Tuesday, March 31, 2009
Deciding that it was worth broaching, I launched into a brief diatribe about how people often associate TB with poverty, and a diagnosis of TB in a poor person, a person of color, or an immigrant can often feed into stereotypes and bigotry. Looking them each in the eye, I assured them that we would do our best to make sure that this does not happen, and that any public statements made about the state of TB in our community would be worded in such a way as to circumvent xenophobic thinking.
There are many diseases that cross all racial and socioeconomic boundaries. I want my patients to feel that they will not be targeted for their diagnosis, and that they are not judged for having developed such a disease. Beyond case management, medication side effects and epidemiology, we are dealing with the feelings of human beings, and their humanity must always remain foremost in our minds as we navigate the waters of disease management and treatment.
I am off to a good start with this patient and his family. We made the human connection, and that connection will serve us well as the weeks and months go by. May I always hold my patients' humanity above all else, because if humanity is honored, the rest will naturally follow.
Monday, March 30, 2009
According to our state Department of Public Health, every patient with active or latent TB who lives in the community must have a nurse case manager, and the local Public Health Nurse (if there happens to be one, that is) usually fits the bill. Thus my work is cut out for me.
Things have been pretty quiet on the TB front in my little town for the last few months, with a few patients finishing treatment and sent on their merry way. Now, without divulging any important details, I will say that a new case has emerged that involves complicated and multiple social contacts, a language barrier, sensitive cultural issues, and the potential for a media and public backlash due to the frequency of tuberculosis among immigrants from outside the United States.
When a new case of TB comes to light and is reported by a medical provider to the state, a great epidemiological and bureaucratic machine is set in motion. There are contacts to investigate, families and friends to test for TB, complicated medication regimens to dispense, and an investigation that can easily consume the time of an erstwhile Public Health Nurse who has many other duties with which to contend. Tuberculosis is serious business, and it is taken very seriously by state and federal agencies that seek to contain it wherever it surfaces. And surface it does.
In these days of global air travel, an individual with undetected (and untreated) tuberculosis can sit on a transatlantic flight for many hours as nearby passengers breathe in the recirculated air carrying the potential for infection. While not everyone on a plane may be at great risk, close contacts who have shared the same air space for a number of hours are indeed suspect, and testing and close monitoring are crucial in order to catch new infections. If the infected individual attends school, works in a restaurant or hospital, or lives in a dormitory in close proximity with others, contact investigations are key to ascertaining who is at greatest risk of infection.
My TB case load has been light these last months of winter, and for that I'm very grateful. Now, an interesting and compelling case begins to draw my attention, and I will be put to the test as I summon my communication skills, cultural sensitivity, and ability to tease out the details of what may be a complex investigation.
Saturday, March 28, 2009
Friday, March 27, 2009
With my new job being right downtown, I plan to take advantage of the warm weather by doing outreach to local businesses, visiting churches, and making inroads to various groups within our community. I find that many individuals and organizations have no idea what the local Health Department does, and most people don't even know that our town has a Public Health Nurse. In fact, some nearby towns have no nurse to call their own, so we are especially blessed to have such a well-funded Health Department.
Our Medical Reserve Corps (MRC) chapter has historically been relatively small, usually between 30 and 40 members, only a fraction of whom are actively involved on a regular basis. Although our title emphasizes the medical aspect of our mission, all MRC chapters welcome laypeople and non-medical professionals into our midst, since a diversity of talents and strengths is indeed important in emergent situations. Thus, we are actively recruiting veterinarians, clergy, business owners, IT professionals, HAM radio operators, and any other people who are simply interested in being of service when the proverdial feces hits the fan.
While members of the MRC are all trained to respond to emergencies and lend a hand when police, fire and other entities are overwhelmed (MRC's have assisted in hurricanes, floods, fires, and other incidents), we also like to do community outreach and emergency preparedness education. Thus, some of my Springtime efforts will include outreach to seniors, church groups, civic organizations (like the Knights of Columbus), and private and public groups of all sizes and persuasions.
Beyond that, working in town also gives me a route by which to take the "pulse" of the town, talk to people about my work, and enlist community partners in improving public health in its myriad aspects.
Spring has certainly sprung, and I want to take advantage of the pervasive feeling of optimism in the air, reaching out to those who might be willing to contribute to improving the overall health of our community.
Wednesday, March 25, 2009
As dry as this topic may seem, there is a passion that people in the public health world feel for this work, and many people have dedicated entire careers to this avenue of work. As a newcomer, I listen, watch, and feel my way through this maze of information, and I consider the many decades of human effort that have led us to this point in history.
The 20th century was very much focused on the control and eradication of communicable diseases like polio and measles. We've done a pretty good job in that arena, and vaccine-preventable diseases have been on the run for some years, at least in the industrialized world.
Now, multidrug-resistant TB, HIV/AIDS, malaria and other diseases have us on the run, and the fight is raging around the world. Billions of dollars are being spent every year, and philanthropic organizations like The Gates Foundation feed a great deal of private capital into some of the larger public health engines that drive the action.
For myself, I'm a very small cog in a series of multilayered wheels that turn in combinations still beyond my comprehension. While I see my actions as very small when compared with what's happening "out there", I also recognize that my interventions on a local scale---counseling a patient with TB, vaccinating a child, preventing illness---are part of a wider web that is made even more meaningful (and, in fact, effective) based on the very small, local actions of a multitude of individuals.
Prevention, surveillance and protection of the public is a year-round and frequently thankless job. Public health happens in the background, if you will, and the public and the media generally only think about such things when something goes wrong. This is understandable, and if the price of such vigilance is relative anonymity in a world made more healthy and safe by their diligence, most public health professionals would probably accept that outcome with a knowing smile.
I am still surfing on the learning curve, gleaning what I can from every day on the job, and relishing the lessons that bring new personal and professional meaning and importance to my work. It's an interesting ride, and I'm often impressed by the multifaceted nature of the field into which I have so recently stumbled.
Tuesday, March 24, 2009
"World TB Day is observed each year on March 24 to commemorate the date in 1882 when Dr. Robert Koch announced the discovery of Mycobacterium tuberculosis, the bacterium that causes tuberculosis (TB). Worldwide, TB remains one of the leading causes of death from infectious disease. An estimated 2 billion persons are infected with M. tuberculosis. In 2006, approximately 9.2 million persons became ill from TB, and 1.7 million died from the disease. World TB Day provides an opportunity for TB programs, nongovernmental organizations, and other partners to describe problems and solutions related to the TB pandemic and to support worldwide TB control efforts. The U.S. theme for this year's observance is Partnerships for TB Elimination."
The CDC states that, following more than three decades of decline, worldwide TB cases increased by 20% from 1985 to 1992. And although concerted global efforts have attempted to stem the tide, multidrug-resistant tuberculos is on the rise, and certain ethnic and racial groups are still significantly vulnerable.
To access the CDC's Division of Tuberculosis Elimination, click here.
To visit Stop TB USA, click here.
To read several of my previous posts about XDR-TB, click here or here.
Saturday, March 21, 2009
With my public health nurse position consuming 30 hours of every week (and a large percentage of my cerebellar real estate), my per diem hospice position was so much background noise cluttering my mind and causing me professional anxiety. All of us who work in health care are acutely aware that maintaining a position at any facility or agency means that one has to attend trainings, keep up with changes in policies and procedures, and keep one's finger on the pulse (pardon the pun) of the organization. As a per diem nurse, this can become quite a challenge when one's life gets in the way of staying abreast.
In January of 2008, I quit my full-time case management position and entered a period of self-employment, working a number of part-time and per diem positions, consulting gigs, and online writing assignments. That professional juggling act was exciting and novel, but now that I've settled into a more or less full-time position in a demanding municipal job, keeping up with other agencies' changes and demands becomes less and less attractive and more of an emotional and mental drain.
Giving up my position of per diem hospice nurse is a mixed decision, and one that I make quite consciously. Hospice nursing is close to my heart, and is an area to which I would like to return in the future. However, as a per diem who only takes a shift from time to time, I find that making hospice visits causes me considerable anxiety and concern. When one works with the dying on a regular basis, knowing what to say and what to do becomes second nature. The symptom management, the medications, the little tricks and trade secrets all live in a Rolodex in the nurse's brain and are easily retrieved and shared. For me, those tips and secrets are not second nature, and I am loathe to deliver care that does not conform to a standard of excellence to which I hold myself wherever I work (and I recognize that this is also not in the best interest of the patients and families that I would serve).
As a public health nurse, I am no longer delivering direct care, and I do indeed sometimes miss the direct patient contact and assessment that goes hand in hand with that form of nursing. Less than a few years ago, I was a Nurse Care Manager, overseeing the coordination and care of more than 80 chronically ill patients living on Medicaid in the inner city. That work was a part of my personal and professional identity, and was also great fodder for my writing here on Digital Doorway. But my life has changed, and I have entered a period where nursing has taken on a different veneer, and instead of providing nursing care to a group of individuals, I provide the attention of a nurse to an entire municipality, its residents and its employees.
Letting go of my direct care positions is done with mixed emotions and a great sigh of relief. I have no doubt that my nursing career will take many twists and turns in the future, but for now, I am shedding what feels too burdensome, knowing that one closed door only makes room for ten more doors to open.
Thursday, March 19, 2009
Tuesday, March 17, 2009
Every week, it seems, I have to create yet another username and password for yet another website to which I need regular secure access. Although I try to use the same (or similar) password for everything, sometimes a new formation is required and my brain is further taxed in its ability to access its RAM. And now it seems some sites even require lower-case letters, upper-case letters, numbers and symbols all in one password! The ol' cerebellar hard drive is not what it used to be and no upgrade is forthcoming, at least not in this lifetime.
In my medical work, I now have access to so many programs and databases of medical information, it's hard to keep straight where I am in my password tempest. Several of the programs that I use to access confidential patient information require a change of password every so often, each password being subsequently unrepeatable once changed. Do those programmers know what they're doing to my 45-year-old brain? I bet they're all techie brats in their 20's, hyped on caffeine and sugar with an overstock of neurons. C'mon, guys, I need a break!
Passwords and usernames aside, I add to this tangle of neurons so many other numbers and combinations of numbers: medical record numbers, dates of birth, phone numbers and addresses. So many pieces of information are taking up valuable hard drive space as we speak. Do I need a virus scan? Wait, I have a Mac now, but is my brain licensed by Apple? Where's that warranty?
Computers and computer-driven interactions are certainly here to stay, and as hacking becomes an ever-growing popular sport, our need for increasingly changing and complex passwords will only grow. If only all of those hackers would put their considerable brain power towards solving hunger or curing diseases, we could all relax and let down our digital guard. I expect that this will ne'er come to pass, thus I continue to transmute my various combinations of letters, digits and symbols to satiate the hunger of demonic programs and websites which demand my mind to remain sharpened and alert as I protect my precious information (and that of others) through alphanumeric trickery.
The woes of the digital age are many, but I'm sure that hunting and gathering had its drawbacks as well. Such is the yoke we wear in this digitized third millennium.....
Friday, March 13, 2009
According to an article on BloggerBuster, the Europe-based Wikio ranks blogs based solely on the number of times a blog is referenced within posts on other blogs. On the other hand, Technorati (the most popular and well-known blog aggregator) ranks blogs based on references, backlinks, and blogrolls on other blogs.
Digital Doorway has been referenced on many "best of" lists over the years, and I am eternally thankful for every mention, blogroll, backlink, and other honor that readers choose to bestow. Blogging has been quite an education for me, and I look forward to continued surprises and successes as the years (blog)roll by.
Sunday, March 08, 2009
For women of color who want to be nurses, I am even more adamant that there will be money available for them if they want to pursue it. African American women, Latina women, Asian women, Native American women, Pacific Islanders---nurses of color are needed and there apparently will be money available for those particular groups to pursue their healthcare-related education. Of course, no government pool of money appears to be unlimited (unless, of course, it's money for bank and corporate bailouts), and some of these women and men will not be able to avail themselves of appropriated dollars to pursue their goals. Still, nurses are needed, and as nursing schools build capacity to educate more students, the best and brightest with the most robust resumes will have a corner on the market.
At this point in history, if I was a wannabe nurse, I would get on the phone, interview every nurse I could find, look for places to volunteer and learn, insinuate myself in places where a pre-nursing student would be a welcome extra pair of hands, and I would then proceed to make myself indispensable.
I would build relationships with nurses, doctors and other sympathetic professionals. I would read books and magazines, and then troll the internet for the latest information on nursing scholarships, the hottest nursing schools, the schools with the highest level of open spaces for new students, and the schools without specific faculty deficits. I would befriend nurse bloggers like myself and get the inside scoop on as many aspects of nursing and nursing education as
Once I chose the schools that interested me, I would write to the Dean of Nursing of each school, request informational interviews, meet with faculty if possible, and ask current students what they felt most helped them to get accepted. Making friends with the administrative assistant or secretary at each school of nursing would also not hurt my cause, especially if some gourmet chocolate found its way to their desk when I paid a visit.
Once contact was made, I would send hand-written notes to each Dean or faculty member who met with me, and I would subsequently follow up by email periodically to ascertain any changes or developments.
This may all sound cynical and calculated, but I truly believe that in a world where loans and scholarships for a limited number of slots in a limited number of nursing schools is the norm, building relationships and connections is the best way to find your way into the school of your choice, or at least a school which you would accept attending if need be. Also, one secret at this point in history would be applying to schools in multiple regions of the country. The Northeast , Southeast and West Coast are densely populated, and it would behoove pre-nursing students to examine schools somewhat off the beaten track in regions of the country which are perhaps somewhat less desirable places to pursue an education.
Nurses will be needed in droves for many decades to come as Baby Boomers continue to retire in ever increasing numbers, and as the most trusted people in America for the seventh straight year, nurses are in good moral and ethical standing on a societal level. While nurses may not always earn salaries commensurate with their level of education and expertise, they are desirable professionals providing a valuable and meaningful service to millions of people every day.
Nursing will perhaps soon enter a new heyday, wherein nurses assume an even more central role in health care as preventive care gains an increasing share of the limelight. Most nurses are experts in preventive health care, and we need more nurses to educate and care for the aging population of the U.S. (and other countries).
So, Dear Reader, if you are a wannabe nursing student with a fire in the belly and an itch to get that education under your belt so that you can wield a stethoscope and the ubiquitous nurse's pen, work those connections and hit the ground running. Now is the time to jump into the fray as nurses continue to be the growing edge of the health care industry.
Friday, March 06, 2009
Essentially, the Bush Administration had made it relatively easy for large corporations to protect themselves against lawsuits at the state level, even if state regulations are tougher than similar federal regulations. In this particular case, Wyeth claimed that it was protected by the FDA's labeling of the drug, yet Vermont regulations went further than the feds, and the Supreme Court has sided with states' rights in this regard.
I am not a legal scholar by any stretch, and cannot even begin to understand the nuances of this decision and its ramifications. However, from the point of view of compassion for an individual who suffered an enormous loss, this decision states quite clearly that those who suffer from negligence can indeed receive compensation for their suffering despite federal regulations which seek to protect corporations from such litigation at the state level.
The injured woman, a musician by vocation, lost not only her arm but her means of supporting herself financially. While it has been admitted that the physician assistant who administered the medication IV push was basically following the FDA-approved label for the use of the medication, the label still lacked sufficient warning that such a technique was extremely risky, at best. What is at issue in this case is that federal regulations protected Wyeth Pharmaceutical from liability based on litigation at the state level. With this decision, those federal regulations are brought into question, and thousands of injured individuals---and perhaps whole communities---may now be in an entirely different legal position than previously thought.
Legalities aside, my personal feeling is one of celebration for this woman who lost her arm, her vocation, and a calling that brought her such joy and personal fulfillment. I rejoice for her victory and for the financial freedom that this compensation will afford her. In terms of the legal issues surrounding the case, I will leave that to the scholars to debate, and that debate will likely rage for years to come.
Thursday, March 05, 2009
"I am now seventy-eight years old, and have seen so many, many things during my lifetime.
"So many young people have died, so many people of my own age have died, so many old people have died. So many people that were high up have become low. So many people that were low have risen to be high up. So many countries have changed. There has been so much turmoil and tragedy, so many wars, and plagues, so much terrible destruction all over the world.
"And yet all these changes are no more real than a dream. When you look deeply, you realize there is nothing that is permanent and constant, nothing, not even the tiniest hair on your body. And this is not a theory, but something you can actually come to know and realize and see, even, with your very own eyes."
DILGO KHYENTSE RINPOCHE
Wednesday, March 04, 2009
Just the other day, I was meeting with some regional public health colleagues, and I let it be known that I have started publishing a blog for my local health department. One individual claimed to not know what a blog was (as he lifted his head from under a very large rock). Then the light bulb went off: I would offer a class in Blogging 101 to my colleagues so that they could also have blogs for their local health departments. They were (mostly) thrilled, except perhaps for the hapless middle-aged man emerging from under aforementioned rock.
Moving on from blogs, I entered the Twitterverse several months ago, and began to utilize Twitter for the purpose of micro-blogging and networking. Just this week, my public health and emergency preparedness colleagues realized that Twitter has only recently hit the big time, with the events in Mumbai and the plane crash on the Hudson River being disseminated on Twitter before the mainstream media knew what hit them. Seeing this new reality, many colleagues now see the usefulness and immediacy of Twitter, and I will apparently be offering another class in the art of tweeting quite soon. Hooray for new technologies.
So, my use of the latest technnology and communication tools has parlayed itself into my being able to offer an introduction to such tools to my colleagues who so desperately need to fully enter the 21st century. However, change is the only constant in this universe of ours, and by the time I master Twitter and the art of blogging, a new form of communication will emerge, calling for my (slightly divided) attention. Until then, blogging and tweeting are the forms of the day, and I will soon introduce a very interested cohort of professionals to these extremely useful and contemporary technologies.
Monday, March 02, 2009
According to the 2008 Gallup Honesty/Ethics Poll, nurses are once again in the #1 spot, and have been for the past seven years. In fact, 24% of respondents rated nurses' ethics as "very high", whereas 60% rated nurses' ethics as "high", with only 1% rating nurses as "low" on the ethics scale. Not surprisingly, bankers did not fare so well, along with stockbrokers, people who sell cars, lobbyists, and telemarketers.
My blogger friend points out in her article that the general public adheres to a "nurses are angels" ethos wherein nurses are still regarded as angelic and selfless individuals who serve others due to their higher-than-normal moral standing and ceaseless desire to give. While this "nurse as angel" motif is indeed quite vexing to those of us who would like nursing to eschew it in favor of simple professionalism, the public's consistent habit of equating nurses with the angelic realm has certainly cemented our status as a trustworthy source of care for the infirm. Now, if we could trade in those angel-nurse statuettes for higher salaries, I'd be delighted.
Setting those ridiculous and maddening nurse angel images aside, nurses are indeed a very trusted group of people in many societies, and here in the U.S., it seems that Americans hold us nurses in very high esteem. Personally, I'm happy to be a member of a profession that is so revered. Taking that into consideration, I feel strongly that the nursing profession should more aggressively utilize this trust as a means to, 1) recruit more people into the profession, 2) gain further recognition as a true profession (not just a "calling") with its own code of ethics and standards, 3) advance recognition of nursing research, 4) parlay that trust and recognition into higher pay and better benefits, 5) demand government support for those wishing to enter the profession, and 6) pressure the President to create an Office of the National Nurse that would be on equal footing with the Surgeon General in terms of public health and national health policy.
Nurses have earned the trust of millions of Americans, and it is my point of view that the nursing profession should intelligently and wisely parlay this trust into an acceptance of an agenda of greater professional recognition and increased earning potential.
Speaking of earning potential, here is a conundrum that is especially troubling to this nurse who has actually seen his salary decline over the last few years. If lobbyists, lawyers, bankers, stockbrokers, business executives, and members of Congress rank so low on the public's list of trusted professionals, why do those groups earn so much more than nurses? If nurses are so revered by our society, why are we not paid on a scale that matches the importance of the service which we provide? And why don't pharmacists (the second most trusted professionals) and high school teachers (the third most trusted) receive remuneration equal to their societal value and level of public esteem? As corporate CEOs walk away with multimillion dollar severance packages and bonuses at a time of economic implosion across the board, why aren't the professionals who have actually earned the trust of the American people rewarded for that trust?
Nurses have served the public in myriad capacities for many centuries, and like physicians, nurses frequently hold lives (and troubled hearts) in their capable hands. It is an honor to be a nurse, to know that I am a member of a profession held in such esteem, and I honestly and consciously work to earn that esteem as I execute my professional duties.
My blogger friend feels that nursing is a "unbreakable" profession, trusted and needed by all who interface with the health care system. Yes, we are unbreakable, and as a profession we use integrity, competence and character to garner the trust that is so freely given to us by an appreciative public. Integrity, competence and character are truly a great foundation, and that strong foundation is what will continue to carry us through the difficult times ahead.
Sunday, March 01, 2009
According to the Washington Post, 83 Americans under the age of 18 died from complications related to influenza last year. This year, 17 young Americans have died, not including the two Maryland teens.
Checking in on the CDC website devoted specifically to influenza, 24.6% of all specimens submitted to the CDC for testing have been positive for influenza, and the proportion of deaths is well below the "pandemic threshold".
In terms of the flu vaccine, it appears that several circulating B strains are indeed not covered by this year's vaccine, and several strains are also showing resistance to common antiviral drugs. Still, public health officials and the CDC recommend vaccination in order for susceptible members of the public to be afforded the most protection possible.
When checking on Google Flu Trends, one notes that high levels of flu activity can be seen in most regions of the country, although overall flu activity for the United States is still deemed as "moderate". This information mostly concurs with that of the CDC surveillance site, where widespread activity is seen throughout the northeastern, southeastern and southwestern US.
In terms of pandemic flu, resources have been mobilized by the federal government to prepare for such an eventuality, and public health officials like myself are regularly updated on how national preparations are developing. Unbeknownst to most Americans, enormous stockpiles of antiviral medications are currently stored in massive warehouses in every region of the country, and this Strategic National Stockpile (SNS) can be mobilized and delivered to local municipalities within 24-48 hours of its activation. Many of us public health officials have surveyed local schools and buildings as SNS sites for emergency dispensing of such medication, and plans have been submitted to the CDC so that we can quickly receive these deliveries from regional SNS sites.
The 1918 flu pandemic that killed anywhere from 20 to 100 million people worldwide does indeed seem like a long time ago, and protections against such an eventuality were at that time completely nonexistent. These days, the flu vaccine (which we realize can be woefully inadequate at times) and antiviral medications (to which some strains of the flu are resistant) do offer us some modicum of protection. Adding insult to injury, we are now seeing many secondary bacterial infections in patients with the flu, realizing that some of those infections are themselves antibiotic resistant organisms like MRSA (methycillin-resistant staph aureus), adding yet another layer of complication to the prevention and treatment of acute influenza.
Not to paint a picture of doom and gloom, I am simply pointing out that the surveillance, treatment and epidemiology of influenza has become increasingly complicated in the 21st century, and the likelihood of further resistant strains developing is rather high. Since most epidemiologists feel that a worldwide pandemic is indeed likely in the coming century, it seems that the judicious use of government resources to prepare for such an event is indeed quite prudent.
While I have not personally been touched by an influenza-related death, I feel deeply for the parents of children who have died during this flu season, and I hope that our collective efforts to thwart further unnecessary and tragic losses are widely successful. We've seen that influenza is no laughing matter, and being prepared for the worst often seems to be our best defense.