Tuesday, June 30, 2009

New "Black Box" Tylenol Warning Label

Acetaminophen (brand name Tylenol) is one of those over-the-counter (OTC) medications that seems pretty harmless. We use it often in our society to treat mild to moderate pain and to reduce fever. It is a safe and effective medication when taken according to the manufacturer's recommendations. It is most definitely possible to overdose on Tylenol, either accidentally or on purpose.

New Black Box Warning for Medications Containing Acetaminophen (Tylenol)

"Black Box Warnings" are to be added to the labeling for medications that combine acetaminophen (Tylenol) with another drug. Black Box Warnings are found on the labels of medication deemed by the FDA to potentially pose a serious risk to consumers. The text of such warnings is typically surrounded by a black box to draw attention.

Acetaminophen Overdose

According to the U.S. National Institute's of Health (NIH), Tylenol overdose is one of the most common types of poisoning worldwide. An overdose of Acetaminophen can result in the need for liver transplantation or can cause in death as a result of rapid onset liver failure. Tylenol overdose requires hospital treatment--best results for a satisfactory outcome occur when the patient is seen within 8 hours of the medication overdose. Tylenol levels in the blood are monitored at regular intervals. A medication called N-acetylcysteine (also known as Mucomyst) is the first drug of choice in preventing liver damage from acetaminophen overdose.

Too much acetaminophen can be consumed on purpose in an attempt at self-harm, or by pure accident. Many over-the-counter medications contain Tylenol in combination with other (cold, flu or pain) medications. When making decisions about over-the-counter and prescription medications, it's possible to consume a toxic level of medications in the system without realizing it. Take a look at the two lists of prescription and non-prescription medications containing acetaminophen courtesy of FamilyDoctor.org (additional information is available here about other potential medication interactions that should be clarified with your physician.)

How much Acetaminophen is too much?

The maximum daily dose of Acetaminophen 4 grams in adults and 90 milligrams per/kilograms (mg/kg) in children. The toxic dose of acetaminophen after a single acute ingestion is 150 mg/kg in children and 7 grams in adults. The at-risk dose may be lower in some susceptible patient populations, such as persons with alcohol abuse, malnourishment, or viral illness with dehydration

Two tablets of regular acetaminophen equals 650 mg. Per the dosage instructions the medication can be taken every 4 to 6 hours. The maximum daily dose is very nearly achieved if the medication is taken very 4 hours for 24 hours (3.9 grams would be consumed).

Two tablets of extra strength acetaminophen equals 1 gram, dosing instructions advise it can also be taken every 4 to 6 hours--but not more than 8 tablets (4 grams) within 24 hours.

Obviously if any additional "hidden" acetaminophen consumed within the 24-hour period in over-the-counter pain medications or cold/flu medication, an unintended toxic dose of acetaminophen could easily be consumed.

Signs of Acetaminophen Overdose:
  • stomach pain
  • nausea & vomiting
  • jaundice
  • irritability
  • convulsions
  • coma.

APAP is a common medical abbreviation for Acetaminophen

Consider this medication and dosage: Hydrocodone with APAP, 10/500 mg. This medication contains 10 mg of Hydrocodone and 500 mg of Acetaminophen (APAP). Understanding that APAP refers to acetaminophen and carefully reading labels will help you uncover the "hidden" acetaminophen so that you can avoid consuming toxic levels of this usually benign and helpful medication.

National Poison Control Number: 1-800-222-1222

No matter where you live, this toll free number is the same. Staffers are available 24/7 to answer any questions.


Links for Additional Reading:

American Liver Foundation: The Progression of Liver Disease
Emedicine article by Gagan K. Sood, MD: Acute Liver Failure
FDA Consumer Update: Acetaminophen and Liver Injury: Q&A for consumers
Black Box Warnings, by FormWeb: http://formularyproductions.com/blackbox/

.

Monday, June 29, 2009

Blenderized Diet . . . Fractured Jaw Diet . . .No Chewing Allowed

(See below at bottom fourth of the article, I have a number of links to reliable websites for those needing to temporarily follow a blenderized diet.)

For some reason a former patient popped into my mind a while ago. I was working at the pre-op clinic and this slender young teen was about to commence her summer vacation by undergoing corrective jaw surgery that would require her to follow a blenderized, or fractured jaw, diet for at least 4 weeks. Her mother was concerned about keeping weight on her size zero during the recovery phase. The purpose of our pre-op teaching and history gathering was to deal with specific issues and concerns such as these. The dietitian was unable to join our meeting, but we did put in a consult for her expert advice for the period in which the patient was to be in the hospital. However, advance planning was also in order. Our hand-out on blenderized diets was woefully disappointing to the mother--a many-times-over photocopied, one-page handout that was meant to help a patient determine how they would take oral sustenance for 6 weeks . . . The mom was right, our information sheet lacked so much that it was embarrassing.

Fractured jaws or Jaw Surgery

We rest a broken jaw in order for the bones to knit just as we rest a fractured arm or leg. Stressing the healing bones with chewing is painful and interferes with healing. Often during the recovery phase, the jaw is wired closed for a period of weeks. Some hospitals are better than others at providing good information about the importance of continuing oral care as well as providing specific suggestions for promoting optimal nutrition when a liquid diet is required during convalescence.

Advanced preparation--more than purchasing a blender

Before I was a nurse, my husband had jaw surgery. Advance preparation for the procedure included purchasing a blender. We were given a very simple handout from the surgeon's office with a few suggestions. There was no Internet to go to for advice, so my husband's blenderized diet was boring, repetitive and did not provide him with the level of calories and protein he needed. He lost a LOT of weight during the recovery phase--and he didn't have any extra weight to spare . . .

What am I going to feed [my kid, myself, my spouse, etc.] on a blenderized diet?

I want to begin by stressing the absolute necessity of consulting with a dietitian at the hospital if you or your loved one has special, underlying nutritional issues such as the need to also follow other diet restrictions such as: gluten-free, diabetic, vegetarian, bariatric, etc.

American Association of Oral and Maxillofacial Surgeons addresses post-operative nutritional concerns on their website. They specifically caution about the importance of taking in adequate amounts of free water and calories. The AAOMS recommend keeping a journal to record fluid volumes taken in and calories consumed to ensure these needs are being properly met. The suggest planning blenderized meals in advance. It's hard to "wing it" unless you have all sorts of options available in your kitchen to make the blenderized meal appealing. It's important to understand that liquids are digested more quickly that solids. In order to maintain energy and keep up with the body's metabolism during recuperation, it's necessary that the blenderized meals be given on a more frequent basis (perhaps 4 to 6 times daily). Protein shakes are recommended for all blenderized diets--I'll have some links to follow below, for specific recipes.
For the lactose intolerant, the milk-based tendency for blenderized diets may seem a bit disconcerting at first glance, but there are lactose-free options in the form of soy milk, and nutritional supplements such as Ensure, Boost, or Osmolite.

Web pages with blenderized diet information

I recommend looking at every one of these. They all offer good advice, but you will find some great suggestions that are unique to each specific site.
  1. Dartmough-Hitchcock Medical Center fractured jaw diet
  2. Dartmough-Hitchcock Medical Center blenderized diet information
  3. Aspirus-Wausau Hospital Diet for Jaw Surgery (Blenderized Diet)
  4. Ohio State University Medical Center Blenderized Diet for Jaw Wiring
  5. Kaiser-Permanente, "No Chewing Required," Blenderized Diet

An interesting product

I have no commercial interest in any medical products and don't receive or seek any income or favors from anything I've written on my blog. In looking for my fractured-jaw, blenderized diet information, I came across this this interesting product that is supplied by some hospitals for their post op patients. It's a bag with a "straw-like" device affixed. Actually the straw is not for sucking. Instead you squeeze the liquid-filled bag and the straw is like a tap--the fluid just flows into the mouth. It can be used to clean and rinse the mouth as well as to easily take in fluids. This product looks like it would be very useful in the first few post-operative days, for sure.

Read more about Zip-n-seal here and be sure to check out their Zip-n-squeeze blenderized diet nutritional page.


Do you have suggestions?

Please let me know of other good tips and sources of information for people on blenderized diets. I'll be happy to post your suggestions or links here. I'd particularly like to know about blenderized diet recommendations and resources for individuals on special diets like gluten-free and diabetic diets.


Tuesday, June 23, 2009

Bloody nose: Stop a nosebleed and prevent recurrent bleeding

Why do nosebleeds occur? In medical terminology, a nosebleed is properly called "epistaxis." Trauma from an injury is probably the most common way to develop a nosebleed. Dry weather and irritation from fingers in the nose are also commonly associated with nosebleeds. Anyone who takes blood thinning medication (such as Coumadin) or even some vitamins and supplements(such as fish oil, vitamin E, etc.) are more susceptible. Cancer patients undergoing chemotherapy may have nosebleeds due to loss of clotting factors called platelets that are destroyed by the chemo. Uncommon reasons such as inherited problems of the blood vessels are disorders such as Osler-Weber-Rendu Syndrome (Hereditary Hemorrhagic Telangiectasia) or an inherited blood clotting disorders such as a type of hemophilia.

How to Stop a Nosebleed:


1. Sit or stand the person with the bleeding nose UPRIGHT with their head tilted FORWARD. This keeps the blood from going down the back of the throat and into the stomach which will cause irritation and often results in vomiting. Allow the blood to flow into a basin or onto a cloth if available. Stopping a bloody nose is the priority--you can worry about cleaning a mess later.

2. Have the person with the bleeding nose breathe through their mouth as they (or you) pinch the nose together to apply pressure. You'll know that you are doing this correctly if there is no longer visible blood coming out while you are applying the pressure. Make sure to pinch the soft part of the nose to apply pressure--the lower third of the nose, just above where the nose flares outward. Obviously if you try to pinch against the bony part of the nose you won't really be applying any pressure. Remember to encourage them to sit upright with their head tilted forward. In addition to applying pressure, you can also put an ice pack over the bony bridge of the nose to constrict the blood vessels even more.

3. Don't let up the pressure for at least 5 minutes--not even to take "a peek." Time this by the clock, don't wing it. You are trying to establish a clot in the bleeding vessels--steady, constant pressure is important in doing this. After 5 minutes of direct pressure, check for bleeding. If the nose is still bleeding, repeat step 2, only this time keep the steady continuous pressure going for at least 10 minutes.

4. Have you done all this with no improvement? In that case, it's time to visit the doctor or ER. Don't forget to continue pressure during transport and in the waiting room. Depending on the circumstances the ER doctor may have to resort to nasal cautery to stop the bleeding, by packing the nose with a gauze "nasal tampon," or by some other means to apply compression to the bleeding vessels.

5. All fixed? What now? After the nosebleed ask the patient to rest in a reclining position with the head elevated above the heart, limit strenuous activity for the rest of the day, and avoid bending and heavy lifting. It's okay to gently sniff, but avoid blowing the nose and if the patient must sneeze--encourage them to do so with an open mouth to minimize pressure through the nose.

6. What if the nosebleed starts up again?
  • Follow steps 1-3 again.
  • If unsuccessful in stopping the bleeding, or if the patient is experiencing any associated symptoms such as severe headache, body sweats, weakness, or shortness of breath--it's time to go to the ER. Remember to ensure that pressure is maintained in an effort to control the bleeding during the ride to the ER.
  • If the patient has already seen the doctor--review the discharge instructions and follow the written advice the physician gave--phone the doctor's office for any questions or concerns. Proceed to the ER if indicated.
  • On their website, the Ear, Nose, and Throat Associates of Corpus Christi give this additional advise for recurrent nosebleed: "Clear nose of all blood clots by sniffing in forcefully," and "Spray nose four times on both sides with decongestant spray (such as Afrin,® Duration,® Neo-Synephrineetc.)

Quick sources for additional reading:

Ask Dr. Sears: About Nosebleeds
The Children's Hospital, Aurora, Colorado


Below: Jay Dolitsky, MD, Clinical Professor and Director of Pediatric Otolaryngolgy at the NY Eye and Ear Infirmary offers his expert opinion about nosebleeds in this YouTube video.





Sunday, June 21, 2009

Happy Father's Day!


Our Dads . . . without them--well, it would surely be impossible for us to be here . . . Happy father's day to all of the dads including my own dad, Bob Venard; my husband (Bob Cooper); and (remembering) my late father-in-law, "Mr. Billy" Cooper on this Father's Day 2009. (At right, Dad and I, circa 1987.)

Something to remember today, particularly if you have an elderly father--research confirms--these members of the "greatest generation" are not inclined to ask for help. Rebecca Fairbanks wrote a great article in 2007 offering suggestions on ways to help elderly parents without offending them. Just as our teenagers don't appreciate us when we act as "parachute parents" hovering over them, our parents don't deserve that that either. With both generations subtle and carefully considered gestures are likely to have the best results.

What can you give your dad today? Give him the opportunity to teach you something you wish you would have learned from him years ago . . . Give him the chance to reminisce with some stories from his past that you've never heard before--or haven't heard for a long time. Give him your undivided attention with electronic devices safely out of sight and mind . . .

For your consideration, the AARP has a list of helpful links appropriate for those who are caregivers for their parents:
http://www.aarp.org/families/caregiving/caring_parents/


.

Thursday, June 18, 2009

Digital Conversion Box Trouble and Your Health

For help with Television Digital Conversion, these reputable sources are recommended:

http://www.dtv.gov/
http://www.fcc.gov/cgb/consumerfacts/digitaltv.html
Consumer Electronics Association
Ehow's list of reputable recycling options for analog televisions

A Health-Related Topic?

Why is this a health-related topic? Because I'm acquainted with some elderly individuals who want to make the digital converter work for their analog television, but who are having significant difficulty doing so, and it's REALLY stressing them out. Despite help from more technology-savy friends and relatives and numerous calls to toll-free numbers that promise help and support--they are left with less-than-optimal television reception, inconvenient use of their remote controllers, and inadequate volume control. There comes a point when frustration leads to the path of least resistance and that's where these folks are headed. They plan to discard, donate or somehow rid themselves of their analog television, complete with the newly installed converter box. Then they'll doll out precious savings to purchase a new television with a digital receiver already built-in.

Money that could be Better Spent

This topic relates to health because of the affects of the unanticipated cost of a new television with a built-in digital tuner (could be at least $450) when budgets are already strained by basic needs. If the new fully-equipped television purchase is out of the question, feeling coerced into purchasing basic cable television can add around $25 to the monthly bills ad infinitum.

Television is certainly not indispensable, and as a nation we are certainly overly-dependent on this medium of entertainment. However, it's a great tool for health education and communication of important safety and health messages. The Internet is a great substitute for television for many of us, but not every segment of the population is ready to replace TV as their main source of information and entertainment.

Living on a Budget

Sure we've known about the television digital conversion issue for at least the past year; granted it's been in the works much longer, but last summer the ominous local television. But it's been a year of financial hardship for many--and the most vulnerable among us always suffer disproportionately in an economic slump.

Living on a budget may mean forgoing the luxury of cable TV . . . struggling to make the house payment discourages purchase of a newer, digital-ready television when the old old [analog] TV "works just fine." Certainly the government made an effort to offset the consumer's cost of this change-over by offering coupons for a television converter box worth $40 to those analog television viewers who didn't subscribe to cable TV. However, the coupon didn't completely cover the cost of even the simplest converter.

For the technologically challenged, there are underlying issues that make "hooking up the converter box" beyond frustrating. It's been less than a week since the change came about, and I suspect we will be hearing more about digital conversion problems in the near future.

Pollution!

This topic is also health-related because "dumps" are going to be bulging when frustrated consumers discard (formerly perfect) televisions in order to purchase one that works well for them in this post-digital conversion age.

Gary Shapiro, CEO and president of the Consumers Electronics Association, estimated that "53% of the nation's households [would] own a digital television by the end of [2007]," and he further projected that consumers would purchase at least 70 million new digitally ready televisions by the end of 2009. So where are all of the old analog televisions going? Perhaps relegated to the attic or basement . . . or set up as a DVD/VCR "only" television . . . donated to the Salvation Army or Goodwill . . . or piling up in a landfill leaching harmful chemicals.


(It is a bit of a stretch to write about the TV digital conversion here--but I hope the links may help someone, somewhere along the line.)


Wednesday, June 17, 2009

Tracheostomy Care and Suctioning

A link to a very remarkable video series crossed my path today: "Breath of Life: a caregiver's guide to pediatric tracheostomy care." When their infant daughter Elizabeth needed a tracheostomy due to severe laryngomalacia and tracheal stenosis, Matt and Melanie Dragovits used their professional backgrounds in video production and education, respectively, to produce this video which also features expert advice from respiratory therapist Ron Barrows. The caliber of tracheostomy care training Matt and Melanie received in the hospital after Elizabeth's surgery inspired this educational video, because they were left with the feeling that "more could have been done to help them take Elizabeth home." After watching this well-produced, professional video, I'm convinced that adult tracheostomy patients would also benefit greatly by watching this video.

Breath of Life is available free online, but can also be purchased as a DVD for those without internet access.

Among the patients assigned to my care in the hospital recently have been two adults with new tracheostomies. Both of these tracheostomies were intended for long-term (probably permanent) treatment of the underlying condition. In one case, a cancerous tumor was encroaching on the airway, while the other "trach" was necessary because severe injury damaged tissue in the upper airway.

Once upon a time . . . it was commonplace for an RN to provide comprehensive health teaching on a regular, shift-to-shift basis in the hospital . . . this education and evaluation of the patient's/family member's understanding was an emphatic component of the care provided to patients who were about to leave the hospital and embark on a life-altering course of complicated self-care . . . It was with shame and remorse that these recollections crossed my mind regarding these two patients--meanwhile, the obligations of the patient load as a whole whirled me away from contributing to reinforcement of the essential teaching points.

The consequences of poor tracheostomy care and suctioning can mean the difference between life and death. In Echo Heron's nursing anthology, Tending Lives, Diane C., a home health nurse, wrote a chilling account of poor trach care that haunts me to this day. A few years ago while working in an outpatient care center, a foster mother brought her toddler with a trach in to provide a mucus sample to determine the nature of the child's chronic lung infections. I was glad that I decided to observe the mother suctioning the trach to obtain the specimen. Her technique was so utterly wrong that she grossly contamintated the child's lungs with each suctioning that she'd performed during the months that the child was in her care. I remember literally feeling faint with the shock of what I was seeing. This foster mother meant no harm--but she was truly misinformed to a degree that could have certainly resulted in fatal harm to the child had it continued.

Most of us are visual learners who retain new information best when we can watch a demonstration--often more than one time. As inhabitants of the modern Western hemisphere, we've been influenced by many, many years of television viewing which have reinforced our visual learning preferences. It's also possible to find YouTube videos about tracheostomy care. Granted, they are not the same quality as professionally produced videos, but these amateur videos can definitely provide some helpful, additional visual images of trach care.

Once we have the visual image of the procedure clear in our mind, it's much easier to process the excellent written instruction instructions provided by Cincinnati Children's Tracheotomy Care Handbook and at tracheostomy.com. (These are just two of the many excellent resources for trach information that I selected based on my online trach patient information search.)

It's imperative that you follow the advice of your physician, home health nurse and respiratory therapist and immediately consult them with any questions or problems about your loved ones tracheostomy.





The Best Medicine: Prevention

Benjamin Franklin is one of my personal heroes. He's certainly an American icon, but I don't believe his myriad of contributions to our way of life are realized so much by the general public any more. His contributions to the medical world were concrete and practical, for example, the flexible urinary catheter that he invented for his ailing brother. But his analytical mind also lead to innovative discoveries, such as the relationship between lead exposure and nerve damage. As a public health advocate, Ben Franklin was co-founder of our nation's first public hospital. He was also an advocate for early advocate for the vaccine against smallpox.

Although some sources attribute one of Ben's most famous quotes to fire-prevention, it is an exquisite and absolutely perfect philosophy for just about any problem imagineable:

"An ounce of prevention is worth a pound of cure."

My health-related advice to everyone for years has been simple: "Don't get sick." That's my flippant summary of Ben Franklin's quote. I don't want to see anyone be placed in the hospital setting if it can be avoided, because quite frankly the care given is marginal in many, many settings--and it saddens and sometimes scares me. That sentence is putting it nicely, based on my wide-ranging experience, and will offend many people with a vested interest in keeping the status quo in current hospital and extended care settings. Any health care worker with recent "boots on the ground" experience in these settings and a conscience will understand my concerns.

Exercise, eat right, and avoid bad habits--that's how we can make the attempt towards the best possible health status. And those three general behaviors will help in mitigating the consequences of illness or injury that we can't avoid.

A CDC co-sponsored health campaign called "Ounce of Prevention" recently caught my attention. Posters and other resources are available which emphasize prevention through knowledge about some central issues: cleanliness, food preparation, antibiotics, immunizations, and issues regarding pets and wildlife. A kid-focused component to the Ounce of Prevention campaign is brought to you by the makers of LYSOL® and the National Association of Pediatric Nurse Practitioners (NAPNAP). Order a free "Healthy Habits" activity book for kids or download a copy now.


.

Tuesday, June 09, 2009

Caringbridge . . . Connects Families During Health Crisis

CaringBridge logo

Several years ago I read a newspaper story about a beautiful young mother fighting for her life against bacterial meningitis. I didn't know the lady, but the story was so sad and compelling that I visited the link provided in the article which took me to Sheila Redington's "Caringbridge" website. I followed Sheila's story for days--prayed for her and grieved for the loss of this remarkable lady.

Caringbridge is a non-profit website that allows families facing a health crisis to make a free webpage for their loved one. The web page is almost like a blog which helps keep family and friends in the loop about a loved ones' health issue. Only individuals who are privy to the website for your loved one can view the information unless you choose to share it with the general public. You can post as much or as little information as you wish; see Sheila's story for an example. A wonderful feature of the website is that your loved ones can also communicate their thoughts and good wishes in the online "guest book" for your webpage. The over 1000 touching messages in Sheila's Caringbridge guestbook stand as a tribute to the outpouring of emotion expressed by her friends, extended family members, and others.

Some hospitals have partnered with Caringbridge to inform families of this great, free option. Here's what the Universtiy of Maryland Medical Center tells their patients: "The personal site is private and only those with the site address may visit. 'Caringbridge is a remarkable resource for patients and their families during a challenging time,' said Anne Williams, Manager, Patient Resource Center at UMMC. 'Family members can easily update loved ones without having to field too many phone calls and questions during an stressful time in their lives. They find comfort and encouragement in the messages of support posted in their guest book.' A Caringbridge website helps keep loved ones informed during difficult times. In return, family and friends give patient and caregiver support through guestbook messages."

Learn more about CaringBridge, a nonprofit organization



Monday, June 08, 2009

Hard of Hearing? Suggestions for the Health Care Setting.

Last year one branch of my family had a large reunion luncheon that included slide shows and oral history presentations. The event organizers made certain that an excellent sound system was in place within our modest venue. Our common ancestor, "Granddad Colley," passed some very prolific genes down to us. One striking feature very obvious among the attendees was the abundance of pre-maturely silver-white hair. Less obvious, but very well-known within our family is the tendency to inherit Great-Granddad's severe age-related-hearing loss. Some of my older cousins actually recall Great-Granddad using an ear trumpet to amplify sound. Other cousins who thought Great-Grandma was rather mean for yelling at Great-Granddad so much, now concede that might have been her strategy to communicate through the hearing loss.

In the health-care setting, patients with hearing loss may try to cope by keeping quiet, pretending that they have understood the information that was provided, and by providing incomplete or incorrect answers to questions they may have misunderstood.

The Americans with Disabilities Act insists that individuals who suffer from deafness or other hearing loss be guaranteed equal access to health information and appropriate communication in hospitals and nursing homes as well as in doctor's offices. The National Association of the Deaf provides insight about what the law requires in a list of frequently asked questions including this example: "Q. Why are auxiliary aids and services so important in medical settings? A. Auxiliary aids and services are often needed to provide safe and effective medical treatment. Without these aids and services, medical staff run the grave risk of not understanding the patient's symptoms, misdiagnosing the patient's medical problem, and prescribing inadequate or even harmful treatment. Similarly, patients may not understand medical instructions and warnings or prescription guidelines."

The American Academy of Family Physicians' tips for working with your doctor if you are hard of hearing offers some good suggestions as follow:

In the waiting room

Unless the health care facility issues you a vibrating pager or uses lighted boards to indicate "who is next," it may be difficult to hear that it's your turn to be seen. Upon arrival, be sure to explain to the receptionist that announcing your name or number is not the best way to inform you that the doctor is ready to see you.

Don't be shy

As difficult and embarrassing as it may be, advocating for yourself is of the utmost importance. Do ask for a quiet, well-lit room in which to converse with your health care provider.

  • Do ask for privacy if a health care provider starts to loudly discuss private matters with you in a public space.

  • Do ask your health care workers to speak clearly to you in a face-to-face posture with their mouths unobstructed.

  • Do remind your doctor or nurse that if they must wear a mask for a procedure, you will not be able to understand their spoken words and therefore require instructions before hand.

  • Do not allow your health care provider to dismiss you until your questions have been answered and the answers clarified to your satisfaction.

Personally, in the hospital setting I like to have a letter-sized word document posted just above the head of the patient's bed at care-giver eye-level. The boldly printed document serves as a visual reminder that the "patient is hard of hearing--please speak loudly and clearly." If and when the Colley hearing-loss gene affects me, I think I'll carry something like that in my purse, just in case.




Saturday, June 06, 2009

Me and My Flu . . . Again . . .

(Another personal note--me, complaining about my flu again.) Weeks after symptoms began . . . my liver enzymes are back to normal . . . the chest xray did not show pneumonia . . . my stamina is NOT back to normal. And after a few days of seeming respite with just an occasional dry cough, the productive wet cough has returned. I have never had asthma and have never smoked; my lungs have always been healthy. Now after this flu, and depending on my level of activity, I have this moist, persistant cough producing yellow sputum. This whole ordeal got "old" a long time ago.

Friday, June 05, 2009

Healthfinder.gov is a Great Site for Reliable Health Information

Because I get an email with the daily health news headlines from Healthfinder.gov, I must admit I don't visit their main site much. I had forgotten what a great portal to a wide variety of health information is available there. There really are enough features here to provide a good hour of browsing just to familiarize and explore.

If you want to quickly find specific health information, select Healthfinder's Health: A to Z. It's one of many options available on their site. Choose a topic from the comprehensive list and you'll be linked to other reputable government-sponsored, health-related sites. Browse the choices available on this A to Z listing for some compelling options.

This is one of the useful sites that the Healthfinder blog linked me to: Questions Are the Answer. My Florence Nightingale quote (see upper right-hand corner of my blog) is the absolute truth so I certainly advocate for patients who want to know what's going on! The tide is not turning in healthcare yet in spite of the abundance of information that is available to share with patients. Therefore, patients are often still kept in the dark (not on purpose, but because of the "hurry up and wait" attitude that still prevails in patient care, treatment, and education.) I can implore you to get more involved with your healthcare, but please be assured that it's up to YOU to do that in order to help yourself and your loved ones. Knowing what questions you should ask your doctor is a great first step towards being informed and able to make the best decisions. NO ONE will care more about your health needs and those of your loved ones than YOURSELF and those who are closest to you.

Another site that Healthfinder linked me to which pertains to being a more informed patient: Ask Me 3. The National Patient Safety Foundation recommends asking at least three basic questions: What is my main problem? What do I need to do? Why is it important for me to do this? There are plenty of other great suggestions for patients and their doctors and nurses on this site.

Healthfinder Prevention Tips: Here you'll find a quick guide to healthy living recommendations.

Tuesday, May 26, 2009

Case Study: H1N1 Swine Flu, my influenza experience

Is this really a case study? Okay, it's more of a personal accounting of the last twelve days, during which I've been suffering from severe respiratory influenza . . . I'm not 100% well yet . . . but much better. Certainly my intent in blogging is not to write about "me, me, me" . . . On the other hand, my flu experience has been so weird and prolonged, I want to share in case someone else can benefit.

Here's a rundown of my recent illness:

Day 1: Thurs. eve., May 14th. I noticed that tell-tale "tickle" in my chest and the urge to cough deeply. My husband the mailman had brought this upper-respiratory virus home earlier in the week. After four days of body aches, rest, and frequent cough--he was finally feeling well. I had planned to go visit my elderly parents for the weekend. With the symptoms beginning, I decided to re-evaluate on Friday morning. I didn't want to take them any germs.

Day 2: Fri. May 15th. Woke up feeling "icky" and immediately postponed visiting my folks. A bad headache, cough, body aches and really sore throat came on gradually through the day until I was officially sick by late afternoon.

Day 3: Sat, May 16th. Full blown sickness all day. My sore throat was severe. The headache escalated with every cough and my over-the-counter meds didn't make a lot of progress against any of the symptoms. Lemonade, Popsicles, and fitful sleep punctuated by strange dreams were the theme of the day. I emailed my supervisor to let her know I needed a substitute for my nursing shift on Tuesday--the way I felt it was obvious I wouldn't be well enough to be around either patients or other staff by then. I assured her I'd be able to work my planned Friday shift, however.

Day 4: Sun, May 17th. Full blown sickness, day 2. Same as day 3. No appetite at all, icky taste in my mouth, terrible sore throat, and frequent cough with nasty phlegm. My husband was again a huge help in bringing me fluids . . . muscle aches in the upper arms, thighs, abdomen, lower back, and what felt like spasms of deep bone pain to my left lower leg and right upper thigh. (I didn't have much headache from this day forth, however.) By late evening I got out of bed and onto the couch to rest so hubby could sleep. I felt well enough to putter around the kitchen--I suspected I was feverish--and confirmed that with the thermometer. (Fever is nature's way of killing bad germs, so that doesn't frighten me at all by the way. I was hoping this meant the illness was going to peak and resolve.) I had chills and was generally just plain sick. I did take a dose of Tylenol. My fever stayed in the 101-102.5 range most of the night.

Day 5: Mon., May 18th. My highest temp was 103 at 6 am on Monday morning, but fever and chills stayed with me. My cough was bringing up very thick, green phlegm. My plan was to call the hospital where I work to speak with the employee health nurse. I wanted them to know about my fever and influenza symptoms and see if our facility was doing any lab surveillance for flu among the employees. (We were not.) I phoned my doctor's office to ask if they were interested in a specimen for surveillance. The nurse related my symptoms to the doctor, and advised that she wanted to see me in the office based on my symptoms, but surveillance for H1N1 was only taking place in hospitalized patients in our community. There were no appointments available, and I didn't want to get out of bed anyway. I had my laptop at the bedside and felt well enough to write a blog note about my flu. I felt like a "wuss," because my health is robust and I'm not used to being so fatigued and achy. My only moments out of bed were to the nearby bathroom. I caught a glimpse of my reflection and noticed my face was a waxy, pale yellow. I thought I looked jaundiced! My tongue was also VERY PALE. I thought the fever had somehow left me anemic. For a moment I thought about checking the whites of my eyes in the mirror, but the room was too dark and the hand mirror seemed "too heavy."

Day 6, Tues., May 19th. More of the same. I was again shocked to see how yellow I was as I passed the mirror. Again, I thought about looking at my eyes with the hand mirror to check for icterus--but I lacked the energy. There was no noticeable improvement in body aches, sore throat, cough or fatigue. I stayed in bed. Just up to soak in the tub and use the bathroom. I had my laptop at bedside, but didn't have much interest in anything. Much as I was resting, it was difficult to get any satisfying sleep. One of the cats seemed injured and was acting strange and hurt in the evening. It seemed likely he'd been stung by a bee. We had no liquid benadryl in the house so I reluctantly dressed and went to Walgreens. I planned to grab a mask to wear in there, but they didn't have any!! Not wanting to infect anyone, I made my purchases quickly and was back home. Of course the cat seemed recovered enough not to need the medicine.

Day 7, Wed., May 20th. I had a feeling that I would not be able to work on Friday after all. I wasn't well yet--still coughing green stuff constantly. Still with a terrible sore throat. After no fever for two days, I started with chills again in the evening and a low grade temp of 100.5. I thought I'd better see the doctor the next day, just to get a note for work so they wouldn't think I was "playing possum."

Day 8, Thurs., May 21st. I was the patient in a mask at the doctor's office--well, I did see one other patient in a mask. The doctor suggested possible pneumonia as a consequence of the influenza. New symptoms had also developed--my left eye was draining green pus! My temp was still hovering in the low 100's. My neck glands were swollen and tender. I had a chest xray, throat culture and blood work. I told the doctor I felt 70% of normal--so much improved from earlier in the week. The sore throat, cough, and malaise were lingering . . . I got antibiotic drops to instill in the infected eye. I came home to rest and while my husband was getting the eye drops, he bought me a teddy bear. That's how pathetic I've been feeling . . . Reluctantly, I had to notify my boss once again that I would have to cancel my Sunday shift.

Day 9, Fri., May 22nd. My doctor called in the morning. The chest xray hadn't been read yet by the radiologist, but the lab work didn't show any bacterial infection in my throat. The most unusual finding was in my blood work. My liver enzymes were alarmingly elevated suggesting that the influenza virus had battled with my liver and caused an acute hepatitis earlier in the week. My shocking yellow color on Monday and Tuesday was, indeed, jaundice. I was feeling better Friday . . . so much so that I decided to sanitize certain parts of the house. I focused on disinfecting my kitchen/dining area which included a thorough mopping of the floor and scrubbing of the sink, refrigerator, counters, and trash can. I vacuumed my living room including the crevices of the couch & chairs, did loads of laundry, changed all the sheets, and threw open the doors and windows to get fresh air in and germs out. I even cooked my son a light supper, but was spent before my husband made it home from work. Overdoing it exhausted me. I took a 5-hour-nap on the couch before going to bed.

Day 10, Sat., May 23rd. All that progress from Friday made me optimistic that I'd be able to have a normal day. Instead I was still very fatigued and my abdomen was so sore in the round ligaments from the constant deep productive cough.

Day 11, Sun., May 24th. This was a day of feeling better for a change. As it is Memorial Day weekend, I wanted to take advantage of a sale at the nearby Bergner store. I made the trip, got my items (deeply discounted towels and rugs) and came home. The air was so fresh, I wanted to get out in the yard to check my flowers and vegetable plants. The herbs smelled so fresh. It was all so inspiring, I got out some branch cutters and did some pruning. Again, I later found that was taxing enough to exhaust me into a long nap. I woke up suffering from positional vertigo!!! I've had this vertigo in the past, but it's always a little disconcerting.

Day 12, Mon., May 25th. The sore throat is almost gone. My eye is better. I still have positional vertigo. The cough is what I call "moist"--it's nagging in spasms that interfere with sleep, but not bringing up as much phlegm. My need for napping is ridiculously high, catching up on a sleep deficit from the illness, I am sure. I still have occasional body aches. Appetite is not back and the "sickish-taste" is still there. But, I feel like I'm 93% back to normal. Fortunately, I have no scheduled days of work this week.

Day 13, Tues., May 26th. Well, technically it's Tuesday since it is nearly 2 am. My most lingering symptoms are the cough and a vague, generalized pain in my chest--a constant presence over the past week or so, that is not unbearable. I still have positional vertigo, but obviously my energy and enthusiasm is returning if I'm feeling interested enough to write for a while. Just for my own curiosity, I'll call my doctor later to see what the xray result showed. Overall, this has been a really persistent illness. Because the symptoms have waxed and waned so much I can't be confident that it's over yet. I am certain that I've never been affected by an illness for so long in my adult life.


You might find these relevant articles of interest:

This page from the CDC website explains when it is recommended to collect specimens for H1N1 surveillance. Obviously we want to have an idea of how much influenza is out there, where it is located, and the emerging patterns of the illness. At the same time, it's unwise to test everyone, everywhere for the illness. We'd be expending resources at a cost that doesn't give us any benefit. Influenza as a general diagnosis can be made based on symptoms. Antibiotics are not a treatment for viral illnesses like influenza, and anti-viral medications are not frequently used either. This is one of those illnesses that requires our immune system to fight the virus.

Here is a 2006 article explaining a relationship between Influenza and a bout of acute hepatitis: Systemic Viral Infections and Collateral Damage in the Liver David H. Adams and Stefan G. Hubscher. (American Journal of Pathology. 2006;168:1057-1059.) See paragraph 2, Understanding Hepatitis in Influenza.

Want to review the basics about influenza?

Here's a link to my general information about the flu.

. ..

Monday, May 18, 2009

The Flu and I

This is on a personal note . . .

I couldn't be more surprised. I am all but certain that I have the influenza--maybe not H1N1, but still, influenza. Tomorrow I'm calling my doctor and my workplace health office to see if either of them want to confirm that by lab analysis. I'm not seeking sympathy, but sharing this information since the influenza news has predictably died off lately. For the past week I've enjoyed some time off work. I planted my flowers, worked on my "collections of things," and even cooked some pretty good family meals for the three of us. I haven't been around any patients for over a week, and even then none of them had flu-like symptoms . . .

My son had a nagging cough recently that resolved without incident . . . he gets some seasonal allergies to the Illinois pollen. After all he grew up in a desert for the first 3/4 of his life. We weren't fortunate enough to have a yard full of trees and flowers--and it was a challenge to even raise grass (lots of water goes on the lawns of El Paso, TX).

My husband got a bit of a nagging cough days after our son was over his completely. I think he picked it up from his buddies at work--the other postal carriers? I felt immune to it; just thought he wasn't quite up to par and, in retrospect, I could have been more sympathetic. : (

Now--husband's symptoms not quite gone and I was ready to go up to Western Illinois to visit my folks for the weekend, when I noticed late Thursday night that something was coming on.

It started with that little tickle behind the breast bone that makes you feel like you should cough--but you can't really produce one. Then that feeling of "yuckiness" that overcomes you with the flu. Next morning, bad headache that was hard to get a handle on despite the ibuprofen and over-the-counter flu meds. Sore throat and a deeper, productive cough joined the symptoms, as did large muscle aches like the thighs, lower legs, back and abdomen. When I look in the mirror my face is pale yellowish and my tongue is white--all signs that, yes, I am sick!!! I thought I might start to feel better today, Sunday--but now the body aches and fever are here. Brrrr! So far just a low-grade temp of 100.6 F . . . I doubt this is the H1N1 (Swine Flu). I checked the national pandemic flu prevalence website and learned the prevalence of diagnosed cases is low in my area. Interestingly, in a press conference last week the CDC acknowledged an unexpected spike in non-H1N1, seasonal influenza.

Did I follow my own advice?

Yes, I pretty much covered all the bases in after writing about the H1N1 (Swine flu) a few weeks ago. I'm avoiding public spaces and particularly vulnerable people (like my aging folks and the auction crowds.) The chicken soup and lemonade have been most satisfying as was a heaping scoop of mashed potatoes and gravy from KFC. Decreased appetite is huge. My Diet Pepsi is not even as appealing as usual . . .

Links to my flu blog articles: my influenza flu blog articles.

What I would do differently:
  • I didn't buy any Popsicles and I really, really want some for my throat!
  • We (my husband) had to replenish our supply of over-the-counter flu-type remedies
  • We also had to stock up on more ibuprofen and Tylenol (remember--NO ASPIRIN with flu-like symptoms--particularly for children)

What to do to prevent the flu?

Obviously avoid me for the next few days . . . Be careful with public surfaces. My husband said he had to wait in line at the grocery store today for a cart--not because of a lack of carts, but because the customers were dilagently wiping down the handles with those bleach-type wipes they have onhand. In an abudance of caution, many high schools and universities are foregoing the traditional graduation handshake at commencement this year to avoid spreading the flu virus!!

Wow! Here's hoping you all stay well . . . and a public "thank you" to my husband for nursing the nurse during my flu-like symptoms. He's doing great now, by the way!

**Follow up at 2 in the afternoon the following day--after a night of fever up to 103. I'm awake & at my normal 96.8 . . . still not well by a long shot . . . have the very productive frequent cough. I could sure give a specimen for lab analysis, but no one is doing flu surveillance via lab analysis here unless the patient is hospitalized . . . My doctor's office in our little town was not surprised--said we've had plenty of flu in our little town recently . . . first I've heard about it . . .

. . .

Sunday, May 17, 2009

Prevent Drowning, May is National Water Safety Month

From friends and relatives relatives I correspond with, I know that warm weather has arrived in some places around the U.S. Here in Central Illinois we have been a little less fortunate this spring. When browsing through the list of the many national health observances meant to be recognized in May, I didn't overlook the fact that this is National Water Safety Awareness Month. I thought I'd skip in favor of some of the lesser-known observance topics this month . . . but . . .

Why Think About Water Safety and Drowning Prevention

I changed my mind today after browsing the online newspaper of our erstwhile hometown of El Paso, Texas (where it's definitely more than warm, by the way, they'll reach the low 90's tomorrow while we can only hope for 72.) This is the time of year when El Paso kids often get to take a day off school to have a big outing for the day. Some lucky students spend a day at the nearby giant waterpark, Wet N'Wild Waterworld. Almost 700 student from various schools were enjoying one of those days of swimming last week, when a 14-year-old boy tragically drowned. Sadly, another drowning made the national news last week. In Jacksonville, Florida 2-year-old twins drowned in a backyard pond near their home.

It's painful to recall drownings of children and young people who have somehow been peripheral to my circle of friends/acquaintances/and relatives. It hasn't happened often, but the memories of those tragedies are particularly difficult to bear. Often survivor's guilt haunts those left behind for years to come. I will bear witness to the fact that it doesn't matter who you are--how well educated the parent, how strong the swimmer, how many safety precautions were set in place beforehand. These tragedies can and do happen in mere moments.

The upcoming weekend we celebrate Memorial Day. In many places this even marks the opening of the local pools as children are released from school for the summer.

What You Should Know . . .

In 2001 the National Institute of Health, National Child Health and Human Development published a study advising that infants less than age one are more likely to drown in a bathtub at home. Toddlers and adolescent males were more likely to die from drowning. Toddlers typically drowned in a swimming pool. From the age of 5 upwards, children were more likely to drown in a fresh water environment such as a pond, lake, or river.

Read more about how to Prevent Drowning:

I'm leaving it to expert advice from the following reliable sources:
Don't feel like reading?

The CDC has a podcast to download and listen to, Protect the ones you love from drowning. You can also print at that site transcript if you prefer.



.

Thursday, May 14, 2009

May 15th, Vascular Birthmark Foundation, International Day of Birthmark Awareness

As newborns we preferred to fix our gaze upon the faces of those around us. When we lacked a living human face to observe, our attention was instinctively drawn to shapes and patterns which approximated the features, and mirrored the symmetry, of the human face. Scientific research has repeatedly demonstrated an innate human appreciation for (and attraction to) symmetry in facial features.

Wisdom and maturity eventually allow us to see with our hearts as well as our eyes, and then we learn the real truth about beauty . . . it doesn't really abide in physical features, but emanates from the soul. Of course, there are always some people in the world who received less than their fair share of wisdom and maturity. Children are often cruel and insensitive towards peers who lack traditional beauty or are otherwise "different." As adults we know this. We were kids once.

As parents we understand the implications of "being different" as it pertains to a child's development of self-esteem and confidence. So we prepare our kids for a world where compassion and tolerance may be lacking. And if we are really doing our job, we'll go a step beyond--and teach ALL of our children to be decent and respectful to one another and in the world at large.

As an ani-bully, I feel strongly that International Birthmark Awareness Day is a good idea. We all have some kind of birthmark, most often something simple like a handful of inconspicuously scattered moles. This awareness day, however, is meant to focus on birthmarks that are much less subtle.

Vascular birthmarks such as hemangiomas ("strawberry marks") and port-wine birthmarks (correctly called "nevus flammeus") are diffcult to ignore . . . They attract unwanted attention because they are large and colorful . . . and they frequently occur on one side of the face, disrupting the oh-so-important-symmetry that our species values.

The Vascular Birthmarks Foundation is sponsoring this awareness day. Their website is a source of information and support for individuals and families affected by vascular birthmarks. Recognizing the need to reach children on their own level, they've published an awareness story book written by Donna and Evan Ducker to provide age-appropriate education. Before leaving their website, be sure to check out a very compelling essay with many photos, Mei's Hemangioma Story, written by the adorable Mei's mother, Tara.

Visit Nevus.org to learn about other types of large birthmarks, Large Nevi and Neurocutaneous Melanocytosis.

Recommended reading for teens, with or without a facial birthmark, North of Beautiful by Justina Chen Headley. I have only read the synopsis and reviews, but those were enough to convince me, I will most definitely read this book.



"No human face is exactly the same in its lines on each side, no leaf perfect in its lobes, no branch in its symmetry . . . All things are . . . more beloved for the imperfections which have been divinely appointed . . ." ~ John Ruskin

. . . .

Monday, May 11, 2009

World MS Day is May 27th


Who Gets MS?

Multiple Sclerosis, or MS, is a chronic and often disabling autoimmune condition that strikes the central nervous system. Although men can get MS, it most often strikes women who are in the prime of life, typically those from 20 to 50 years of age.

Genetics and the environment are both thought to play a role in the development of MS. A familial tendency has been demonstrated, with persons of Northern European heritage being more likely to develop MS. Even living farther from the equator (and therefore being exposed to less sunlight) is a theory. (And it's a compelling one--I sure didn't see much MS in the desert Southwest, while I was astonished at the number of MS patients here in Central Illinois. Of course, few of my patients in the desert were of Northern European heritage . . .)

Having a tendency towards this autoimmune condition is only one part of the puzzle, however. Ultimately, there must be some "last straw" that triggers the immune system to damage the body that it is supposed to protect. (Theories about "the last straw" that triggers autoimmune responses often vaguely suggest that some type of viral infection may be to blame.)

Central Nervous System is Affected by MS

We've already established that Multiple Sclerosis affects the central nervous system. The brain and spinal cord are the major players in this system. They send out signals that communicate with the rest of the body to control every function--even ones we aren't consciously aware of.

Neurons are specialized cells that transmit information from the brain and spinal cord to the rest of the body. Most neurons have a protective, insulating covering which is called myelin. In MS, the immune system damages the myelin covering (often called the myelin sheath), causing the portion of the nerve cell underneath it to become exposed to injury and permanent damage.

(I always like to paint a picture in my mind to help me "see" physiological concepts as a simple analogy. In this case, think about roller skating across a smooth, flat varnished floor all the way from point A to point B. Easy right? Now imagine roller skating across that same surface--except now between point A and point B, a segment of the varnished floor has been stripped away, leaving rough gravel in your path. That kind of gives you an idea of how the "message" a nerve is transmitted becomes halted in its course when the myelin sheath is disrupted along a nerve path.)

Clinical Stages of MS

Symptoms of MS vary from one person to the next and may be as mild as numbness and tingling in the limbs, or as severe as paralysis or loss of eyesight. The progression of the disease and its severity are likewise impossible to predict with certainty. Several distinct clinical stages of MS have been recognized and are useful in guiding treatment decisions.

  • Relapsing-remitting: Symptoms come and go. During periods of relapse, inflammation of the myelin sheath causes MS symptoms that ultimately resolve (they may resolve completely or their may be some residual symptoms that persist).
  • Secondary progressive: There may still be some periods of remission, but this phase shows a steady progress of nerve degeneration and physical deterioration. The nervous system has been damaged enough so that there isn't the ability to bounce back as with relapsing-remitting MS.
  • Progressive relapsing: This is the least common type of MS. In this case, the symptoms progress from the very beginning without the benefit of remission. On the contrary, the progression of the symptoms are punctuated by periods of relapse in which the neurological function actually temporarily worsens.
  • Primary progressive: A gradual and continual progression of symptoms is the hallmark of this type of MS. The course of this type of MS doesn't include periods of relapse or remission.

Treatments for MS

Check out the National MS Society website for comprehensive information on treatments for MS. Like other autoimmune diseases, there is no cure yet for MS, but there are a number of treatment options and strategies designed to slow disease progression, treat relapses, manage and control symptoms, and improve physical function and enhance safety.

Recommended reading:

National Institute of Neurological Disorders and Stroke: Multiple Sclerosis

MS Overview from WebMD

MS tutorial from medlineplus

National MS Society

Mayo Clinic article about MS and remyelinization

. . . . . . .

Friday, May 08, 2009

Fentanyl Transdermal Patches for Severe, Chronic Pain

A few days ago an elderly cancer patient was admitted to one of my rooms directly from the doctor's office for management of severe, chronic cancer-related pain. She rated her pain at "more than 10 of 10" on the pain scale. I'm always quick to give pain medication, but in this case we had no doctor's orders for one thing, and the supplies to access the patient's IV port-a-cath site (that's the same thing as an infus-a-port) hadn't arrived yet from the distant central supply department. Despite her pain, it was reassuring to review her home medication list and see that she had listed the Fentanyl transdermal pain patch among her medications. (Duragesic is a well-known brand-name for the Fentanyl patch.) The strong medication released from the patch on a slow, continuous basis is absorbed through the skin and provides great pain relief to most patients. Later in my admission assessment I asked her specific questions about the last time she took her home medications in order to complete the medication reconciliation process. It turned out that although the patient had filled the Fentanyl patch prescription, she had never used any of them.

My patient told me that after filling the Fentanyl patch prescription, she happened to catch an attorney's television commercial which warned about using Fentanyl patches. "The lawyer said those patches are 80 times more powerful than morphine, and they can kill a person." Unfortunately, my patient suffered quite a bit of intense pain and ended up admitted to the hospital due to that frightening television commercial. It's true that the Fentanyl is a MUCH stronger pain medication than morphine (about 100 times stronger), and certain circumstances related to this medication have come under well-deserved scrutiny in recent years--see FDA's 2007 Fentanyl Advisory--but with proper safeguards, this medication is both safe and very effective.

Some generic versions of the Fentanyl patch of the dosage 25 mcg/hr were recalled in 2008; check this list to learn more about the affected lots. The damaged patches released the pain medication too quickly, therefore putting patients at risk for an accidental overdose which could have caused them to breathe way too slowly--or not at all--due to oversedation.

I'll probably come back to tweak this blog entry later. For now, I want to point the reader to the patient information guide, instructions for use, and the "black box warning" for the Duragesic Fentanyl Patch.

The following "Important Safety Information" can be read in its entirety at the Duragesic site.

Here are some of the key points you need to know about using the (Fentanyl transdermal system) with my own bold/italics added to emphasize certain points.
  • It is used to manage constant moderate to severe chronic pain that needs to be treated around the clock which cannot be treated by: combination narcotic, short-acting, or non-narcotic pain treatment products.
  • It should only be used by people who are receiving or have developed a tolerance to pain therapy with products known as opioids. It should not be used if you have pain that will go away in a few days, such as pain from surgery, medical or dental procedures, or short-lasting conditions.
  • One serious important side effect is slow, shallow, and/or difficulty in breathing, if the dose is too high. This sometimes happens the first time someone uses the product, so they should be watched more closely during the first 3 days of treatment.
  • It can be abused in ways similar to other legal or illegal pain products. Care should be taken in storing this medication.
  • It is a thin, adhesive, rectangular patch that is worn on your skin and delivers a strong pain-relieving medicine called Fentanyl through the skin and into the bloodstream. Using damaged patches can change the amount that is absorbed and cause too much medicine to be absorbed through the skin that can cause serious and sometimes fatal breathing problems.
  • Do not combine with alcohol or other CNS depressants (e.g., sleep medications, tranquilizers) because dangerous additive effects may occur, resulting in serious injury or death.
  • Avoid exposing the Fentanyl application site and surrounding area to direct external heat sources, such as heating pads or electric blankets, heat or tanning lamps, saunas, hot tubs, and heated water beds, while wearing the system. Avoid taking hot baths or sunbathing. There is a potential for temperature-dependent increases in Fentanyl released from the system resulting in possible overdose and death.
  • Keep patches (new and used) out of the reach of children and others for whom Fentanyl was not prescribed. A considerable amount of active Fentanyl remains in the patch even after it has been used as directed. Accidental or deliberate application or ingestion by a child or adolescent will cause respiratory depression that could result in death.
  • For more information about DURAGESIC® Fentanyl patches, talk to your doctor or call 1-800-526-7736, 9:00 AM - 5:00 PM (EST), Monday through Friday.

For additional information, here's a link to an FDA article, Proper Use of Fentanyl Pain Patches.

. . . .

Thursday, May 07, 2009

May Health Observances 2009 (Part 1)

May is Lupus Awareness Month. I'd never heard of Lupus until 1981 when my Army roommate in Germany tearfully confided that her mother back in Ohio was battling a severe-form of this chronic, auto-immune disease which can damage organs, joints or skin. Treatments for Lupus were not as good then, and her mother ultimately passed away in her 40's due to complications of the disease. Women of child-bearing age are most commonly afflicted with Lupus, with women of color at greater risk than Caucasians. Neither men, nor children, are immune, however. Learn more about this illness at the website of the Lupus Foundation of America. While there, don't overlook the links of additional Patient Resources. For a Lupus-oriented blog, try this one: On the Road to a Cure.

Amyotrophic Lateral Sclerosis (ALS) (a.k.a Lou Gherig's Disease) ALS is an insidious and progressive neurodegenerative disease that attacks nerve cells in the brain and spinal cord causing, muscle weakness, atrophy, and eventually total paralysis. ALS is not contagious, but certain envrionmental exposures may increase its likelihood. Learn more by reading "Facts You Should Know about ALS." I'm sure others have accepted this illness with as much dignity and class, but Lou Gherig's farewell speech to baseball fans in 1938 is, never-the-less, uplifting and gives evidence of a gracious spirit. (On a personal note, an affectionately-remembered, distant relative passed away last year after battling ALS for nearly five years.) Want to know more about ALS? Check out the Muscular Dystrophy Association's ALS page entitled, "Anyone's Life Story."

Celiac Disease Awareness Month. Celiac disease is yet another autoimmune illness, this one affects about 1% of the U.S. population (it's MUCH more common in Ireland, Finland, Sweden, Italy and Austria). Although it may seem obvious, it's worth stating that those of us of Northern European descent are more commonly afflicted by Celiac Disease (and, by-the-way we are more inclined towards two other autoimmune disorders, Type 1 Diabetes and Multiple Sclerosis).

In Celiac disease the gluten protein found primarily in wheat, rye and barley, triggers an immune response when it enters the small intestine (where most of our food's nutrients are absorbed.) Damage to the small intestine's lining results in troubling physical symptoms such as pain, bloating, and bowel issues, but even more seriously--the disruption of digestion from a compromised small bowel that can lead to more serious systemic complications as a result of vitamin, mineral, and other nutritional deficiencies. Strict life-long adherence to a gluten-free diet is the essential treatment for Celaic Disease. This illness is also in my extended family, so I understand that it's a real challenge, but my relative is the picture of health and a true beauty.

Check the sidebar on the right for youtube videos which convey important information related to two other health awareness campaigns this month:

. . . .

. . . .

Tuesday, May 05, 2009

World Asthma Awareness Day

I hope you'll be hearing a lot about asthma awareness today. Not only is the month of May, Asthma Awareness Month, but today is World Asthma Awareness Day. We all know that April showers bring May flowers and blooms. Along with all that loveliness we get an abundance of pollens which adds to the already pervasive triggers that asthma sufferers deal with. The Global Initiative for Asthma sponsors this awareness day. The theme today: You Can Control Your Asthma (find downloads for a publication by the same name and more, including publications that advise you how you can control your child's asthma, in section #5 of the link.)

For more asthma-related information this month, check out the World Health Organization's asthma pages.

The U.S. Environmental Protection Agency (EPA) advises all of us to "Take Action During Asthma Awareness Month." They offer an unexpected variety of helpful information for the control of asthma. Asthma triggers like mold and dust mites may be right under your child's nose. For tips on making the home environment asthma friendly, visit noattacks.com/.

Asthma Medications

A lot of folks around here call their inhalers "puffers." In healthcare we often refer to them as MDI inhalers (metered dose inhalers). Now days we have a wide selection of hand-held asthma inhalers for asthma, COPD and emphysema. It's important to have a good understanding of the purpose and function of each type of inhaler. Some inhalers are known as rescue inhalers; these propel medication into your lungs to quickly dilate the bronchioles, allowing the constricted airway to relax and allow a refreshing deep breath of life-sustaining oxygen!
Maintenance inhalers are meant for long-term control and prevention of symptoms. (Some maintenance inhalers include steroids.)

There are a variety of medications taken in pill form, as inhalers, or as nebulizers. Understanding what you (or your child) is taking is an important fundamental in control and prevention of symptoms.

Are you getting the most out of your asthma inhaler?

As a student nurse in clinical rotations, I spent a semester in a school nurses office. It was obvious that many of the children coming in for their pre-PE puff on their inhaler were using poor inhaler technique. Their expensive inhalers were puffing medication into their mouths, but not necessarily delivering it into their lungs. Using the package inserts (each box containing an inhaler has one), we made posters demonstrating the proper use of each inhaler and spacer and carefully retaught all the kids, having them give us a return demonstration showing understanding of the correct procedure.

Based on that past experience I was delighted to see something similar on the Global Initiative for Asthma site: Instructions for 18 inhalers and 6 spacersInstructions for 18 inhalers and 6 spacers to include diagrams and instructions for the effective use of these devices. View, print, and download this page for your own use. (It occurs to me that a diagram of the correct use of your child's inhaler would be very helpful when you leave the kids with a babysitter.)

Additional Resources of Interest:

I really like Dr. Paul's Children's Health & Wellness Asthma Corner, in particular, the helpful hints for using a puffer/inhaler.

Here's a video aimed at children to demonstrate proper usage of their puffer/inhaler with or without a spacer:




. . . ..

Monday, May 04, 2009

May is MCS Awareness Month (Multiple Chemical Sensitivity)


A Man Unmasked: Living with Multiple Chemical Sensitivity

Copyright 2004
Carolyn Cooper, MPH, RN

Cloudcroft, a village nestled 9,000 feet above sea level in southern New Mexico’s Sacramento Mountains, boasts an idyllic setting. In the winter months, Cloudcroft, named for the “field of clouds” that sometimes hovers beneath it, is a popular weekend getaway for ski enthusiasts. In the summer, the cool mountain temperatures attract nearby desert-dwellers seeking respite from the heat. Surrounded by a national forest populated with coyotes, deer, and elk, Cloudcroft’s year-round-residents are privileged to enjoy a seemingly pristine environment.

For Rodger and Jean Norris of Cloudcroft, a pristine environment is not only desirable, it is a necessity—both indoors and out. The sign at the foot of their driveway may bewilder some passers-by, but by designating his property as “Southern New Mexico Confinement Facility,” Rodger, 53, tries to find some dark humor in the illness that does indeed confine him.

For the past 8 years, Rodger has been afflicted with a chronic debilitating disorder known as multiple chemical sensitivity disorder or (MCS). MCS is also sometimes called “20th Century Disease” or environmental intolerance (EI). All of these names refer to a syndrome that medical science finally recognizes, but still finds hard to explain.

“My doctor’s have candidly reassured me that I have the body of a 65-year-old, however, the problem is that I am about 15 years shy of making that mark,” Rodger, age 53, explains with a wry smile. His self-deprecating humor is tempered by the frustration he endures as a result of the illness that keeps him from living a normal life.

For Rodger Norris, “It’s not the flowers, not the trees . . . ” that trigger a reaction that tightens his lungs into a spasm that requires him to retreat from the offending agent, don his protective mask and administer the oxygen that he keeps for use in emergencies. But artificial fragrances and a growing list of other usually harmless odors have caused him, by necessity, to retreat into a life of virtual isolation.

Chemical exposures are certain and unavoidable in our modern day-to-day lives. Recent studies have reported that up to 15 percent of the population claim to experience unusual sensitivity when exposed to common chemicals. Exposure to such chemicals may cause physical reactions such as headache, fatigue, weakness, or breathing difficulty. Persons afflicted with MCS experience these reactions as a result of hypersensitivity rather than an allergy. An allergic reaction results in inflammatory symptoms that are usually relieved by antihistamines. Reactions based on hypersensitivity are less easily dealt with.

Before being diagnosed with MCS, Rodger was successfully treated for skin cancer, a malignant melanoma, but otherwise enjoyed good health and an active lifestyle.

“At first my symptoms seemed to be nothing more than common allergies,” Rodger recalls. “Then as it progressed, I could no longer speak or communicate with even the doctors. First, my doctor thought that the melanoma had moved to my lungs—however, all the tests were negative.”

His more recent medical history is extensive and, along with his respiratory symptoms, includes spinal degeneration which has required several surgeries, a calcified left kidney, hundreds of painful kidney stones in the past eight years, and a heart condition that required the placement of a pacemaker last year. His recovery was complicated by the fact that he has also developed sensitivity to medications that are routinely used to treat heart problems.

“Now I am 'aspirin sensitive' and allergic to sulfa drugs, iodine, Celebrex, peanuts, and almost any petrochemical based product or drug . . . . Petrochemical products are deadly,” Rodger stated.

Rodger’s experiences with MCS are typical, “I saw a total of 20-some different doctors in a period of about 18 months before anyone figured out what was going on, and I still see at least two doctors every month.”

As an illness, MCS has always been difficult to diagnose. Dr. Theron Randolph was one of the first physicians to link environmental causes to chronic illness in the 1950’s. He pioneered the sometimes controversial field of medicine known as “clinical ecology.”

Some scientists contend that MCS is a psychosomatic disorder, because existing tests make it difficult to attribute the physical symptoms to an exact cause. However,
multiple chemically sensitive individuals are thought to have received a chemical exposure that precipitated their condition. Two scenarios have been theorized: either a long-term exposure to one or more chemical agents, or a single-massive chemical exposure, may be responsible for a physical injury that gradually progresses into a chronic course of hypersensitivity.

Symptoms, such as severe shortness of breath, result from exposure to a “triggering” chemical, even though there is typically no history of previously existing lung disease or asthma. Blood tests may not reveal abnormal results, and allergy tests are often negative. MCS patients often feel stigmatized and discouraged when their symptoms are dismissed as being “imagined” because no precise physical cause can be pinpointed.

Rodger doesn’t know exactly what exposure caused him to develop MCS. “It could have been something from Vietnam.” But he harbors stronger suspicions about the years he spent handling wood treated with pesticides and preservatives. For 15 years, Rodger and Jean ran their own sign business in El Paso, Texas. They contracted with a number of realtors and were responsible for placing thousands of “for-sale signs.”

“Our whole business consisted of 10,000 pieces of wood. We were advised that we needed to treat the wood to prevent termites and damage from insects,” Rodger recalls.

The “colonial posts” used to hang the signs had been pretreated with Chromated Copper Arsenate (CCA), a chemical agent once commonly used in wood preservation. Arsenic, a component of CCA, is highly toxic and a known human carcinogen. The FDA now forbids the use of CCA treated wood in residential areas, and as of December 31, 2003, the United States banned CCA treated wood from both import and export. Wood treated with CCA is still available until current supplies are exhausted, but it is now tagged with explicit warning labels.

“There were no warning labels when we used it” Rodger said. “I applied diazinon, malathion, and Sevin to the wood, because I was told back then that was the way to handle it. I cut the wood treated with CCA and I didn’t wear a mask when I did it. Now the label warns against it, and you can’t even get the people at Home Depot to cut a piece of it. They know that it’s poison.”

Medications have not been very successful in treating hypersensitivity reactions; instead, MCS patients find that preventing a reaction by avoiding the offending agent offers them the most reliable management of their condition. What makes life even more difficult for the chemically sensitive is the curious progression of their illness. In a phenomenon known as “broadening,” they become sensitive to more and more unrelated chemicals, at levels of exposure that the average person barely notices or may find pleasant. Perfumes, many artificial fragrances (including those in scented soaps and toiletries), smoke, paint, and even fresh newsprint are frequently cited as irritants to the chemically sensitive. In addition, the odors that are emitted as a result of “outgassing” from new synthetic materials such as carpeting, clothing, furniture, and building materials also provoke symptoms.

Over time, avoidance becomes increasingly challenging. Reactions are experienced not only to an increasing amount of chemicals, but the reactions also become more severe and long-lasting. Symptoms spread to a variety of body systems. Stomach upset, short-term memory loss, muscle and joint pain, and kidney problems have been described among frequently reported symptoms. MCS patients are forced to make dramatic concessions in their daily lives. Eventually, many are forced to adopt chemically-free lifestyles and as a result often become socially isolated. A respirator mask may be worn in public places when exposure to chemicals can’t be avoided.

“It is just amazing when you come down with this, the way your life has to change. It all comes back to slap you in the face . . . I didn’t expect to get ill. I was outside working every day,” Rodger reflects.

Now, Rodger wears his respirator mask in public and, like others afflicted with MCS, he has been gradually forced to adopt a lifestyle based on avoiding the fragrances and chemicals that aggravate his condition. He and Jean fondly recall trips they made to Ireland before the illness changed their lives. Now traveling on a commercial airliner is impossible. He hasn’t eaten in a restaurant, stayed in a hotel, or attended church services in the past 7 years.

Rodger finds that his respirator mask intimidates some people: “People say I’m an ‘unfriendly person,’ I’m ‘standoffish.’ I’ve watched my friends slowly move away from us because of me. There are people who think you are going to give them this illness.”

Rodger observes that “children are the best” however, because,“They just ask why I wear my mask. Most of them understand and respond with questions about how pollution hurts lots of things.”

The role of a devoted partner cannot be overemphasized when one must live with a complicated illness as Rodger attests to.

“My family has dealt with this, but my wife has been the rock and foundation for my survival. She never expected to be put through what she has had to endure with me, and she could never have been asked to do it. She has been with me every minute providing protection and care. When I married her 28 years ago, she said for better or worse and in sickness and in health, but she never expected this. The stress on her has been beyond belief, but she is still at my side,” Rodger pondered.

“I’m his first-line of defense,” Jean admits as she describes the preventative measures she takes to ensure Rodger’s scent-free environment. Her sense of smell is heightened because she is forced to avoid products harmful to her husband, so she is able to pick up on fragrances that may trigger a reaction. If people are to be admitted to the house, they enter through the mud room where Jean first performs the “sniff test.”

Meanwhile, pollution is increasing as more people build in Cloudcroft. Diesel pick-up trucks are popular, and traffic is increasing. As a result, Rodger sometimes cannot even tolerate a walk in his yard without donning his mask for protection from fumes. Rodger reports that the side effects of his hypersensitivity reactions can endure from two to seven days.

“When the highway department sprays for weeds, or if a neighbor sprays for insects, that will normally put me in bed for 5 days.”

Guilt tops the list of Rodger’s reaction to his illness. “We were building a retirement life, and this illness has taken it all from us. More than $2,500 per month for prescriptions ate our savings almost as quick as the doctor bills after our insurance was cancelled. Now my wife and I live on a small monthly disability check.”

Financial concerns are all that are keeping Rodger and Jean in Cloudcroft. They would like to move soon, to the more remote New Mexico community of Timberon where a friend has given them a suitable lot. They expect Timberon to afford them fresher air and more seclusion. However, Rodger is finding it a challenge to raise the $15,000 they need in order to afford the move. A bank has already turned down his request for a loan, but the couple plans to persevere.

“The bankers may think I will not be around to pay them back,” Rodger acknowledges, but, actually “this [move] may be our last hope to extend my life”.

For now Cloudcroft remains home to Rodger and Jean, and still a more pristine environment than many other communities could offer. MCS has altered Rodger’s perception of home as he sardonically explains, “I tell everyone that my home is my prison, and that it is a life sentence.”


(Five years have passed since I worked with Rodger and Jean to prepare this article. I'm happy to say they are happily settled in Timberon. MCS is still very much a battle that the Norris' face together. Visit their website to find out what's new in their lives.)

. . . .