Author: writenp

Testing 1 2 3

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The Covid tests on my schedule are like the bread in a sandwich, first part of the morning and last part of the afternoon. It’s done like this to preserve PPE, a term sadly, everyone seems to know now. The positivity rate in our clinic is high — 30% — much higher than in the surrounding area. This is because our patients cannot afford not to work, even if the conditions are unsafe, even if they themselves are sick. They do not have the luxury of social distancing in their crowded homes, often with rooms rented out to strangers to help pay the rent. They are also Latino, for the most part, which puts them at greater risk as well. They tend to have comorbidities such as Type II diabetes, obesity, and high blood pressure, which may them more susceptible to the virus but undoubtedly makes it more dangerous for them should they contract it.

But today I am writing not about them, but about me. Which is selfish, I know. As I mentioned before, we have enough PPE, which is wonderful. Our medical director cares about our safety. We are directed to wear eye protection —  face shields or goggles — as well as a medical grade surgical mask, to each and every encounter. When we are testing for Covid, we wear N95 masks, surgical gowns and gloves in addition to the eye protection. But still I worry. When positive results come back, I review the visit. Did I lift up my goggles just a bit to better see the computer screen? Was my mask gap-free all the way around? Did I remove the PPE properly? Did I avoid touching my face? Most of the time, after so many tests in a row, it is impossible to remember. And impossible not to worry about my own and my family’s health.

This is a second career for me. Being late to the game, I was never going to be in the ER or ICU. I wanted to be in community health. Far from being an adrenaline junkie, I take pride in getting to know my patients during a first physical and helping them on the road to better health. I like to cheer their progress and try to help them overcome the obstacles of chronic disease. It’s enough. Sure, it’s discouraging at times but the small victories are sweet.

That’s all changed now. We are encouraged to do virtual visits, which is sometimes difficult for our patients to manage. Still plenty of patients just walk in and sometimes, no matter how well the staff questions them, they only reveal their exposure to Covid and need for a test, to me. Who is not currently wearing an N95 and needs to back out of the room to get one along with a gown and gloves.

Of course this is nothing like what my compatriots on the front lines face every day. There aren’t enough words to express my admiration for them, along with the acknowledgement that I could never do what they do. This is about me (remember, I’m being selfish here) and my unglamorous and usually not life-or-death work-day. A day that used to be filled with physicals and pap smears and well-baby visits, with the occasional strep throat, UTI, or STD thrown in to jazz things up. Sometimes a grind, yes, but infinitely preferable to the current situation. What I did was important in its own way and I mourn the loss of that kind of routine health care. I hope in the not so distant future, the ability to deliver that kind of care returns.

Asking the Nurse Next Door: What I Tell Family and Friends about Staying Safe During the Pandemic

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I never learned to intubate, only suctioned a dummy, and can’t start an IV. Procedures are not my strong suit. The skills I pride myself on — diagnostics, well visits and health screenings,  follow-up of chronic health conditions, and communication, aren’t particularly useful in the thick of the pandemic. I’m sure they will be again, but for now, I try to use my training to make sense of the science and to advise friends and family when they ask. Or in the case, of my children, even when they don’t.

Before I go on, a caveat: this information should not take the place of consulting with your health care provider. Especially if you are vulnerable due to a compromised immune system, age or other health conditions, you should follow expert advice to the letter and err on the side of caution. The CDC and local department of health websites are excellent sources for timely information about best practices for protecting your health in this changing situation. Think of this as my attempt to share, in layman’s terms, what I believe, and what I am doing currently for my own well-being.  

In terms of the science, there is so much unknown. When I first started hearing about the virus’s infectiousness, I questioned whether it was spread solely via droplets as was being reported.  The way the virus has spread appears more like a hybrid of droplet and airborne contagion. Both tuberculosis and chicken pox spread through the air, which explains why they are so very contagious. We’ve also learned that duration of exposure and dose of virus particles are key to whether you are going to get infected, and perhaps how ill you will become. Of course, age and other health conditions also play a role. But we have seen young, healthy people get very sick and even die, while some nonagenarians survive. And then there are questions about genetic immunity, whether it’s blood type or some other genetic determinant that makes the lungs more susceptible to the havoc Covid !9 can wreak. We will understand so much more of this in time, but for now here’s what I do, and suggest others do to be safe without going crazy.

When you leave your home: Always have a mask that covers your nose and mouth ready, in case you cannot maintain a distance of at least six feet. I am a runner and hate running with a mask on – it makes me gag. But I have one around my neck before I venture out for a run and if there’s a chance I will come closer than 6 feet to someone, I put it on. Always wear a mask when entering an enclosed space. Avoid touching your eyes, nose and mouth. And wash your hands for 20 seconds as soon as you enter your home.

Grocery shopping. From what we think we understand at this point, the risk of contracting the virus is inversely proportional to the amount of time exposed and the dose of the virus – ie, whether you are exposed to copious secretions of an ill person up close. So masked, socially-distanced-grocery shopping is not as risky as we once thought it was, as long as you take precautions. Have a list and be efficient so you can limit your time. Sanitize your cart. Use hand sanitizer once you are back in the car, or when your leave the store, if you are walking.

Taking in mail and packages. While the virus has been said to exist on surfaces up to 72 hours in ideal conditions, keep in mind that conditions outside the lab are not ideal and viruses are notoriously fragile. At the onset of the pandemic, I used to leave the mail and packages on a table for 48 hours. Now I am not as worried so I am just careful to thoroughly wash my hands after handing deliveries.

So far these are all caveats, and isn’t it tiring to always hear what not to do?

Here are activities and routines that help me feel better during this stressful and uncertain time: Maintaining a healthy diet with lots of fruits and vegetables and drinking plenty of water. Sticking to a regular sleep schedule. Not overdoing it with the alcohol. Exercising vigorously 3-5 days a week and getting outside every day.  Plus limiting the times I check news and social media during the day.

These are the health-related items I tell my friends and family to have on hand: A thermometer, acetaminophen, and a pulse oximeter to measure your oxygen level if you get sick. This last item will help your health care provider determine how your lungs are functioning and whether you might need to go to the hospital for breathing assistance. A spirometer is also a good thing to have to exercise your lungs if you are sick. You likely used one if you’ve ever had surgery. All of these items are available on-line and some at drugstores.

Okay, what else? I for one have been trying to live more in the moment, not a natural thing for me. Setting some time aside to meditate, or just breathe slowly and let your mind wander. Just a few minutes will help and is worth it no matter how busy your lock-down life is with work, childcare, school. Plan things for which you can look forward with happy anticipation. A walk in the park, a game or book. And yes, this is the time to binge watch for entertainment. Definitely schedule virtual meetups with friends and relatives even if they feel artificial at first.

Looking ahead. Yes, things are loosening up, for sure. The other day we had our first social event in real life since the lockdown. We sat on our next door neighbors’ open deck at our own table at least 6 feet away from theirs and we brought our own libations. But no masks since we were outdoors. It felt incredibly liberating. We will plan similar gatherings, but at this point, always outside and socially distanced. We might consider sharing food in certain situations but will be especially assiduous about hand disinfecting and not touching ones face. That’s it for now. Stay well.

All rights reserved. © 2020 by Eileen Healy Carlsen

Saying Goodbye

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It is never easy. It’s the promise you make when you first take your puppy home. You are going to do your best to give him a healthy, happy life. Though you can’t imagine it at the time, when that playful ball of fluff exemplifies all that is joyful in life, there is another promise implicit in the first: when the quality of that life deteriorates, when your dog is neither healthy nor happy, you are going to facilitate a peaceful, comfortable death.

We have had to say goodbye to five cherished pets this way, keeping our promise as our hearts were breaking. Yesterday, it was our beloved 12 ½ year old English labrador, Logan, whose failing kidneys led to failure of his other major organs, leaving him bewildered, very weak, and miserable. He had a good death: a peanut butter treat to distract him from the sedative, a few minutes of drowsiness while he was being petted and kissed, and then the final injection which sent him into oblivion. His suffering was over, while our grieving had commenced. We toasted dear sweet Logan that evening, remembering his goofiness, his annoyingly incessant licking, his joyfully wagging tail which could knock over a full cup of coffee, his friendliness to all, and his pure loving heart.

When and if I am in that state, I would welcome that same death to mitigate my suffering and that of my family. Under current law, that is not my right. When my parents were each dying of cancer, they would have welcomed it as well. The best medicine had to legally offer was strong and stronger opioid doses which rendered them pain-free (I hope) but too out of it to recognize even me, their only child.

A sad state of affairs and no easy answers, I know.

Consumption

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I find the magnitude of consumption of health care frightening, and I’m a health care provider. I’m not talking about preventative care, which I think, if anything, more people should consume.  And of course people must seek care for sickness and trauma. I am referring to medical testing and specialty care.

Medical tests such as blood work and imaging studies (x-rays, MRIs, CT scans, and ultrasounds) are overconsumed. Most health care providers, in their personal lives, are quite prudent about their own consumption of medicine in general.  We know that every test has a downside and we want to be sure the information it will provide overcomes the potential risks.

Many people, particularly those with very good insurance, think when it comes to testing, more is better. I understand that some people really want assurance that there is nothing wrong. My Spanish-speaking patients frequently ask me — “favor de chequear todo” — to test for everything – including all cancers, to get a clean bill of health.  Of course that is not possible.

Another type of excess consumption occurs when patients want to consult a specialist for the most minor of complaints, ones that could easily and safely (not to mention more economically) be taken care of by their primary care provider. Specialists are a great resource but if one sees a myriad of specialists more than your primary care provider, sometimes health care suffers. It is very possible no one is stepping back to take a holistic approach to you as a whole person, not just a foot or a heart or a GI tract.  Patients don’t always tell their PCP which specialists they’ve been to and specialists don’t always send a report, especially if the patient has not provided a PCP because they don’t need a referral.  Contrary to popular belief, providers don’t all know each other and records don’t magically get sent to your provider’s office. This is especially problematic when medicines are prescribed and there is not a complete list which would make checking for potential interactions possible.  You as the patient need to be pro-active about this, for your own good health.

While it is true referrals are a pain for all concerned, the concept of a gate-keeper for your health, i.e., the PCP, is a good one. Yes, insurance companies use the referral mandate as a way to cut costs, but the upside is that your PCP knows what is going on with your health. We can help you determine which kind of specialist to see, if warranted. Often this is not as clear-cut as one would imagine.  So even if you don’t need a referral, you might want to talk to or message us about what is going on and why you think you need to see a particular specialist.

That being said, there are some medical offerings I wish my patients would consume more of.  Screening colonoscopies and flu shots come to mind.  I sometimes have to have to push very hard for both.  Hope you got your flu shot this year – it’s still not too late. While it’s true it’s not as effective at preventing the flu as it’s been in past years, the efficacy is still around 30%.  Way better than nothing.  Plus the flu shot mitigates the severity of influenza if you are unlucky enough to still catch it.  I was very grateful for even this level of protection when I was taking care of patients with influenza last week.

Stay healthy, and be mindful of your medical consumption.

©2018 by Eileen Healy Carlsen, FNP-BC.  All rights reserved

Living Like A Dog

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The expression, dying like a dog, has a negative connotation.  Not sure it should.  It evokes the image of some poor canine smashed by a car and taking its last whimpering breath alone on the side of the road.  We’ve had many dogs, and when it was necessary, facilitated good deaths for them: a special meal, a comfortable bed, petting and paw-holding as the needle went in. But this post isn’t about dying like a dog, it’s about living like one, especially in the face of medical uncertainty.

Dogs don’t even try to make sense of the universe. Maybe that’s why they sleep so well. They wake up each morning with high hopes, tail-waggingly ecstatic just to be alive and with their family to start a new day. They like their routines and have certain expectations, sure. Something good happened once, maybe it will happen again. Like breakfast kibbles. Or that bird who flew into a window and landed stunned at the bottom of the outside basement stairwell. Our three dogs checked that space for months afterward for another gift from heaven. (Don’t worry. We rescued the bird before it came to any harm but it was exciting for the dogs, just the same.)

Dogs are optimistic but they are not without their fears, and that doesn’t just pertain to rescue dogs. The gate fell on one of our dogs once. Now she will not push on it even when it’s clear to an observer that it’s just resting against the stair. Or something fell on another dog from a shelf when he was eating in this corner of the kitchen – he really can’t have a relaxing meal in that spot so the bowl gets moved.

When I admire how dogs live I am thinking of how they live in the moment and find joy in routine things – a walk, just being let out into the backyard, going for a ride in the car, finding an old toy. Each happenstance sparks pure happiness. It never gets old.  Dogs are always up and always up for anything. At least a good part of the time. Dogs get ill and dogs get injured but how they deal with these setbacks is to minimize them and try to carry on. Animal behaviorists say this is due to the pack mentality – if a pack member shows weakness, they will be left out, left behind or perhaps killed. I get that, but I wonder if there’s more.

Just as dogs naturally want to exercise their bodies, which of course, is beneficial to their health, I wonder if they naturally want to continue to enjoy life through illness and injury. To live until they die, so to speak. We had a chocolate lab once who quite suddenly lost the use of her back legs due to a spinal tumor. She valiantly attempted to walk in the yard and managed to do her business. She wasn’t in pain and when she noticed our concern looked nonchalant as if to say – what? I walk like this now. She also famously pulled herself up the stairs to the 3rd floor that same day. She refused to give in to this thing that was happening to her. Sadly, we found the tumor was malignant and the prognosis dismal, and she was euthanized.

As a health care provider, I applaud when my patients take care of themselves and value their health. However, I have friends, acquaintances, relatives and yes, patients, who I think spend too much time worrying over every symptom when they could be enjoying the day. By all means, get your symptoms checked out if they’re worrisome or you are unsure. Follow your provider’s advice in terms of treatment and surveillance. But don’t obsess about the unknown. None of us knows exactly when we are going to die, but die we all will. The thing you worried about the most, likely is not the thing that will kill you. And even if it is, what did the worrying accomplish but compromise your enjoyment of everyday life?

Live like a dog while you can. Run after the ball, savor the treat, and smile when the wind blows back your hair. Be generous with your affection and most of all, spend time with the people you love.

The Other Side of the Stethoscope

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When a loved one recently had a scary diagnosis and surgery, we found ourselves on the other side of the stethoscope, so to speak. I took my own advice. (See post: A Bad Diagnosis) We researched, got a second opinion and made the best possible decisions we could at the time. We chose what we believed was the best hospital, and the best surgeon for this particular case. Then we just had to wait to get scheduled.

One of the hardest parts for me, as a health care provider well outside her field of expertise, was relinquishing control and not focusing on minutia. When I found myself, having never performed any kind of surgery, up in the early hours researching the merits of different surgical clamps, I realized I had to let go and the let the surgeon do his thing.

For the most part, I wasn’t in a hurry to reveal my health care background once we were in the hospital. As I frequently say “I’m not that kind of nurse.” Not the kind who executes hospital procedures with ease or can scan an EKG in seconds. Not the kind who can fix a misbehaving infusion machine with the press of a few buttons. Or the kind who can matter-of-factly inflict pain when necessary. (Still don’t like giving injections.)

Basically, I didn’t want to get in anyone’s way, or interfere with the practiced execution of care. Still of course, I was watching. So I noticed that a loosened tourniquet was the reason a nurse couldn’t get any blood out of my husband’s arm.  I wordlessly retied it. Or when I blurted out in recovery that his pulse ox was a little low and got that bemused look from the nurse, before she gave him some supplemental oxygen. It was okay though. I fessed-up and we chatted about NP school.

Once on the floor, I kept careful track of his pain med schedule and asked what was being given if the nurse did not explain. She usually did, though. (No male nurses on the floor when we were there.)  Change of shift, as it was when I was still in nursing school, was a chaotic time, resulting in delays moving from recovery to a room, and also in getting discharged because of something that wasn’t communicated.

An advantage to usually being on the other side of the stethoscope is an understanding of how things work, how busy people are and knowing not to take up their time unnecessarily. My husband does not like to rock the boat and there were a few times I wanted to call the nurse (or have him call her) to remind her we were awaiting a lab result, or pain medication and he stopped me. My “nursey sense” alerted me there was a problem, and in both cases, was spot on.

This experience was revealing in a lot of ways.  I don’t know if nurse practitioners communicate to their patients differently than doctors do, but we resented when we knew results were in and there was still a delay in communicating them. This didn’t happen across the board but it did happen.  I always call my patients ASAP with results I know they are concerned about. Of course, if the news isn’t good, I need to have a plan for next steps formulated. But I don’t delay for days until everything is in place. I feel comfortable saying: we are going to refer you to this type of specialist, I am just awaiting a callback so that we can get you in as soon as we can. In our case, we waited unnecessary, agonizing days for results.

Some good things. Our surgeon was an excellent communicator. He was easy to read and was able to read us as well. And whenever he did stop by, no matter how busy he was, he always found a chair to sit down and talk with us. That face to face time, eye to eye, meant a lot. I will be more conscious of that with my own patients, when I’m on the other side of the stethoscope.

Hobbled: Running, Plantar Fasciitis and My Mom

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One of my earliest memories is of my mother instructing me how to propel myself on a swing to soar above the then cement-covered playgrounds of New York City. “Stick your legs out and pump!” she coached three-year-old me. I didn’t know what “pump” meant and she had no understanding of aerodynamics. It didn’t go well.

Like many runners, I did not grow up athletic. In fact, I come from a family of remarkably uncoordinated couch potatoes, particularly on my mother’s side. This did nothing to stop my mother from attempting to teach me physical skills she herself did not possess, such as the afore-mentioned swinging.

One concussion and many skinned knees later, I accepted my lack of athletic prowess. After all, I was in good company. Hardly anyone in my family knew how to swim, let alone skate, ski, or play tennis. You’d think it had to do with lack of money but my father, the lone exception, grew up poorer than anyone, yet knew how to swim and skate. He learned to swim by being thrown by his buddies into New York City’s East River. I know. Amazing he was able to procreate after swimming in that toxic soup.

According to family legend, my mother sank like a stone when thrown into a local pool as a teenager and had to be pulled out ignominiously by the seat of her raggedy bathing suit. I have to assume being thrown into a body of water was a rite of passage back then. Lacking my father’s innate abilities, my mother was unfazed, and determined that I learn how to swim.

When teaching me by the side of the local pool didn’t pan out — “Kick your legs, and alternately stroke with your arms, taking a breath every other stroke!”– my mother scrimped to send me to a day camp specifically to learn to swim. I contracted a bad case of swimmer’s ear on day one and had to sit out pool time for the remaining two weeks.

Cutting her losses, my mother set her sights next on bike riding. Quickly she realized this kind of tutelage required a degree of coordination and strength far beyond her own. This was especially true when the child in question had no sense of balance. Someone was bound to get hurt.

My father finally managed to teach me how to ride without training wheels when I was eight, a feat akin to teaching Koko the gorilla American Sign Language. Soon after, I got bumped by a car when I attempted to cross the street between two parked cars. (Hey that’s how we rolled in the Bronx.) Lacking the self-preserving reflexes possessed by most humans, I failed to put my arms out to break my fall. For weeks I sported a grotesquely fat lip and lost the tooth I hit 10 years later.

Catholic school did not help me improve my athletic skills. The backs of my legs always sported welts from misadventures in jumping rope. Jumping-in eluded me and forget about Double Dutch. The dreaded dodge ball in gym was a little bit “Lord of the Flies” in terms of lax supervision and Piggy, I mean I, knowing neither how to throw nor to dodge, was often the worse for wear.

I found my people when I left the nuns and went to a “special” public high school with a concentration in science. You had to take a test to get in and it had nothing to do with physical fitness. Our most popular team was math team. My dodge ball days were over.

In college, there were two major obstacles for the non-athletic — the dreaded swim test and a gym requirement. The swim test, though well intentioned, was a source of severe anxiety to certain demographics. Namely, the poor, the foreign and the phobic. We had not learned to swim as children and could not believe we had to do so now.

There was no choice but to take the introductory swim class. Yes, it was a bit like that rite of passage my parents endured. But at least it counted toward the mandatory gym credits. I found it was a major advantage not to be phobic and to have English as a first language. I actually learned to swim the required three strokes as well as tread water after jumping off the deep end, a feat never to be repeated.

I’m drawing a blank on how I managed the remaining college gym requirements This might have something to do with repeated head trauma sustained during introductory volleyball — I couldn’t help closing my eyes when the ball was in flight.

I know I tried to be more active during those four years. Inspired by a boyfriend at the time, I even attempted “jogging” for the first time. I barely got to half a mile before I had to sit down on the curb, out of breath and half suspecting I might be having a heart attack.

Fast forward 25 years or so. My daughter joins the cross country team her first year of high school. Inspired by a not well-received wish to show solidarity, I start to run. And I like it. I took it slow and was gratified to find that my prior life of sloth left me pristine knees and hips compared to experienced runners.

I started doing some races. Controverting popular running wisdom, I began with a very hilly 10 K and finished (that alone was my goal) in a little over an hour. The vomiting at mile 3 was just an added bonus. Running became my way to relieve stress, to think, and to keep middle age weight gain under control while still eating (and drinking) what I wanted. This past summer, I toyed with the idea of a half-marathon and upped my distances, getting to 12 miles.

I felt strong and fit. Clearly I was overconfident. Ran perhaps more than I should have one weekend with friends who were marathoners. Or maybe it was the neon Easter-egg colored minimalist shoes that didn’t give enough support but were so cute. The next time I ran, I felt this searing pain in my heel about 2 miles in that would not permit me to continue my run. I hobbled home.

Plantar fasciitis (PF). Once thought to be an inflammatory condition, currently the etiology was being debated. There was no consensus on best treatments. It depended somewhat on whether you consulted a podiatrist or sports medicine orthopedist, how far you were willing to go (injections of platelet rich plasma, anyone?), and how much you were willing to pay.

As a health care provider, I tried what the literature suggested and what I in turn had suggested to my patients. Non-steroidal anti-inflammatories and prednisone, an oral steroid, didn’t help, which gave credence to the latest thinking that PF might not be an inflammatory response to injury. I did all the proscribed stretching exercises daily. I took up yoga again. (Downward dog is the perfect stretch for plantar fasciitis.) Decided to eschew steroid injections based on my research and orthotics based on prior bad experience.

I believed the cause in my case was a sprained ankle about six weeks prior that I ran on too soon. The ankle was weak and threw off my gait. So I started cross training at the gym to build up strength. Faithfully stretched, used a foam roller and massaged my foot with a frozen rubber ball daily. Wore the snazzy Strasburg sock at night (https://www.amazon.com/strassburg-sock).  Got fitted for more supportive (albeit slightly less cute) shoes at a running store.

Almost six months later, it is definitely getting better. Some days I have no pain at all. I can run four miles outdoors, five on the treadmill with minimal discomfort. I’m back, baby.

I often wonder what my mother would have made of this newfound running obsession and my recent struggles. She wouldn’t have understood it but she would have put her two cents in. “Propel yourself forward while swinging your arms,” she might have called out, undeterred as always by her lack of personal experience. “Shorten your stride and increase your cadence. And don’t forget to stretch.”

Thanks, Mom. I think I got this.

#plantarfasciitis #RunningInjuries, #unathletic, #HobbledNoMore #RockingThatStrassburg Sock

 

Comfort Zones Part 1: The Night Shift

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When I was in my last year of NP school I volunteered at a weeklong sleepaway camp for kids living with HIV. This was in the days when “living with”  was a euphemism for “dying from.” What was I worried about going in?  Not contracting HIV.  Not even seeing kids who were very sick.  I was concerned about the night shift.

Having gone straight through nursing school to graduate school, I hadn’t worked as an RN. Many new RNs start out on the night shift. Somebody has to do it and it’s viewed as paying your dues.  In the camp program I was in, everyone was assigned one night shift, and we were partnered up so noone was alone.

Of course the night shift per se should have been the least of my worries. We were taking care of some very sick kids with j-pegs, and kangaroo feedings and weak lungs susceptible to Pneumocystis pneumonia. My nursing experience was all academic at this point. I could ace a test, but maybe not save a life.

But what I was worried about was staying awake.

In this particular program, there were mostly inner-city kids. HIV knows no demographics – anyone can contract it. But these kids were all born with it. Their only risky behavior was being born. Many of their parents had drug problems at some point. Many of the children were orphans and many whose parents were still living, were in foster care.  This I knew going in. What I did not expect was to see how happy the kids were, getting off the bus. All seemed to be excited to have a week of camp, whether they were six or 16.

The facilities were not impressive, but there was a lake for swimming, basketball courts, and plenty of room to run around. The kids stayed in cabins with a counselor, and while not fancy, accommodations were adequate. The counselors told me the kids were not used to the lack of traffic sounds and were at times frightened of the sounds of the natural world. We were not technically in the country, more like an ex-urb, but to these kids, it was very remote.

We nurses spent our shifts keeping everything stocked, treating bug bites and minor scratches, and of course, giving meds. The kids were all on a lot of meds. There were a number of ICU nurses there who easily took care of the parenteral feedings and med administration. The rest of us took care of the oral meds. The kids were stoic, having grown up taking lots of nasty-tasting stuff and swallowing large pills. They just wanted to get it over with, anxious to get back to the fun.

Our team was led by an ER doc who had done this a number of years. His mantra was to just keep all the kids well enough to continue camp. Cellulitis? Medicate and cover up to avoid transmission. Toothache? He just injected procaine as often as needed so the little boy could enjoy camp. I felt so sad that he could get this kind of a toothache at this age, but of course, he was one of the ones in and out of homeless centers without regular dental care.

My scheduled night shift was in the middle of the week. I polled the experienced nurses to see if they recommended napping that day in the afternoon. No consensus.  I tried, but it was very noisy and I wasn’t able to sleep.   Finally it was time for my 7 o’clock shift. I had coffee with my dinner but was already feeling tired. The other nurse had just gotten off the night shift at her job in a small community hospital a few months ago so she was an old hand.  We chatted. Listened to music.  Played tic tack toe.  This was in the days before smart phones.

Around 2 am we heard the crunch of footsteps on the graveled path leading to the door of our makeshift clinic. The screen door slammed as one of the male counselors came in, carrying a boy who looked about six, piggy-back style. He informed us the boy had fallen out of his bunk bed. We both knew Victor (not his real name). He was kind of like the camp mascot. He always seemed to be having fun and giggling. He had skin the color of tea with a drop of milk, blondish, nappy hair, and the sweetish smile imaginable. He melted hearts wherever he went and that was before you heard his story. Both his parents were addicts. His father had died of HIV when Victor was two. His mother had been living with the disease until last year, when she relapsed and died of a heroin overdose. Now he was in the foster care system and had had some bad placements.  You would never know it from interacting with him.

Victor looked like he had been crying but was smiling and cooperative as I examined him. His counselor told us he had not lost consciousness. He had woken from a bad dream and had been in the act of trying to climb out of bed when he fell.  Luckily, there had been s pile of rolled-up sleeping bags on the floor which had broken his fall. He had not hit his head and now he denied any pain. Nevertheless, I gave him a thorough neuro exam, checked his joints for swelling, his abdomen for possible internal injuries. Gave a good listen to his heart and lungs. His vital signs were all normal. We instructed the counselor on what warning signs to look for and they got ready to go, with Victor fully expecting — and getting — another piggy-back ride.  The other nurse told them to “hold on” as she rustled around in the bag of stuffed animals we had and gave him a large plush snake to take back to the cabin.  He was delighted.

The remaining time of our shift went rather quickly and then it was over. I had survived the night shift. My cohort and I were glad to see the day shift, chatted a bit and went to raid the camp kitchen before heading for a long nap. We had the whole day off.

Thankfully, there were no major calamities that week, but as can probably be expected, interacting with the campers was bittersweet.  Whenever I saw Victor, he was clutching the stuffed snake, seemingly none the worse for wear from his early morning fall.

On our last night, a talent show was scheduled and the kids were very into this, even taking time from swimming and games to practice. The karaoke machine was enormously popular.  The campers all seemed to know the latest music and could lip sync songs and dance like the original artists. It was impressive but heartbreaking when one of our older campers, a cachectic 16 year old girl on oxygen, gave an amazing rendition of a Selena song. The kids did enjoy the little number we nurses put together, dancing (after a fashion) and swinging our stethoscopes like feathered boas.

The next morning was a rush of packing up supplies. We had been told repeatedly at orientation not to give gifts to the kids to avoid favoritism and hurt feelings, but some nurses drove into town on their time off and did just that. I was assigned to gather up the toys to pack away for the next camp session. I went from cabin to cabin driving a golf cart and collected them. The kids had been told to deposit them in a box in their cabin. My last stop turned out to be Victor’s cabin.  As I went to drag the box out, I spotted the plush snake’s nose peeking out from beneath a bare pillow. I reached for it and Victor came running in and hugged me. “Please nurse, can’t I keep him?” he asked.

And here’s what haunts me to this day.  I said no. I explained we had to have all the toys back for the new campers next week.  Victor didn’t cry or make a fuss.  He just looked sad and nodded that he understood.  This was what I should have been worrying about instead of the night shift: how I was going to feel about those children. Was my heart already hardening out of self-preservation? I had been relying on the rules to get me through this week, a week that took me way out of my comfort zone.  Victor was dying, all the kids at that camp were.  Why was I depriving him of remaining in his comfort zone, for just a little while longer?

#patientstories, #comfortzone, #HIVcamp

Skin Stuff: or, Yellow Salve Revisited

Posted on by writenp

This is one of my more clinical posts, addressing common skin disorders. If you are interested, feel free to suggest more topics in the comments section.

Cold Sores

As a small child, I developed what our local GP called impetigo on my lips. My mother put this yellow salve on it. I still remember its slightly sweet taste and grainy consistency. I couldn’t stop licking it off.  Salve – it’s such a medieval-sounding name. I’ve not sure if she got it by RX or if it was something the pharmacist just whipped up.  As I remember, it did nothing but dry out the lesions which took about a week to go away. (If you look online for yellow salve, it seems to be making a comeback as an alternative treatment, but I’m not sure it’s targeted towards cold sores or even whether it is indeed the same yellow salve.) Trouble was, this wasn’t impetigo, it was herpes labialis, or your common cold sore.  Kids can develop this in infancy, often by being kissed by someone infected, or contact with the lesions of a playmate. It’s caused by a virus related to chicken pox and shingles, hence the blisters, and has cycles of dormancy and recurrence. It can be brought on by illness, i.e., a cold, stress, or too much sun. If you’ve had it, you become hypervigilant about the first sign of a tingle, the harbinger or “prodrome,” as we say in the biz, of an outbreak.  Best way to diagnose it is through a viral culture. If the clinical presentation is not obvious, I do both a bacterial and viral culture and see what grows out. Treatment has come a long way, and if begun at that first tingle, goes a long way towards stopping a full-blown outbreak which can be very painful, disfiguring, and embarrassing.

For adults, I prescribe valacyclovir (generic Valtrex), the huge 1000 mg lozenge-shaped pills. Take two of them at the first sign and then another two 12 hours later.  So four should treat an outbreak, which is a good thing because they are very expensive, over $10 per pill. Insurers prefer the cheaper anti-viral, acyclovir, which does not work nearly as well.   I also recommend OTC Abreva (www.abreva.com), a cream that can be applied as often as you like. Since it is white, you might want to save this for when you are not out in public.  You can also buy an OTC clear lysine gel which you can use when you are out and about.  Why would you want these extra measures?  If you are already a cold sore sufferer, you know. Those lesions hurt and are unsightly, and you just want to do everything you can to make them go away.   Health care providers are not immune to this desire to overtreat their own outbreaks.  A dermatologist once told me she herself used a topical steroid cream to reduce inflammation.  This is controversial because a steroid can decrease immunological response. Her point was that a lot of the pain and swelling is caused by inflammation and the steroid addressed that.  If you are unlucky enough to suffer from cold sores, make sure you have your provider write you a script for the 1000 mg valacyclovir pills, maybe eight, with a lot of refills. And always carry two pills around with you.

Preventing Skin Cancer and the Problem of Vitamin D

What I (often) tell my kids about skin care is wear sunscreen every day, at least 30 SPF, limit exposure from 12-3pm, wear a hat and sunglasses when in bright sun, and get a yearly full body check by a dermatologist.  Some posit that this kind of vigilance against skin cancer – a good thing – has led to a widespread Vitamin D deficiency – a bad thing.

Vitamin D is a fat-soluble nutrient essential for calcium absorption, bone health, heart health and especially important for those with autoimmune diseases.  It has been advised to get at least 10 minutes of unprotected sunlight daily so your body can make vitamin D.  This is controversial because of the association of sun exposure with skin cancer. Medicine is seldom black and white. We don’t know how much sunlight is safe, and most dermatologists will tell you, no amount is safe.  I always advise it’s best to get your vitamins through food in most cases, although that’s difficult with vitamin D. Web MD lists food sources of vitamin D: http://www.webmd.com/osteoporosis/features/the-truth-about-vitamin-d-vitamin-d-food-sources), some of which include fortified foods (where the vitamin is added). For a while, most primary care providers were checking vitamin D levels as part of regular screening blood work. You might recall lots of people were deemed deficient and were advised to take megadoses for a period of time. (I was shown to be mildly deficient but chose not to do this. Not a fan of megadoses of anything.)  Now the USPSTF (United States Preventative Services Task Force) recommends against this screening, citing there is not enough information to assess benefits vs harm in testing of adults without symptoms.

Acne

When teens are just breaking out a little bit, simple solutions are the best.  I tell them: don’t overwash, and use a mild cleanser like Cetaphil (www.cetaphil.com). Don’t scrub or use harsh astringents. First try benzoyl peroxide cream (Clearasil: www.clearasil.com) applied to the zits at night. Takes about six weeks to see results, so be patient.  Next step is adding a prescription antibiotic cream, like clindamycin, and mixing the two together. There are premixed creams such as Duac and Benzaclin but insurers are getting less inclined to pay for them.  Some people do well with Differin (www.differin.com) which is a retinoid, similar in the way it works to Accutane or Retin A, but milder, and with fewer side effects. Now you can buy it over the counter. After topical creams, providers try six-week courses of oral antibiotics such as doxycycline, minocycline, or azithromycin. These can work well, but like all antibiotics, they have potential side effects. If the RX topical treatments are not working after six weeks, I recommend seeing a dermatologist.

Diaper Rash

Diaper dermatitis happens to all babies at one time or another, usually after a bout of diarrhea.  At home, treatment is frequent diaper changes, using a diaper balm, allowing the area to air-dry when feasible.  Sometimes, though, the rash is severe, beefy-red, causing obvious discomfort. This is when your child should be seen by a provider. Often, when it gets this severe, there is a fungal component. Usually I can see the rash is deep red, with small affected areas in addition to the main one, called “satellite lesions”.  I prescribe the anti-fungal nystatin cream, and sometimes a steroid cream as well if there is particular discomfort. I advise using the nystatin after each diaper change for 3 days, cleaning with warm water instead of wipes, exposing the diaper area to air as much as is possible.  Not too often, but sometimes, the problem is a bacterial infection, the impetigo I mentioned in the beginning of this post.  In the diaper area, it can manifest with rather large blisters and is called bullous impetigo (which can also appear in other places).  The treatment is antibiotics, usually oral if a large area is affected.

Eczema

Eczema or atopic dermatitis, usually starts in infancy, manifesting as rough dry, reddish patches which can be itchy. It can be mild or severe and is an allergic response to the environment or food and linked to other allergic disorders, such as asthma.  Severe cases are very itchy and can result in secondary bacterial infections from scratching.  Steroid creams are used to treat the outbreak but prevention is best and here’s why: steroids can adversely change the appearance and texture of the skin, making it thinner and at times, darker, which can be permanent, if used for more than two weeks, twice a day.  At times parents need to be educated about this because the steroid cream works so well, they want to use it all the time to keep their child comfortable. If the steroids aren’t helping, there are newer topical meds, such as Elidel and others in this class, approved for children over two years old. At this point, though, I advise having the child seen by a dermatologist. There have been some safety concerns about these newer drugs, including a possible link to certain cancers, but nothing has been proven at this point.

For prevention, I advise only using mild unscented soap, such as Dove for sensitive skin (www.Dove.com), every other day, washing with only water on the days in between. Moisturizing is key. A&D ointment works very well, but some people dislike the rather medicinal smell; others actually prefer it because it makes it seem more like a healing medication. Also good is Aquaphor (www.aquaphorUS.com) or plain old petroleum jelly, which is basically the same thing. The good news is you can use these ointments as much as you want (or can stand, since they can be messy). A little goes a long way. The problem with scented baby oils or lotions is that the scent itself can cause an allergic reaction. Also important is using a detergent for bedding, towels and clothing that is free of perfume and dyes and not using dryer sheets, which can cause a reaction to predisposed people.  If you notice you or your child has an outbreak following a certain food, cut it out. You can get allergy testing down the road but most allergists prefer to wait until children are aged three or older.

There are plenty more skin conditions that could be addressed, but I will stop here. If you have any skin topics you’d like me to cover (or any other clinical topics), put your suggestions for future topics in the comments section below.  No promises, though, and please, no personal medical queries – see your own provider for that.  If you prefer more “Tales From the Clinic” patient stories,  let me know that too.

 

Teeth Don’t Lie, or If It Walks Like a Duck…

Posted on by writenp

It was at the end of the day.  Encounters like this one always happen at the end of the day. You’re tired, your staff is tired, and you’re behind schedule. Welcome to any day of the week at 4pm at a community health center.

I had scanned my schedule as I finished my note on the last patient.  A new patient visit popped up.  A women age 43 with an unfamiliar (for this particular clinic), Nordic-sounding name.  Okay, I thought, maybe someone visiting here and not wanting to go to the emergency room. This was before there was an Urgent Care Center on almost every block. And it was always very difficult to get into a private practice for what is likely to be a one-time visit. The complaint written on the schedule was “teeth falling out.”

Oh.  Or uh-oh. Or at least, hmmmmm.  When I think of missing dentition in a relatively young person, I think homelessness/mental illness.  Or meth.  I dutifully checked Uptodate (www.uptodate.com) to see if I was missing something, like some rare auto-immune disorder. I wasn’t.

Sooo. I walked into the exam room ready for anything.  I encountered a tall, blond women, gowned and sitting on the exam table, shuffling a lot of papers.  Never a good sign. The part about the papers, I mean. I smiled and introduced myself and I asked why she was there.  Sometimes, with our bilingual front desk staff, things can get lost in translation.  For many of the staff, English is their second language and certain physical complaints can be hard to translate.  It was a hopeful thought and I decided to stick with it until I heard otherwise.

“I was at the emergency room all night,” she said, as she thrust the papers towards me.  She had a faint, Germanic-sounding accent.  In fact, she slightly resembled the model Heidi Klum. “They said I had vasculitis.”  She moved the hem of her exam robe to expose a reddish rash going down her thigh.

“Well, what did they give you?” I asked.

“It’s all there,” she responded with a touch of impatience. She tossed her blond hair, a habit from youth, I guessed, but her hair was straggly and dull,  rendering the movement ineffective.

I explained that these reports often fail to contain the information that will be most helpful to me: a diagnosis, test results and medication prescribed.  Often it is page after page of instructions and disclaimers with the important stuff hopelessly buried within, if present at all.

“They gave me this,” she said as she handed me a prescription bottle from her purse. “But I know it’s a steroid and I don’t want to take it.”

“Okay,” I said. “Have you had a bad reaction to steroids before?” It was relatively common to get palpitations, anxiety or insomnia while taking this kind of medication.

“No, it’s not that.  I just prefer to do things naturally.  I don’t like medication.  And besides, the people at the ER didn’t help me with my main problem.”

“Which is?”

“My teeth are starting to fall out.”

Here we go, I thought. “Let’s start at the beginning, is that alright? I just want get your basic medical history. I positioned the computer so I could enter the information while we still talked face-to-face.

The history she gave me was totally unremarkable.  According to her she was the picture of perfect health. She took no medication.  Her teeth just started to become loose about 4 weeks ago.  She made it a point to tell me she lived, not in the town the clinic was in, but one town over – a very upscale suburb. She also mentioned her two children who were excelling at the high school. One had just gotten into an Ivy League college, in fact.

She dug in her purse and I thought it was for her phone to show me a photo but she took out a laminated newspaper clipping with well-worm edges.  “That’s me,” she said proudly. “I was a model in my country. “

“Very nice,” I murmured. It was indeed her, about 20 years ago, and she’d been beautiful. She was handsome, as they say, even now. “Let’s get started on the exam.” I suggested.

I couldn’t really tell what the rash was, but vasculitis seemed a long shot. I thought it was a simple, uninfected contact dermatitis, which could be treated with an OTC steroid cream.  But now I went on to the part I was dreading, the oral exam.  She complained of no pain when I palpated her jaw and cheekbones. She had no swelling or bruising. I did notice her complexion was a little rough and there was one unusual scab right in front of her ear.  When she opened her mouth, it was clear she was missing a few of her back bottom molars, and when I shined a light inside, the top ones too. She wiggled a canine tooth for me like an excited kindergartener. The disconcerting sight gave me goosebumps.

“See, nurse, this is what I’m talking about.” I nodded and completed the rest of the exam. Other than her skin and teeth, nothing seemed amiss.

I excused myself and conferred with a colleague, who agreed that I had to do a tox screen.

“What’s weird is that she’s not asking for anything, no requests for opioids.” I mused.

When I went back in the exam room, I told her I was stumped. I recommended we start with some basic blood work.  I told her we needed to do a urine test as well, to test for drugs.

“But I told you, I don’t even like medication. I certainly don’t take drugs.” She made a point of holding my gaze directly, her clear blue eyes telegraphing her sincerity.

“I understand,” I responded, “But please humor me. Use of methamphetamine is a major cause of teeth falling out.  I would not be doing my job if we didn’t rule that out first “  I also wondered if they had done that at the ER.  If so, I was sure that particular tidbit would not be included in the papers she handed me.

“I will call you with the results,” I told her.

“Don’t I need a follow-up appointment?” she asked, which kind of surprised me.

“Well, you can certainly make one if you wish, but until we get the results, I’m not sure how productive it will be. We may need to refer you to a specialist.”

I went on to the next patient and my medical assistant went in to draw blood and hand her a urine specimen cup.

My last patient was an 8 year old with strep throat. Easy peasy and she was a sweetheart to boot. I was about to sit down at my desk to finish charting when my medical assistant informed me my prior patient was still here because she couldn’t pee.  She was drinking water when I entered the room. My patience was wearing a little thin. “Look,” I said, “We really need to do this test. We can’t continue to take care of you and get to the bottom of this if we don’t.” She regarded me coldly as she took the last swig from the bottle.

“Very well,” she retorted.

By the time I left that day, I had no idea if she submitted the specimen, but it turned out she had.  The next morning the urine test was back.  Positive for methamphetamines.  I called several times, leaving discreet messages asking her to call me but she didn’t.

They informed me at the front desk that she had indeed made another appointment.  She told them this time she wanted to see a doctor, “not a nurse!”, and she wanted a male doctor.  I doubted that she’d show.

I was wrong. I guess her charms were lost on me. Because the doctor, even though I had told him about the tox screen, was driven to find out what was wrong with “this poor women”.  He said she told him that she was taking her child’s Ritalin to concentrate and that’s why her tox screen was positive.

“But I asked her about medication.  She denied taking any.”

“Well, I guess she didn’t feel comfortable with you,” my colleague suggested. And  I guessed  that old modeling photo still had a certain juju.

“And she hasn’t requested any opioids?” I could not help asking.

“Oh, no,”  he responded. “She’s very anti-drug.”

It made me wonder why she came to the clinic in the first place.  Was it for the attention? Was she mentally ill?  A borderline personality disorder, maybe?  But it wasn’t my problem anymore, and there were always more patients to see.

I did ask my colleague a few months later what progress he had made in her case.

“Oh, she just stopped coming.” He admitted sheepishly, and a little regretfully.

“And her teeth?”

“Kept falling out. I referred her to a dentist but not sure if she went. She was going through a divorce and there were insurance problems and money was tight.”

I began to question myself. Maybe I was getting too hard. Could it have been really advanced periodontal disease?  Was it all from stress?  But how and why did she know the exact thing to say that would explain away her positive urine screen?

About six months later, another colleague drew my attention to an article in the local paper. “Isn’t this that women with the teeth?” It was. Her bone structure prevailed even in the mug shot.  Heidi Klum on a very bad day.  She was found sleeping in her car in that exclusive suburb.  Also found was her stash of methamphetamine.  It was sad.  I wondered if the children she told me about were real, and how they were faring in the midst of all this. I asked one of our social workers to look into it.

It continued to be a mystery to me.  Was that first visit a cry for help?  Or did she think stopping her teeth from falling out would prevent her life from falling apart?

©2017 by Eileen Healy Carlsen. All rights reserved.