coffee a Day May Help Prevent Gout). Of course, more than four cups daily may give you other problems. Recent studies have indicated that coffee consumption helps protect you against stroke. Contrary to popular belief, recent studies also show caffeine does not seem to raise blood pressure or cause arrhythmias in otherwise healthy people.

A study done in Japan (Coffee Consumption and the Risk of Oral, Pharyngeal, and Esophageal Cancers in Japan: The Miyagi Cohort Study) showed coffee decreased risk of oral, pharyngeal and esophageal cancers independent of diet or other factors. This is interesting considering coffee has an adverse effect on reflux and long time reflux is associated with esophageal cancer.

Many people who drink a lot of coffee also smoke. Smoking with coffee drinking changes everything. Nicotine and caffeine are both stimulants and complicated chemical compounds, but they work differently, and the two of them together have more adverse effects on your body than either of them alone. You should not smoke, but that is a different post. Just know these coffee facts are about coffee and healthy people.

Coffee drinking may decrease risk for prostate cancer (Coffee May Cut Risk of Prostate Cancer) and protect against diabetes (High Coffee/Decaf/Tea Intake Linked to Lower Diabetes Risk) as well. It seems that decaf worked as well as regular coffee in some of these studies. Coffee has an effect on insulin, glucose and sex hormone levels, and it doesn’t seem to be just caffeine related to these effects. There are many chemical compounds in coffee and it is uncertain exactly which of these contributes to the study results.

If you take medications for cardiac problems or allergies, you may have interactions when you add caffeine. Always tell your health care provider everything you take whether it is medication, herbal remedies, over the counter drugs or have a high caffeine intake. But if you are healthy and there are no contraindications, I say enjoy your coffee!