Debbies Interview

AAA.....and No I am Not Talking About the Car Club

For my clinical presentation for the semester I am doing a presentation on Abdominal Aortic Aneurysms. So I thought I would share some information with you. Let me know what you think. Are you at risk for a AAA?

AA Prevalence

• Approximately one in every 250 people over the age of 50 will die of a ruptured AAA
• AAA affects as many as eight percent of people over the age of 65
• Males are four times more likely to have AAA than females
• AAA is the 17th leading cause of death in the United States, accounting for more than 15,000 deaths each year.
• Those at highest risk are males over the age of 60 who have ever smoked and/or who have a history of atherosclerosis ("hardening of the arteries")
• 50 percent of patients with AAA who do not undergo treatment die of a rupture

Smoking is a Major Risk Factor for AAA and other Vascular Disease

• Those with a family history of AAA are at a higher risk (particularly if the relative with AAA was female)
• Smokers die four times more often from ruptured aneurysms than nonsmokers

AAA Symptoms

AAA is often called a "silent killer" because there are usually no obvious symptoms of the disease. Three out of four aneurysms show no symptoms at the time they are diagnosed. When symptoms are present, they may include:

• Abdominal pain (that may be constant or come and go)
• Pain in the lower back that may radiate to the buttocks, groin or legs
• The feeling of a "heartbeat" or pulse in the abdomen

Once the aneurysm bursts, symptoms include:

• Severe back or abdominal pain that begins suddenly
• Paleness
• Dry mouth/skin and excessive thirst
• Nausea and vomiting
• Signs of shock, such as shaking, dizziness, fainting, sweating, rapid heartbeat and sudden weakness

AAA Diagnosis

In some, but not all cases, AAA can be diagnosed by a physical examination in which the doctor feels the aneurysm as a soft mass in the abdomen (about the level of a belly button) that pulses with each heartbeat.

The most common test to diagnose AAA is ultrasound, a painless examination in which a device (a transducer) about the size of a computer mouse is passed over the abdomen. Sound waves are computerized to create "pictures" of the aorta and detect the presence of AAA. Other methods for determining the aneurysms' size are CT scan (computerized tomography), MRI (magnetic resonance imaging), and arteriogram (real time x-rays).

AAA Treatments

Currently, there are three treatment options for AAA:

Watchful waiting - Small AAA's (less than 5 centimeters or about 2 inches), which are not rapidly growing or causing symptoms, have a low incidence of rupture and often require no treatment other than "watchful waiting" under the guidance of a vascular disease specialist. This typically includes follow-up ultrasound exams at regular intervals to determine if the aneurysm has grown.

Surgical Repair - The most common treatment for a large, unruptured aneurysm is open surgical repair by a vascular surgeon. This procedure involves an incision from just below the breastbone to the top of the pubic bone. The surgeon then clamps off the aorta, cuts open the aneurysm and sews in a graft to act as a bridge for the blood flow. The blood flow then goes through the plastic graft and no longer allows the direct pulsation pressure of the blood to further expand the weak aorta wall.

Interventional Repair - This minimally invasive technique is performed by an interventional radiologist using imaging to guide the catheter and graft inside the patient's artery. For the procedure, an incision is made in the skin at the groin through which a catheter is passed into the femoral artery and directed to the aortic aneurysm. Through the catheter, the physician passes a stent graft that is compressed into a small diameter within the catheter. The stent graft is advanced to the aneurysm, then opened, creating new walls in the blood vessel through which blood flows.

This is a less invasive method of placing a graft within the aneurysm to redirect blood flow and stop direct pressure from being exerted on the weak aortic wall. This relatively new method eliminates the need for a large abdominal incision. It also eliminates the need to clamp the aorta during the procedure. Clamping the aorta creates significant stress on the heart, and people with severe heart disease may not be able to tolerate this major surgery. Stent grafts are most commonly considered for patients at increased surgical risk due to age or other medical conditions.

The stent graft procedure is not for everyone, though. It is still a new technology and we don't yet have data to show that this will be a durable repair for long years. Thus, people with a life expectancy of 20 or more years may be counseled against this therapy. It is also a technology that is limited by size. The stent grafts are made in certain sizes, and the patient's anatomy must fit the graft, since grafts are not custom-built for each patient's anatomy.

Second Opinion

In order to determine if you are a candidate for the interventional radiology procedure, it's best to get a second opinion from an interventional radiologist. You can ask for a referral from your doctor, call the radiology department of any hospital and ask for interventional radiology or visit the doctor finder link at the top of this page to locate a doctor near you.

A stent-graft is threaded into the blood vessel where the aneurysm is located. The stent graft is expanded like a spring to hold tightly against the wall of the blood vessel and cut off the blood supply to the aneurysm.

Efficacy and Patient Safety

Interventional repair is an effective treatment that can be performed safely, resulting in lower morbidity and lower mortality rates than those reported for open surgical repair.

Recovery Time

• Patients are often discharged the day after interventional repair, and typically do not require intensive care stay post-op
• Once discharged, most return to normal activity within 2 weeks compared to 6-8 weeks after surgical repair

Benefits of Interventional Repair

• No abdominal surgical incision
• No sutures, or sutures only at the groins
• Faster recovery, shorter time in the hospital
• No general anesthesia in some cases
• Less pain
• Reduced complications

Disadvantages of Interventional Repair

• Possible movement of the graft after treatment, with blood flow into the aneurysm and resumption of risk of growth/rupture of the aneurysm
• Probable life-time requirement for follow-up studies to be sure the stent graft is continuing to function

Interventional Radiologists are Vascular Disease Experts

Interventional radiology is a recognized medical specialty by the American Board of Medical Specialties. Interventional radiologists are board-certified physicians with extensive training in vascular disease diagnosis, management and treatment. Their board certification includes both Vascular and Interventional Radiology and Diagnostic Radiology which are administered by the American Board of Radiology. This training marries state-of-the-art imaging and diagnostic expertise, coupled with clinical experience across all specialties and in-depth knowledge of the least invasive treatments.

Ipads in the ER

Okay, so I am  a huge Apple fan but I haven't jumped on the Ipad wagon yet. I am still waiting for a better Iphone 4 to come out so I can upgrade my phone. However, I think this is a great idea. However, I feel that we should also have a Plan B when technology fails.

Much as consumers have loved Apple’s iPad since it hit the market in April, busy physicians have been prominent among its early professional adopters. John D. Halamka, Chief Information Officer at Beth Israel Deaconess Medical Center in Boston (BIDMC), bought one as soon as they came out and blogged about their usefulness in daily rounds.
“The Emergency Department is the perfect place for an iPad because all our ED workflows are web-based, wireless and iPad compatible,” he told me. “Since June, I’ve seen increasing numbers of clinicians use the iPad because of its light weight, its battery life, and the easy of keeping it clean.” The last is no small factor, when you consider how cluttered and grimy the standard hospital workstation can become.
Clinical web based applications that physicians normally had to access via the workstation can now be accessed from the patient’s bedside. According to Halamka’s colleague Larry Nathanson, “The EKGs look better onscreen than on paper,” he wrote in a guest post for Halamka’s blog in April. “It was great having all of the clinical information right at the bedside to discuss with the patient. The only problem was that the increase in efficiency was offset by the patients and family who wanted to gawk at it.”
Doctors in the ER are on their feet for hours at a time, which is exhausting. Having a tool that is light, and more importantly lasts for 10 hours without a recharge, is what has helped transform more than a few ERs around the country. Extra bedside time with the patient is no small thing in these days when doctors are already overworked. But when you add in the quick updates to records and notes a doctor can make on the fly when the nurse grabs him or her in between floors, the increase in efficiency is significant.
Web-based electronic health records and other existing clinical software that can be accessed via the iPad’s Safari browser are the most useful applications. But as you would expect there are also apps being developed especially for MD iPad users. “The most popular application is the medication reference tool ePocrates,” according to Halamka, which works on both iPhones and iPads. Also, Nuance Dragon Dictation voice recognition software, which was developed for the iPod and iPad, is something clinicians find very valuable as well.
But BIDMC at least is not limiting itself to just what’s available from app developers. According to Halamka, “Our programmers are planning to build a few iPad native applications that enrich the user experience over the standard web browser access to our electronic health records.”

CRNAs: We'll Be Watching

Since I know I have a lot of friends who want to be CRNAs i have posted some information and a PSA announcement that might be useful.

Nurse anesthetists have been providing anesthesia care to patients in the United States for nearly 150 years. 
The credential CRNA (Certified Registered Nurse Anesthetist) came into existence in 1956. CRNAs are anesthesia professionals who safely administer approximately 32 million anesthetics to patients each year in the United States, according to the American Association of Nurse Anesthetists (AANA) 2009 Practice Profile Survey. 
CRNAs are the primary providers of anesthesia care in rural America, enabling healthcare facilities in these medically underserved areas to offer obstetrical, surgical, and trauma stabilization services. In some states, CRNAs are the sole providers in nearly 100 percent of the rural hospitals.
According to a 1999 report from the Institute of Medicine, anesthesia care is nearly 50 times safer than it was in the early 1980s. Numerous outcomes studies have demonstrated that there is no difference in the quality of care provided by CRNAs and their physician counterparts.* 
CRNAs provide anesthesia in collaboration with surgeons, anesthesiologists, dentists, podiatrists, and other qualified healthcare professionals. When anesthesia is administered by a nurse anesthetist, it is recognized as the practice of nursing; when administered by an anesthesiologist, it is recognized as the practice of medicine. Regardless of whether their educational background is in nursing or medicine, all anesthesia professionals give anesthesia the same way.
As advanced practice registered nurses, CRNAs practice with a high degree of autonomy and professional respect. They carry a heavy load of responsibility and are compensated accordingly.
CRNAs practice in every setting in which anesthesia is delivered: traditional hospital surgical suites and obstetrical delivery rooms; critical access hospitals; ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists, plastic surgeons, and pain management specialists; and U.S. military, Public Health Services, and Department of Veterans Affairs healthcare facilities.
Nurse anesthetists have been the main providers of anesthesia care to U.S. military personnel on the front lines since WWI, including current conflicts in the Middle East. Nurses first provided anesthesia to wounded soldiers during the Civil War.
Managed care plans recognize CRNAs for providing high-quality anesthesia care with reduced expense to patients and insurance companies. The cost-efficiency of CRNAs helps control escalating healthcare costs.
In 2001, the Centers for Medicare & Medicaid Services (CMS) changed the federal physician supervision rule for nurse anesthetists to allow state governors to opt out of this facility reimbursement requirement (which applies to hospitals and ambulatory surgical centers) by meeting three criteria: 1) consult the state boards of medicine and nursing about issues related to access to and the quality of anesthesia services in the state, 2) determine that opting out is consistent with state law, and 3) determine that opting out is in the best interests of the state’s citizens. To date, 15 states have opted out of the federal supervision requirement, most recently California (July 2009). Additional states do not have supervision requirements in state law and are eligible to opt out should the governors elect to do so. 
Nationally, the average 2009 malpractice premium for self-employed CRNAs was 33 percent lower than in 1988 (62 percent lower when adjusted for inflation). 
Legislation passed by Congress in 1986 made nurse anesthetists the first nursing specialty to be accorded direct reimbursement rights under the Medicare program.
More than 40,000 of the nation’s 44,000 nurse anesthetists (including CRNAs and student nurse anesthetists) are members of the AANA (or, greater than 90 percent). Approximately 41 percent of nurse anesthetists are men, compared with less than 10 percent of nursing as a whole.  
Education and experience required to become a CRNA include:

• A Bachelor of Science in Nursing (BSN) or other appropriate baccalaureate degree.
• A current license as a registered nurse.
• At least one year of experience as a registered nurse in an acute care setting.
• Graduation with a minimum of a master’s degree from an accredited nurse anesthesia educational program. As of April 2010 there were 108 nurse anesthesia programs in the United States utilizing more than 1,700 approved clinical sites. These programs range from 24-36 months, depending upon university requirements. All programs include clinical training in university-based or large community hospitals.
• Pass the national certification examination following graduation.

In order to be recertified, CRNAs must obtain a minimum of 40 hours of approved continuing education every two years, document substantial anesthesia practice, maintain current state licensure, and certify that they have not developed any conditions that could adversely affect their ability to practice anesthesia.

Breastfeeding PSA

I choose this PSA because I feel that breastfeeding is the single best thing that a mother can do for their child. Plus its FREE!!!

Liver Cirrhosis

This week in class we are learning about liver cirrhosis. One of the number one causes of liver cirrhosis is alcohol abuse. After reading about it and watching the video below, I think I am going to stick to non-alcoholic drinks.

The liver weighs about 3 pounds and is the largest solid organ in the body. It performs many important functions, such as:

• Manufacturing blood proteins that aid in clotting, oxygen transport, and immune system function.
• Storing excess nutrients and returning some of the nutrients to the bloodstream.
• Manufacturing bile, a substance needed to help digest food.
• Helping the body store sugar (glucose) in the form of glycogen.
• Ridding the body of harmful substances in the bloodstream, including drugs and alcohol.
• Breaking down saturated fat and producing cholesterol.

Alcohol MySpace Comments & Myspace Comments

Cirrhosis is a slowly progressing disease in which healthy liver tissue is replaced with scar tissue, eventually preventing the liver from functioning properly. The scar tissue blocks the flow of blood through the liver and slows the processing of nutrients, hormones, drugs, and naturally produced toxins. It also slows the production of proteins and other substances made by the liver.

According to the National Institutes of Health, cirrhosis is the 12th leading cause of death by disease.

What Causes Cirrhosis of the Liver?

Hepatitis C, fatty liver, and alcohol abuse are the most common causes of cirrhosis of the liver in the U.S., but anything that damages the liver can cause cirrhosis, including:

• Fatty liver associated with obesity and diabetes.
• Chronic viral infections of the liver (hepatitis types B, C, and D; Hepatitis D is extremely rare).
• Blockage of the bile duct, which carries bile formed in the liver to the intestines where it helps in the digestion of fats. In babies, this can be caused by biliary atresia in which bile ducts are absent or damaged, causing bile to back up in the liver. In adults, bile ducts may become inflamed, blocked, or scarred, due to another liver disease called primary biliary cirrhosis.
• Repeated bouts of heart failure with fluid backing up into the liver.
• Certain inherited diseases such as:
  • Cystic fibrosis.
  • Glycogen storage diseases, in which the body is unable to process glycogen, a form of sugar that is converted to glucose and serves as a source of energy for the body.
  • Alpha 1 antitrypsin deficiency, an absence of a specific enzyme in the liver.
  • Diseases caused by abnormal liver function, such as hemochromatosis, a condition in which excessive iron is absorbed and deposited into the liver and other organs, and Wilson's disease, caused by the abnormal storage of copper in the liver.

Although less likely, other causes of cirrhosis include reactions to prescription drugs, prolonged exposure to environmental toxins, or parasitic infections.

Do People Who Drink A Lot of Alcohol Always Get Cirrhosis of the Liver?

Most people who drink large amounts of alcohol harm their livers in some way; but not all of these people get cirrhosis of the liver. Women who are heavy drinkers are at higher risk than men. People who have hepatitis B or hepatitis C are more likely to suffer liver damage from alcohol.

Emergency Nurses as Advocates

Nurses are the patient's advocate. But when a nurse disagrees with a doctor, how far should they go on behalf of their patient? Where do you draw the line? This is a recent article from the New York Times. 

A recent conversation with a physician at my hospital was laced with tension about the different roles of doctors and nurses.

“When you get down to it,” he told me, “Patients come to me for care, Theresa, not you.”

Both of us were called away before we could talk more, but his words have been ringing in my head ever since.

Jeff Swensen for The New York TimesTheresa Brown, R.N.

I couldn’t believe that this doctor, who had always worked well with the nurses on my floor, had just suggested, at least in my mind, that a nurse’s opinion on patient care matters less because patients don’t directly make appointments with us.

As I puzzled over our brief but heated exchange, I thought back to the events leading up to the conversation.

It all began after the doctor read a story I had written about a leukemia patient in his 70s. The doctor had not been involved in the case, but he was troubled by my role in it. Due to the patient’s existing health problems, I was concerned that giving him chemotherapy would cause more harm than good.

During the course of the treatment, the patient complained in agony, telling me “I can’t take it,” and I relayed his misgivings to the patient’s care team. A more aggressive lament from the patient — “What the hell are you doing to me?” — also got communicated to the team. I was the patient’s nurse and his advocate, and I worried that it was not ethical to subject him to more chemotherapy when he was clearly having a hard time with the treatment. The chemo we had given him before this latest round had already sent him into permanent renal failure and caused congestive heart failure.

Other members of the team shared these concerns, but the man’s doctor did not. He checked in with the patient to see if he wanted to continue treatment. After some gentle prodding by the doctor (“You want to keep going, right? Right?”), the patient agreed.

I recounted that story with great sadness, as it had been agonizing to watch my patient suffer through treatments that I believed he would not have chosen had he known the harm they could cause and the unlikeliness of being cured.

He eventually was admitted to hospice and died, but only after the chemo had left him with unstoppable and painful bleeding in his bladder, robbing him of a more peaceful and more comfortable end to his life.

The doctor colleague who cornered me at the nursing station was particularly unhappy with my aggressive objection to the patient’s care plan. This doctor felt strongly that for cancer patients, end-of-life decisions should ultimately be the responsibility of the physician in charge of his or her care. That physician, he argued, is in the best position to offer advice about care decisions because he knows the patient’s full history. Floor nurses, he said, usually only see a snapshot of the patient near the end of a long journey.

I understood his point, but I also felt he was too quickly dismissing the observations of oncology nurses, who intimately confront the suffering sometimes caused by well intentioned treatment.

And that’s when the conversation became tense.

Obviously, doctors and nurses have different roles in the hospital. Our training is different, and so are our responsibilities. It’s also true that patients choose their doctor and only end up with a particular nurse through the luck of the draw. But when a doctor and a nurse disagree over patient care, should the doctor always prevail?

Many of the nurses I know could share their own, dramatic stories of rescuing patients or catching frightening errors by other health care workers, including doctors. In fact, the same day the doctor cornered me at the nursing station, I had caught a potentially risky medication prescribing error by a doctor in training. I took my care question to a clinical pharmacist and the attending physician to insure that my patient was given the right treatment. Nurses don’t have the power to make certain types of care decisions, but they do have the power -– and the responsibility — to go up the ladder until they are satisfied that good decisions are being made.

Nursing care is also an important factor in a patient’s recovery. Several studies now show a strong association between nurse staffing levels and rates of patient complications like pneumonia or internal bleeding during a hospital stay. Patients in hospitals with high nurse staffing ratios get better sooner and have shorter hospital stays. Many doctors will tell you that it’s nursing care, not physician care, that makes the biggest impact on a patient’s recovery.

So is the doctor-patient relationship really more sacrosanct than the nurse-patient relationship? I don’t think so. Physicians have the ultimate responsibility for treatment decisions, but because nurses spend so much more time with hospital patients than doctors do, we have a unique view of how the patient is really doing. And at times, patients present very different faces to nurses and to doctors — complaining to a nurse in a way they never would to a doctor.

And while my physician colleague said that nurses only see a snapshot, that picture is often one the doctor does not see.

Later, I had another chance to talk to the doctor who raised this issue in the first place. I told him that I was planning to write about our discussion of the role of doctors and nurses. “Yes,’’ he said. “We never got to finish our conversation.”

So we finished it. He shared difficulties he’d had with nurses criticizing treatment decisions when they had only known the patient for a few hours. I nodded. Then I said that physicians can have blinders on, too, and he nodded as well.

In the end he said, “The point is, it needs to be a conversation.” And we both agreed on that.

But when in doubt, I will err on the side of aggressive advocacy for my patients. Nurses have a professional obligation to make sure that patients receive the best care possible and to insure that all care given in hospitals is safe. For better or for worse, patients who come into our hospital are the responsibility of the nurses, even if the patient has been admitted by a doctor of her own choosing. A good nurse will share his or her opinions with the medical staff — sometimes loudly — because that’s part of our job, even if we ruffle a few feathers in the process.