For your amusement...#pregnancyproblems

 #pregnancyproblems

When your full bladder keeps triggering unpleasant Braxton Hicks contractions, but you’re supposed to drink lots of water

When you eat a good amount of food because you’re *so* hungry, and then you get indigestion.

When you crave french fries, donuts, and popcorn, and you don’t feel like having self-control!

When you squat to pull something from the lowest shelf at work and literally fall on your butt

#pregnantnurseproblems

When pregnancy brain makes you blank out on a coworker’s name… that you’ve worked with every week for months… in front of a patient

 

When you keep getting your scrub tops wet at work because every time you wash your hands, your belly is too close to the overpowered automatic faucet

When you are past a certain point in your pregnancy and every single patient / family asks you about it

When you have a question about your patient for their provider and… nope, it’s gone.

On Crossing the Picket Line

An open letter to my fellow nurses, on strike this week:

My Fellow Nurses, 

     This week, on Wednesday, you walk out of your facility for 5 days. The same day, I and 350+ nurses walk in to take your place. Historically, those who cross the picket lines of a strike are called "scabs" by the strikers and others.   I also know that historically that term has also been a derogatory term, but I will set that aside and use that term for simplicity's sake. For decades, when employees feel oppressed or mistreated by their employers, and negotiations fail to result in adequate changes, the employees unionize, and go on strike. In mills, factories, mining sites, and grocery stores, unions have protected the rights of workers, allowing them to stand up for safer workplaces, better pay, and other reasonable demands. Unions and strikes have lead to labor legislation, changes in safety practices, and better pay and benefits. By flexing their collective power, employees get their employers to listen. A strike, as a heavy duty weapon, forces employers to listen by hitting them where it hurts - their bottom line. Companies can't make money if they can't make or move products, because their workers walk out and the production line stops. 

     So then, what if the industry is not a factory or a coal mine, but a hospital? What if the "product" is not an item, but a human being, in the form of a patient? 

     In other industries, "scabs" allow the employer to hold out longer and not give in to their employees' demands, because the industry can continue. But what if the industry will keep going with or without the workers, because the production line has no stop button? What if patients still come into the ER, still stay in the ICU and can't transfer, or have an urgent need for surgery? Nursing and health care are not like other industries. While a factory may be able to shut down for awhile with the only impact on the products and the market, a hospital can't shut down, and without nurses, patients' lives are at risk. 

     There are some nurses who still feel that other nurses betray them by coming to work in their place. But without those travel nurses in their place, eventually nurses would not be allowed to strike, because laws would be passed to protect the public from the risks. 

     Some nurses understand that nurses have to take their place when they strike, but they still believe the "scabs" help the employer not feel the brunt of the strike. Does it? Unionized hospitals carry strike insurance, which means that a great deal of the expenses they pay to have travel nurses come cover the strikers are covered. However, strikes are still very expensive for the hospital, and the costs are not always covered entirely by the strike insurance. In addition to the hourly wages of the incoming nurses (usually significantly higher than the typical wage), they also pay for their document processing, orientation, lodging, transportation, security, and travel. Traveling last minute gets expensive, so instead of paying $200-400 like you would ahead of time, they are paying $1200 for the same trip. The agency that finds and processes the nurses gets paid to do so, as well as to run the strike coverage from on site. The hospital also continues to pay benefits for all their regular employees. Additionally, patients are often diverted from the hospital when possible in order to offload it when it has minimal staff. Patients with elective procedures may reschedule or switch hospitals if they are able. The hospital loses out on the profits from those patients, even though there are nurses covering the strike.  One of the most impactful aspects of a strike, though the least quantifiable, is the impact on a hospital's public image. For healthcare facilities, the trust of the community is vital. When nurses go on strike, it hurts the facility's relationship with its community. It also impacts stakeholders and future employees, who may find out about the strike and decide not to invest there or work there. 

     "Scabs" are a necessary part of protecting nurses' right to strike, and protecting the patients of that community during a strike. 

     To my fellow nurses, who walk out of their facility this week, to ask primarily for better staffing policies so that they aren't working so much overtime that they all burn out, I support you. I hope your employer gives you what you feel you need to function, and that the strike helps resolve the situation. I hope that striking doesn't hurt any of you financially, since hopefully the union dues will help offset lost wages. Most of all, I hope you know that I will care for your patients to the best of my ability, so that they feel safe and you don't have to worry about them. I hope the minor chaos in the facility caused by bringing in so many new nurses only brings awareness to the patients and their families, so that the community will be on your side. Know that I will be speaking of you in supportive ways when I speak to members of your community. By being here, I hope I hurt your employer enough financially that it just makes sense to them to give you what you're asking for. I am glad that I can enable you to fight for your rights and stand up for yourselves, because I understand that a strike is never undertaken lightly. 

On Healthcare & Technology

     This post may be on the intersection of healthcare and technology, but in a way it's just a portion of the way technology is used - social media. Otherwise, I could make this part one of many, and I'm not sure I want to do that just yet. This came up recently at work; a family member was trying to film some nurses doing their jobs while the family was in disagreement with or simply unsatisfied with the health care team about their loved one's care.

     Today I want to share some of my thoughts on why it can become an issue that technology is everywhere, and that so many people are trigger-happy with that "Share" button for social media.  These days, most healthcare facilities have several policies on the use of technology and social media, if not a person whose job that is, or even entire departments devoted to it.  Sometimes they cover the public relations for the facility, and most of the policies relate to how staff members are expected to appropriately use technology/social media, but some are focused on how members of the public can use technology and social media while in that facility.  For example, I have heard of a hospital where the staff is instructed to not allow family members to film the birth of their child, because it's against the policy.  I think that's an extreme end of the spectrum, but let me explain some of what our thinking is (members of the health care team, that is).

     First, and the biggest concern for hospitals, is that the use of technology and social media in patient care areas is a major threat to patient privacy, which is protected by federal laws, and enforced with hefty fines against the facility. It doesn't matter if the hospital has no idea that the relatives of the patient next door to you take a picture that has your name and room number in the background, or you for that matter, and post it online, it's considered the hospital's breach of HIPAA laws and the facility pays the price.  The fact that technology is everywhere means that we have hardly any control over this happening, so if we do see it, we don't allow it.  

     Now what if you want to take a video of me while I'm doing my job, whatever the motivation?  I personally wouldn't let you film me doing my job, for several reasons, whether or not my facility has a policy against doing so.  Primarily my concern in that situation is quality of care.  I don't need to deal with the distraction when I'm in the middle of a code blue, or any situation that may arise in ICU (or elsewhere).  This use of technology is very distracting, and cannot simply be ignored, because of a few problems.  One, if you are not 100% satisfied with my care, or your doctor's care, etc,  you can put me and my facility in the court of public opinion by posting a video online, rather than through normal channels of making a formal complaint, that goes to people that hear both sides, and know all the facts and variables.  This is especially true because anyone can edit a video to show only what they want to show!  I could easily lose my job and risk losing my license because of someone's vendetta -- like I said, public relations, which sometimes necessitates that the facility take action so they look like they're doing something about a situation, even if the person getting fired is really a scapegoat.  The second problem is a more personal one: I have no control over my personal privacy if you take a video of me and post it online.  I personally am fairly cautious about what I post online, and am extremely guarded about what I own up to by attaching my own name (searchable by future employers, to say the least). If you take a video of me, and list my name (even if it's a generally positive video!) I still have no control over it.

     Thankfully, this issue doesn't come up terribly often for me, but in some areas of medicine/nursing it comes up frequently. One of those areas is, of course, labor and delivery, where people want to film their births. I think this should generally be an exception to the facility's rules about video/photos, because it's a very special moment in a family, and not merely a medical issue.  I can, however, completely understand why a facility would want to cover themselves by outlawing even that.  If something goes wrong during the birth, you have proof that you can manipulate through editing to say whatever you want when you go to sue the doctor and/or facility.  The reality is, you as the patient chose to give birth at that hospital, and by doing so must abide by their policies.  You have options (usually).

     Like I said, I think there should be exceptions to these policies. I am fine with photos and video as long as they are in the patient's room (and it's a private room) so that no other patient's privacy is infringed upon, and as long as they are patient-focused.  I would allow and even encourage recording video messages or taking photos/videos of a person who was dying, for example.  The main difficulty is that hospitals have an easier time enforcing an across-the-board, this-is-never-allowed sort of policy than any policy that involves exceptions for certain circumstances. Just look at visiting hours policies to see proof of that!

On Power

      When I was in nursing school, I had the privilege and opportunity to visit a client during our home health rotation that made a long lasting impact on my life.  This particular client was a former nurse with a rare, debilitating, chronic disease that had nearly taken her life on several occasions, and which left her bedbound, on a breathing support machine via tracheostomy.  For simplicity's sake, we'll call her "Nicole".  Although the tracheostomy limited her communication somewhat, she made it a point to impress upon my classmate and me a few key lessons during our brief visit.  Those lessons have stuck with me, even to now, three years later.  One thing she told us was to always remember that it could be one of us in her place, as the patient, and her in our place, but for the grace of God.  That was powerful to hear, and important to think about.  We should never treat our patients differently as people simply because God's plans for our lives led us to opposite sides of the bed rail. 

      The second point she made was also impactful, and closely connected to the first.  She told us that we healthcare providers easily get in the habit of unconsciously assuming that we have the power in our interactions with patients.  We come barging into their rooms without knocking, telling, not asking, patients to take their medications, or have a test done, or take off their clothes.  It's probably borne out of our intentions to help, combined with the idea that we know better than the patient what they need to do to get better, along with the urgent nature of our busy, demanding jobs.  Still, Nicole wanted us to realize that we hold most, if not all, of the power in our interactions with patients, and we need to remember to give some of it back to our patients whenever possible.  We need to knock first, ask for permission, listen to them, treat them with respect for the people they are, and give them choices as often as we possibly can.  In some cases, it may be that we can only give them a choice between taking their meds with juice or water, but once we start working with the right perspective, we may realize many more opportunities for patient choices arise.  In home health, this is even more important to remember, because you're on their turf.  It would be incredibly rude to come into someone else's home and start bossing them around, acting like they should listen to everything you say only because you're the nurse, without also giving them respect as a person.

      I was reminded of these lessons recently because I took a shift with my old in-home care agency -- my first since moving back to California -- and it was a struggle.  I expected to have difficulty with the wrong things.  Yes, it's harder to stay awake and not be bored when you're sitting in quiet darkness with no one to talk to and far less walking than my usual job.  Yes, it can be hard to remember that I can't do all my usual nursing responsibilities when I'm functioning as a personal care assistant.  What I didn't realize would be the biggest struggle was this shift in power.  In that home, I was not in power.  My usual reasons to do things my way or in my timing didn't apply because my client is on hospice.  I wasn't there to make him better, I was there to make him comfortable.  Since no one but the patient can determine if he's comfortable, it wasn't up to me.  I didn't have any reason to push him to take the meds I know would help his pain or itchiness, because it was 100% his choice.  You may think (or rather hope) that this would not be so very different from my usual job, but in most hospitals, it absolutely is. 

      Patients in hospitals have autonomy, but unfortunately most of the time that power of choice is more theoretical than literal.  If a patient declines a medication, the nurse may try to change his or her mind at the least, and he or she risks it affecting the rest of that nurse's care of him or her at the most if that nurse acts miffed about it.  I had a patient tell me last week that at another hospital, she was handed a stack of forms and told to sign them.  This is fairly standard, but what was not standard was that when she paused to read what she was signing, the nurse basically told her she didn't need to read it, just sign, and then took the papers away and documented that the patient had refused to sign them.  Now, it's not that we don't have good reasons for doing things a certain way, at least some of the time; if I try to change a patient's mind about taking a medication, it's most likely because I know it's important and not taking it could be detrimental to their health.  However, we undoubtedly cross the line, and take this unbalanced power situation for granted.

      It's an unfortunate situation that medical professionals have become accustomed to holding all the power, and using it thoughtlessly, rarely giving any power to the patient.  We need to remember that our patients are people, with autonomy and deserving of respect.  We need to look for opportunities to put the power back in patients' hands, with little decisions and big ones.  We need to remember that our situations could easily be reversed, but for the grace of God.  Last night's in-home care shift was a good reminder to check myself, examine my own habits, and change what needs to change.

Doing Our Due Diligence: Part 2

     If you are just joining me, you may want to read this introductory post to better understand where I'm coming from before reading this one.

     The topic I want to address today is a subject that has managed to polarize most of the country, one that many people have very strong opinions about, and which has even led to extreme reactions including violence: abortion.  This post will probably not manage to sum up the entirety of my thoughts on the subject, and I am certainly open to further civil discussion.  I can guarantee that not everyone who reads this will agree with me, but that is likely true of every issue.  I simply want to articulate in writing where I stand, in part for my own benefit as I verbally process my thoughts.  It has certainly become an important issue in this upcoming election, so I think this is timely.

     I was prompted to write about this issue by several things, and this post has been a work in progress for some time now.  First, I had strong feelings about this photo, seen on Facebook.

 

     This photo, and the Facebook page that generated it, distinguishes between "pro-life" and "abolitionism", which I thought was a helpful and significant distinction.  More on that in a bit.

    Another motivating factor for me was this article about congressman Joe Walsh's recent statement: http://www.npr.org/blogs/thetwo-way/2012/10/19/163239925/life-of-the-mother-never-a-reason-for-abortion-congressman-says

     That article is the second example lately of idiotic foot-in-mouth moments, unfortunately by Republicans, regarding abortion. The previous instance, referenced in the article, was Todd Akin's statement that a woman couldn't get pregnant if she were "legitimately" raped.  First of all, let us be clear that both these men are (at best) ill-informed, because there absolutely are cases of pregnancy from rape, and there absolutely are risks involved with pregnancy today, in this country, despite all our advances.  Setting aside their inaccuracies, the bottom line is that both men are trying to be pro-life without exception, right?  Neither one wants to allow any reason for abortion to continue to be legal.  Well, I have a problem with that.

     The photo above differentiated between being "pro-life" and being an "abolitionist".  It also implies that abolitionism is the only possible moral action one can take when one's moral opinion is pro-life.  I am 100% unapologetically pro-life.  I am not, however, an abolitionist.  I believe life is sacred, and all life has value, and I therefore believe that I cannot in good conscience support making abortion illegal without exception.

     Because I believe all human life is valuable and all lives should be protected, I believe the life of the mother has equal value to the life of the unborn child.  Abortion is the tragic loss of the life of an unborn baby, but if abortion was never an option, there are cases in which two lives would be tragically lost.  I believe abortion is evil, and when used without limits it is morally reprehensible, but I also believe it is a necessary evil in some instances.  Ectopic pregnancies, where the fetus is implanted outside the womb, will always or nearly always threaten the life of the mother, and the fetus cannot even survive that way.  There have been cases when a woman finds out she has cancer while she is pregnant, and although some bravely wait to have treatments until after they deliver, that is not always possible.  In that difficult situation, there is no easy answer.  I could come up with more examples, but the fact remains that this issue is not as simple as many people make it out to be.

     Secondly, because of the value of all life, I do not want to revert to the era of seriously unsafe (read: fatal) abortions.  Before abortion was legal, far more women died of infections and botched abortions.  Don't get me wrong, and don't be deceived: they still do.  There are injuries and deaths of women every year because of abortions.  Making abortion illegal, however, is not actually going to eradicate them, and it's certainly not going to help make them safer.  I am a nurse, and as a medical professional I am privy to the fact that there are less than scrupulous medical professionals who do not document truthfully.  As such, it would be incredibly easy for abortions to continue if they are illegal, because some would simply not document them as what they are.

     Many Christians (perhaps the vast majority) are pro-life and/or do not support abortion.  I think it is likely that many of them have not thought it through extensively as far as what it means to be "pro-life", but that is beside the point.  There are many Christians who believe that we must fight against abortion, in part by working to make it illegal.  Yet, we are not here to Christianize the culture, we are here to share the good news of Jesus Christ.  Although our country was founded on Judeo-Christian values, it is not a Christian nation, and will never be God's chosen nation.  By trying to make abortion illegal, aren’t we at least partly relying on the government to change what people do, rather than recognizing God is far more effective at that since He changes how people think and what they value?  I strongly doubt that debates over “rights”, whether to personhood or control of one’s body, or the successful reversal of Roe V. Wade will change people’s hearts.  Arguments don’t change hearts, they merely address the issue intellectually and may even lead to hardened hearts.

     I do think that abortion is incredibly overused.  I believe we as the medical community have failed women in a terrible way by allowing this to happen.  In part, this failure is due to our passing the buck to abortion clinics rather than maintaining a stricter control on abortions, and holding the procedures (and locations) to higher standards of safety and cleanliness, as well as performing honest academic studies on the effects of abortion on the body and particularly its impact on the psyche of a woman.  Regardless of what you think of abortion morally, everyone should acknowledge that this is a surgical procedure, and is not without risk of complications or death.  In fact, I guarantee that the clinics who perform abortions give their patients a waiver regarding these things.  I would fully support legislative changes limiting abortions so that they are not used as a form of birth control and not available to just anyone for any reason.  I’ll be the first to admit I don't know what those regulations would look like.  I do wonder what would happen if some of the people who work so hard to abolish abortion redirected their focus to that effort.  A smaller victory, yes, but I think it would be an effort in which the “pro-lifers” may find some surprising supporters and unlikely allies.

      So, if we Christians shouldn’t necessarily be putting so much of our efforts toward making abortion illegal, what should we do?   Put our “money where our mouth is”.  I once read a comment online from a person who was “pro-choice” who asked something to the effect of, “Who would adopt all the babies put in the system after not being aborted? Would you?”.  It was clear from the tone and comment that this person expected that query to make a “pro-lifer” hesitate, but I mentally answered, “yes! I would!” without pause.  I believe that kind of thing is exactly what we Christians ought to be doing.  We should be standing outside abortion clinics, not yelling in protest, but available to talk, counsel, and deter women from having abortions by giving them other options.  Our efforts through crisis pregnancy centers and community involvement should be so excellent that all women who feel they cannot handle a pregnancy should know where they can go.  We should be lovingly supporting those women emotionally, financially, and providing a place to stay.  Then, once we’ve made an impact with our actions which speak louder than words, we can have the opportunity to share the gospel with them and support and counsel them spiritually.  That should be our goal and is our calling.  Yes, saving the lives of unborn babies is vital, but saving the souls of their mothers as well as giving them the chance for life is better by far.

Doing Our Due Diligence: Part 1

      The first subject I want to address is one that may surprise some people – ultrasounds. 

      Decades ago, people thought x-rays were safe enough to be used in shoe stores and on pregnant women, and the general populace did not sufficiently question the safety of routine use of a technology approved (implicitly if not explicitly) by the medical profession.  Similarly, we have insufficient evidence to conclusively determine that the benefits of routine use of ultrasound technology outweigh its risks.  We as the medical profession have accepted the use of ultrasounds for every pregnant woman, and it is for that reason that nearly every layperson considers them normal and safe.  A simple internet search will tell you over and over that the evidence is lacking, and medical associations do not recommend routine ultrasonography.  According to the Society for Maternal-Fetal Medicine, “a fetal ultrasound with detailed anatomic examination […] is not necessary as a routine scan for all pregnancies” and, “has also determined that no more than 1 fetal ultrasound with detailed anatomic examination is necessary per pregnancy, per practice, when medically necessary (SMFM, 2004)”.  The American College of Obstetricians and Gynecologists stated, "The use of either two-dimensional or three-dimensional ultrasonography only to view the fetus, obtain a picture of the fetus, or determine the fetal sex without a medical indication is inappropriate and contrary to responsible medical practice" (ACOG 2009). [1]   

      Somehow, despite these recommendations, health care providers in the field of obstetrics continue to routinely offer and use ultrasonography.  Perhaps the problem is that we as providers are uninformed, or perhaps it is simply difficult to resist using technology that offers such an amazing view.  There are certainly a great many people who love using technology merely because we have it, holding a “why not?” view on technology.  In doing so, however, we are doing a serious disservice to our patients, who are commonly much less informed than we are and who trust us to provide safe treatment.  

      If you are wondering what the dangers of ultrasonography may be, there is an excellent, detailed article from Midwifery Today describing the risks associated with ultrasounds [2].  The short version is that ultrasound waves have been linked to low birth weights, brain cell damage, and even (possibly) autism spectrum disorders.  I have hypothesized, though I have not yet found any research on the subject, that the excessive use of ultrasonography may one day be linked to the increased incidences of ADHD as well as autism (ASD).

      Please understand, the last thing I want to do is be yet another voice preaching at pregnant women that yet another thing is dangerous to their babies.  As a nurse, I constantly emphasize to my patients that they need to educate themselves and become an informed and participative patient, and that is extremely important for pregnant women too, since we know there are things that can have lifelong consequences for a child exposed in utero.  I have included several links below to help people begin to inform themselves.

Citations:

[1] http://www.aetna.com/cpb/medical/data/100_199/0199.html

[2] http://www.midwiferytoday.com/articles/ultrasoundrodgers.asp

Links: 

1. An article (with references to multiple studies) from the Association for Improvements in the Maternity Services (U.K.), 2004: http://www.aims.org.uk/Journal/Vol16No4/ultrasound.htm

2. A study on ultrasounds from the Society of Gynecologists & Obstetricians of Canada, 2005: http://www.sogc.org/guidelines/public/160E-CPG-June2005.pdf

 Note: Although an internet search on the subject will bring up results in forums, I urge everyone to think critically about the responses and the responders' expertise, background, or lack thereof. Please question commenters who reference but do not cite "research" they use to make their point!

Doing Our Due Diligence in Health Care: Introduction

      Starting with this post, I want to begin to discuss my views on health care.  At this point, I am not going to get into the politics of health care by discussing how our nation ought to pay for it, or how I think the people who make the laws about health care should consult more often the people who actually work in health care.  I may address those issues down the road.  For now, I want to look at how we balance the use of all our medical advances, technology, and medicine, with what we know is healthful for the body, even if it means more low-tech methods and natural remedies. 

      I want to make it clear that I am not like the stereotypes of natural-health people, militantly only eating organic and/or vegan, not vaccinating their children, questioning any use of prescription medications, using home remedies, etc. [By the way, please do not be offended if you feel that I just described you; notice the use of “stereotype”?  I’m not making a statement on my opinion of any of these things.]  I hesitate to put myself in a category at all near the kind of person many consider obnoxious or preachy.  My husband called me an “integrationalist”.  Not the actual dictionary definition of the word, regarding racial integration as opposed to segregation, but in terms of my views on medicine and health care.

      I am both a nurse and a patient, due to my fibromyalgia, so I try to look at everything medical from both perspectives.  Because I went through nursing school, I have the background in medical lingo and research to understand the language of research studies and to know the importance of evidence-based medical practice.  Everything we do in nursing should be evidence-based (most all of it is), and medicine as a whole needs to be held to the same standards.  For the most part, I know it is, but there are some parts of medicine in which I believe we overstep our bounds as health care providers, and some practices for which we do not have sufficient evidence to use routinely and consider safe.  As you can imagine, this is a huge subject, but today I will start by discussing items relating to just one area of medicine: obstetrics.