Energized

After working the weekend: 12 hrs Saturday & 24 hrs Sunday – Monday a.m., the sun was finally shining on my drive home. The transition from night shift to day shift sucks so I try to stay busy on that day so I go to bed tired and have my ‘normal’ days off. Today, because the sun was finally out on MY day off, I felt energized. I needed to do something outside but what? I made a couple of eggs for breakfast and then took the dogs out for a walk in a (sunny) cemetery and read the headstones – so old. So many children died young in the late 19th century early 20th century!! Entire families were wiped out, sometimes five children under the age of 5 years old leaving the poor parents without any progeny. This particular little cemetery in town has the distinction of President Pierce’s burial place (and wife and two young sons, both died as children) enclosed (with other headstones) in a small fenced off portion of the cemetery. After arriving home I sat on the deck with a coffee observing the back yard with the overgrown embankment; – sigh – nature always encroaching. I decided while the sun was out and it wasn’t hot and humid (the worst weather on the planet) that I’d get out my electric chainsaw and cut down some saplings to allow more light and better growth of certain trees. By 4:00 I was done, tired, feet hurt and I had a tree tops toppled in my backyard that I thought I’d save for tomorrow. I like the shade that these trees provide but the foliage of so many saplings makes it too dense for any one tree to grow properly. There was also a lot of dead branches, etc. that needed to be cleaned out. I don’t particularly want to see my neighbors back yard any more than they probably want to see me in mine but I feel good for having done the physical work. After all that I bough a six-pack of Sam Adams and soaked in my hot tub in the waning sunlight with my Pandora. Later, pizza, movie, bed.

I am grateful for – finally – a sunny day. The sun energizes me to work outside, burn off some calories and get some Vit. D.

Stay safe everyone.

Droplet

Humans produce droplets when talking, coughing and sneezing and these droplets can contain cells of the immune system, epithelial cells (which are barrier cells like skin & blood), physiological electrolytes within mucous & saliva, as well as ‘germs’ such as bacteria, fungi and viruses.

The droplets vary in size, content and how long they remain suspended in the air. For respiratory purposes, a “droplet” is a particle that is 5-12 µm (microns) in diameter and to give you an idea of how big that is; one human red blood cell is 5µm in diameter. Droplets this size tend to “fall” to the ground/floor (or other surfaces) via gravity and, therefore, if one is at least three feet from someone talking or coughing, transmission of a potential infectious agent is minimal. Contagious infections that are considered droplet are the common cold, influenza, pertussis, mumps and bacterial meningitis. Direct contact is when a susceptible person comes in physical contact with an infected person (host) or in contact with a host’s oral secretions (by standing closer than three feet when a host coughs or sneezes, thereby, inhaling those droplets). For droplet precautions a simple surgical mask is used (by healthcare workers) along with gloves/goggles. Indirect transmission is when someone contracts an infectious agent by touching a surface where droplet has landed (transmission characteristics such as how long an microorganism can live on a variety of surfaces vary depending on the microorganism), therefore, attention to cleaning/disinfecting surfaces that are frequently touched is advisable along with frequent hand-washing.

Droplets smaller in size, <5µm, are called ‘droplet nuclei’ and these are the particles that can remain suspended in air (airborne) and live outside a host for longer periods of time, depending on the microorganism, therefore, one can contract an airborne disease long after the host has left the vicinity. Tuberculosis, measles and chickenpox are a few examples of transmittable diseases that are airborne and require (healthcare workers) the use of an *N95 mask (which requires a specific procedure to *’fit-test’ that the mask will work for you. I did not pass my fit-test for an N95 mask, so I am required to use…) or a PAPR (Powered Air-Purifying Respirator).

If a droplet precaution patient requires certain procedures such as intubation (inserting a ‘breathing tube’), bronchoscopy (for lung biopsies), administration of nebulized therapy, disconnecting the patient from the ventilator, CPap and BiPap use, CPR (cardiopulmonary resuscitation) or manual ventilation via an ambu bag (what you typically see on TV when someone is squeezing that bag over someone’s face), airborne precautions are required.

The information being relayed from the CDC and WHO about the novel coronavirus and/or Covid-19 is ever evolving and sometimes seems contradictory but we need to keep in mind that the efforts to determine the characteristics of this ‘novel’ virus have really only been concentrated in the last 2-3 months when it became more apparent that it is a very contagious and a very deadly virus. And, as viruses go, it’s ever evolving (e.g. influenza can evolve from the time it ‘starts’ in the south to the time it appears in the northeast). A most recent brief (3/20/20) from WHO states that, based on available evidence, it’s recommended that people who care for covid-19 patients use droplet and contact precautions. WHO recommends airborne precautions under circumstances where procedures generating aerosol or support treatment are performed (see previous paragraph).

There’s also been mixed messages/information regarding non-infected people using masks and, personally, I think some reasons are: to avoid depleting supplies and to avoid increased fear on behalf of the general public. Here’s my personal opinion: anyone who’s health is compromised by a pulmonary condition such as asthma, chronic bronchitis, emphysema; anyone who has a cardiac condition; or anyone immunocompromised; or anyone who just wants to be sure that they stay safe &/or keep their family safe – use a mask or any face covering. Almost any barrier between your mouth, nose, eyes is better than no barrier.

Breathe safe.

 

 

 

 

CPap

A CPap (Continuous Positive Airway Pressure) device is a small machine with a hose and face mask or nasal mask used by some people while sleeping and has become more common in the last decade – I’ve even seen it used on TV programs, sometimes as shot at humor but more often it reflects ‘typical’ life. Over 25 million Americans suffer from some form of OSA (Obstructive Sleep Apnea) and about 60% require a CPap unit to sleep well. But sleeping well isn’t just about getting a good night’s sleep for some people, it’s about physical and cognitive health. It’s about staying alive longer and having a better quality of life.

Apnea is when one temporarily stops breathing and the most common form of apnea during sleep is obstruction, when the throat muscles intermittently relax and collapse the airway causing snoring, a key sign of OSA. The duration and frequency of these apneas throughout sleep vary and most of us at times have some interruption of sleep with snoring (not to mention other people trying to sleep with a “snorer” in the room) and it isn’t life threatening. But many people experience such frequent interruptions and longer durations of apnea that it becomes a serious threat to their health.

Sleep disturbances cause one to wake up in the morning feeling that they haven’t slept at all…and it’s true. During sleep we go through repeated cycles of the same phases in sleep and when these phases of sleep – when the brain is actively trying to create and retain memories, engaging neurons, making bodily repairs, boosting the immune system, and more – are repeatedly interrupted the body does not achieve the levels as frequently nor for as long as it needs. We all know how it feels to be deprived of sleep; we feel tired, we’re irritable, we can’t remember as well, and we can’t think as well. Imagine putting the body through this cycle every day.

Another sleep disorder is hypopnea; abnormally shallow or slow breathing that causes pO2 to decrease. I don’t think I need to elaborate on the importance of oxygen.

A sleep study done by a certified/registered polysomnographic technologist done at a clinical site is a necessary evaluation of what takes place during the (attempted) sleep. Sleep evaluations are complicated diagnostics measuring each phase of sleep; respiratory rate, depth, or cessation; heart rate; how much oxygen is in the blood or disruptions in that level; and more. Once the study is done, a provider can order a CPap unit with a specific setting for the patient and directions should be followed, namely, USE IT.

The setting is a pressure, for example 10 cmH2O (centimeters of water pressure), and this pressure is the minimum required pressure within the airway to allow it to remain open even when the throat muscles relax. Each person requires a different minimum pressure and this is determined by the sleep study. By using the device, creating a patent airway while sleeping, the body is allowed to continue through all sleep cycles without disturbances and subsequently one achieves more optimal rest, is less tired the next day and can function better.

Many people object to using a CPap unit for a myriad of reasons but my response to these objections is this: adaptation is the key to a more successful and full life; no one gives wearing glasses or a hearing aide a second thought anymore, wheelchairs, prosthetics and portable oxygen is becoming a more common site in public, why would anyone NOT use a CPap in their own home if it means being more alert, clear headed and feeling better not to even mention alleviating some other health issues such as diabetes, hypertension and cardiac arrhythmias? Give it an earnest trial, wear it every time you sleep for a month and notice if you how you feel. You will quickly become accustomed to it, it will just be a part of what you do in your life and you (and your partner) will get much better sleep and enjoy an improved quality of wake hours.

If it’s a ‘fit issue’, try different masks (note: if you opt for a nasal mask or nasal pillows be sure to use a chin-strap. Wearing a mask over just your nose and sleeping with your mouth open is completely useless; the pressure required to keep your airway open is now flowing out your open mouth) or different head-gear. Be sure to follow instructions for cleaning the tubing, the mask, filter & humidifier, if you have one – cleaning the equipment is commonly overlooked/ignored and it’s dangerous because bacteria love a dark, moist place to live and grow and remember, you are breathing through this equipment, you don’t want to be inhaling bacteria.

Breathing is necessary for life. Breathe safe.

As always, thanks to Frederique for the linky-party

B is for blood

“abg” is the abbreviation for arterial blood gas (analysis)

Often when I enter a patient’s room, after my introduction, I ask the patient if the doctor (or nurse) informed them that an ‘abg’ was ordered and the answer is almost inevitably “no”. So I explain that the reason I am there is to draw some blood for this test and, again, almost inevitably the patient states, they already did that or they already took blood, can’t you use some of that? or, indicating the IV, can’t use take it from this? The answer is always ‘no’ and then I explain.

It used to irritate me that the physician – or “provider” is the new term because sometimes it’s a nurse practitioner or physician’s assistant who is the ‘provider’ – didn’t consult the patient, ask permission from the patient, or otherwise communicate with the patient about this, or any other procedure, but I’m over it now; I have my ‘routine’ with patients who’ve been ordered an abg. Many times the topic of an abg is avoided because, as is popularly assumed, ‘it hurts worse than any other blood draw’…but, in my experience as a healthcare worker and as a patient, this isn’t true.

An arterial blood gas is the analysis of the gases from the blood drawn from an artery, not a vein, which is the reason that every other blood draw for lab work cannot be used in place of the arterial blood. The ‘gas’ is both the oxygen and carbon dioxide that bound to the hemoglobin of the red blood cells and the ratio of both is indicative, mostly, of how well the lungs are working: transferring oxygen from the air within the lungs TO the blood and removing the carbon dioxide FROM the blood to be exhaled via the lungs. The arterial blood, usually drawn from the radial artery at the location of either wrist, is blood that has most recently left the lungs and is circulating throughout the body distributing that oxygen to all organs and tissues. Veinous blood is the blood returning from all organs and tissue back to the lungs to ‘drop off’ the carbon dioxide. The most accurate reflection of how well the lungs are working is the blood that has just left them; the arterial blood.

The radial artery is the most frequently used site to draw blood from for several reasons: it’s the most accessible (at most a watch may need to be removed), it’s more ‘superficial’ (that means smaller, shorter needle is used because the artery is so close to the surface of the tissue), it’s the largest of the two arteries in the lower arm (the other artery is the ulnar artery) and lastly, if for some reason the radial artery is damaged (it can occur but it’s rare), the ulnar artery will also supply the hand with arterial blood. Other arteries that can be used but are less frequently used are: the branchial artery located at the inside of the elbow and the femoral artery located in the groin.

In assessing where to draw arterial blood, we palpate (feel) for the pulse at the wrist. We try to avoid using the artery of the dominant hand but we use the artery of either arm with the best pulse and the logic of this choice is because we ‘feel’ for where the pulse is and aim the needle to this area. Unlike vein draws where a tourniquet is used to make the vein bulge and, therefore, visible, the artery is not blocked in this way because we need the blood flow from the lungs/heart to draw the sample.

A very common fear about an abg draw is pain. Personally, any needle entering any part of my body is painful; I’ve had a radial artery draw that I didn’t feel was as painful as the typical antecubital (inside of the elbow) veinous draw. One of my pet-peeves is when another staff member has ‘warned’ the patient that what I’m about to do “really hurts“. This is a disservice to the patient as every patient’s pain threshold is unique to them and every technician’s technique is different as is every situation that requires the lab work in the first place. Communication and creating as a relaxed environment as possible is what I’ve found works the best. Relaxed patient = relaxed muscles = easier needle insertion and draw. I’ve rarely missed and frequently have patients state either that wasn’t that bad or it didn’t hurt at all.  It’s (almost) all in the set up and technique.

Besides pain threshold, the radial nerve runs adjacent to the radial artery. Sometimes, inadvertently, this nerve is struck and when that happens, much like breaking a tooth and exposing the nerve, it’s an obvious and undeniable pain causing tingling up the arm and sometimes causing the hand to contract. Quickly partially withdrawing and repositioning the needle allows the nerve to restabilize and the pain to dissipate, however, the abg process must continue and it’s best to not withdraw the needle completely.

Once the artery is punctured very little blood needs to be obtained for the analysis so most of the time, depending on variables such as heart rate, dehydration, patient cooperation, the actual time the needle is in the arm is short. Pressure is applied to an arterial puncture site longer than venous – especially if one is on a ‘blood thinner’ – because arteries have more smooth muscle and connective tissue, thus, blood is under more pressure within the artery and there is a more likelihood of a hematoma (blood clot under the skin) forming if insufficient pressure is applied post draw.

Lastly, the ‘numbers’ or results of an abg analysis is to determine if the oxygen and carbon dioxide is within normal limits and different institutions’ labs may vary slightly in what is within the normal window: carbon dioxide or pCO2 should be between 35-45 mmHg (millimeters of mercury) and oxygen or pO2 should be above 80mmHg but most definitely above 60mmHg depending on patient/circumstances/therapies. One caveat is that some people (usually smokers) may have results that deviate from ‘normal’ – they may have a high carbon dioxide level that is normal for them and this range is sometimes upwards of 60mmHg but is typically in the 50s. And always we strive for a normal pH 7.35-7.45mmHg. Many factors contribute to an abnormal pH including a high or low pCO2 and this is about as complicated in blood chemistry as I want to get here.

For reasons having to do with state licensing, in NH it is within the legal scope of practice for a respiratory therapist to draw an abg sample and because (we) have the most experience, we are usually the ‘go to’ person but that isn’t a hard and fast rule; doctors, nurse practitioners, physicians’ assistants and, I believe, paramedics who work in the hospital setting can as well. In an emergency, whomever these aforementioned staff has access, ability and confidence will draw for expediency.

I’ll leave you with one last thought: if it’s ever recommended that an abg be obtained, always ask the provider why – be informed. Lab technicians and respiratory therapists are usually paged and, without any other information besides patient name and room number, arrive to do what is asked/ordered. If a patient hasn’t been provided information about what to expect and why and is inquiring, I try to find the ordering provider before I perform the procedure but that can delay results and treatment. Remember, an ABG is an analysis of how well your lungs are transferring gases, that’s the only reason for this lab work. pH can be obtained from a veinous lab sample. Once you’ve agreed to have the lab draw done, just relax. The more relaxed you are, the more relaxed the drawer of your blood is, thus, the easier and less painful the whole procedure will be for both parties.

*Linkz to this site for “linky party”

APD: a cut above all others

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Upon her death in 1927, Alice Peck Day bequeathed her family home to found Lebanon, NH’s cottage hospital, which opened in 1932. I’m not going to re-write the history of this hospital because you can read about (some of) it here. This webpage also contains a photo of Alice Peck Day and of the original home/hospital. It’s not a complete history; this webpage contains a little more and I was disappointed to not see some of the historic photos that are displayed on some of the walls at hospital.

As is life in the 21st century, APD went the way of many small businesses, especially hospitals, for survival in corporate America, and joined or became integrated with Dartmouth Hitchcock Medical Center (D-H) in Lebanon, NH (more on that in another post). Despite the affiliation, which many feared would lead to the impersonal atmosphere known to medical centers, APD has maintained a very ‘small town’ touch and strives to serve the community from which it was born.

One of the many characteristics of the hospital hierarchy which I admire and appreciate, as do the patients, is the dedicated care not only for community/patients but also staff. I have found even before the pandemic that the leaders of this little hospital make themselves present, available, and approachable. It is unlike any other place that I have worked in my professional quarter century – and I’ve worked in many. It’s truly impressive.

A benefit to being affiliated to D-H, the reason for integration and survival, is finances. APD is supported partly through D-H and we now have the medical resources that is much needed in this more complicated medical and technical age. We have the electronic capability now to share medical information instantaneously within the D-H system (computer program) such as lab results, radiology results, cardiac tracings, and more, all with the push of a button. We also have the amazing real-time assistance from specialized medical staff from D-H via a camera in the emergency rooms; during an emergency, ‘contact’ is made and a doctor or other staff is ‘there’ on a large screen in the room, watching, verbally participating and, if needed, they can ‘zoom in’ to see something more closely. It’s like having another set of hands and eyes with us and, I noticed recently, everything being done is recorded (not video/audio) via this connection so while we are busy all-hands-on-deck, someone is documenting each event & time (we’re accustomed to going back later and entering the information from memory and other staff). If a patient needs to be transferred to D-H, the facility already has all the information they need – especially if a doctor was ‘present’ – they only need a nurse-to-nurse report before transfer. It’s all very sophisticated, streamlined, and amazing to be a part of and I am proud, for the first time in my career, to be a part of a healthcare organization. 

During this time of preparedness for the pandemic ‘surge’, our hospital administrators, maintenance, managers and other staff has been working 24/7 planning, organizing, and restructuring how we will operate through this event in history. Every day – several times a day – several key administrators have communicated to all staff via an online ‘news page’ what is going on, how things are changing and always, always one of the first items on the (long) list is the appreciation for all members of our organization. We are always thanked for the work we do, for having positive attitudes and taking care with each other and patients. I have found the top administrators very aware of staff anxiety and concerns that individuals have and they have been addressing these with helpful information and/or advice and where to go for more help; they astutely recognize that without staff to care for patients, this will not go well for the community or for NH. 

I have to say that, despite being ‘on the front lines’ as the saying goes, I am confident that my place of employment has my back and that means a lot to me because I don’t have to stress about what-might-happen-if. Our organization leaders take their responsibility to staff, patients and community seriously and this makes all the difference in this healthcare working environment. I am grateful that I have finally found a place in which to work that I respect and I hope I am here for a long time.

This site is featuring a ‘linky-party’ for all those participating in this year’s A2Z Challenge. Scroll to the bottom of the post to find out how to link your post each day.

 

A2Z theme: 3/31/2020

This is my A2Z lead-in: I’ve been thinking about what and how I want to do this challenge; since I wasn’t going to have a theme, I missed the deadline but I decided that I’d try to ‘contain’ the typical rambling that I do and focus on a particular subject. I wanted to avoid the whole pandemic issue and any other avenues that I’ve written about in the past but…since I’ll be right in the mist of what’s going on, literally, I thought I’d use the virus as a jumping off point and focus on anything interesting that has to do with lungs, breathing, air, health, etc. and that may include some current, personal virus stuff from me. I’ll try to keep it to a minimum and on a positive or, at least benign, emotional level. atoz2020

Welcome to my April  A2Z challenge: all things about breathing.

#A2Z: Y

Y, oh Y, oh Y does the ‘disability’ insurance people repeatedly call me because they can’t get my employment HR department [ BIG, CORPORATE NATIONWIDE FOR-PROFIT HOSPITAL KNOWN AS HCA: Healthcare of America] to ‘confirm that they are willing to allow (me) to work with restrictions?’

For over a week I’ve been the pinball in this game between them. It’s 2019: emails, texts, phones, faxes = instantaneous modes of communication and, for some reason, THEY can’t manage to communicate with each other. I, on the other hand, have no problem getting through to either of them but I’m not the one who has to do the confirmation!

I worked half a shift today. Prudential is supposed to be ‘reimbursing’ me for (60%) of the remaining time I am not working this week (half shifts for two weeks) and they “can’t get HR to respond” meanwhile HR has said that they have emailed back (but apparently not called as I told them to do).

I finally had it today: I emailed both and said that I, the person on disability, shouldn’t be the one having to do all the ‘leg work’ and that I am probably going to have to go outside the organization to make sure I am not being ignored or victimized here.

WTF!

BTW: if anyone thinks that “healthcare workers” have great insurance YOU ARE WRONG. Even my surgeon, before she went out on leave for her pregnancy/delivery said, “We have the worst healthcare insurance!” ~ she has been saving her ‘earned time off’ just so she can stay home with the baby for FOUR WEEKS, instead of the two that ‘we get’ with our insurance…not six months like (other) industrialized/progressive countries. And our premiums are high and our coverage is sh*t. If you require medications or have chronic issues and frequent doctors offices/hospitals and you are looking for a career – DO NOT CHOSE ANYTHING IN THE HEALTHCARE FIELD. Get any state or government job…they rake in the bucks and the bennies and don’t do much for it (according to some I know who are proud of it).

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