October 13, 2016

Are Dead-Tree Books once again a measure of wealth?

Just to be clear, NOT where I grew up.

I grew up in a house full of books.
As an avid reader, this just seemed like a reasonable thing to me. As I grew to adulthood, I occasionally encountered houses that had few books - both my grandparent's homes were like that. It seemed odd, but since I was rarely staying long and usually travelled with my own stash, the lack never really impacted me much.

Not here either!
My house has always been full of bookcases overflowing, books piled on tables, next to the bed, even stacked on the back of the toilet.

Fast forward to the present. Just moved my mom in with us after my dad died in early September. We were in process of moving them both when he passed away pretty suddenly. He and Momma had been in the process of trying to sort through a lifetime of books to decide what was moved and what was donated. I now have a bedroom in this house filled to the ceiling with boxes, and a good number of those boxes are full of books. We moved four bookcases as well. Looking at the number of books and bookcases I am struck by the staggering amount of square footage that is consumed by printed books. Even in tall bookcases, it requires yard after yard of wallspace. Creatively arranging furnishings away from the walls into islands in the middle of the room to allow access to all those books.

Most places I have lived in recent years were far from the top of the list in price per square foot for housing, but it certainly is not near the bottom. If you live in a place with a healthy economy, chances are good you are dedicating a significant percentage of your income to floorspace to house you and your stuff. If you are like me, and on a limited income, then that floorspace becomes even more dear since there is less of it.
Just substitute the kids for dogs...

The advent of e-books have been a huge boon to bibliophiles like myself, they tend to be cheaper than dead-tree versions and they take up no floorspace! They lack the tactile satisfaction of a physical tome, and are generally pretty problematic for sharing, but you can keep your entire library on a pocket computer (They really should not be called smart phones since their telephonic function is generally a poorly executed afterthought. They are better at taking photos than at voice transmission.)

I suspect we are entering a time very soon when once again the library full of physical books will be a conspicuous luxury reserved for the wealthy and/or the eccentric. In the meantime, you will be able to find me buried under boxes of books trying to figure out where the heck to put them all!

The good news here is that libraries become even more relevant as we transition from buildings full of books to electronic archives of knowledge that will need to be curated, sorted, and maintained. And having a central repository that can be accessed remotely without the need for filling one's own electronic floorspace will also be in demand. Having those sorts of repositories that are not privately owned will be essential to ensure the continued free access to knowledge for everyone. Would love to hear from my librarian friends on whether I am completely off the beam here or not.

August 29, 2016

Is 2016 taking all our heroes?

It has been a tough year. It started early, and it seems every time we turn around another beloved public figure has passed away.
Baby boomers are at an age where a lot more of our idols are passing, and the modern world has produced a whole lot more beloved public figures as well.

All that said, every time I see another post of "screw you 2016" lamenting the accumulation of deaths I am reminded of a time when I was the beneficiary of some real perspective.

I started my first job as a hospice nurse on Sept 14, 2001. The management staff of the agency I had been hired at was stranded in another state due to the lockdown of all civilian air traffic. The remaining staff were in shock, trying to deal with everything that was going on while ensuring that patients were being seen and getting the support they needed.

My initial orientation involved going along on visits with various members of the team, and the chaplain was my first week. All anybody was talking about was the national trauma we were experiencing, including our chaplain. As we went on home visits, he was preparing himself to help families traumatized by the attacks on our country, in addition to their own loved one who was dying.

What we found was something that affected me profoundly, and informed how I approached my job ever after. When we entered a home, all that was happening and the only thing that was real in that home was the tragedy unfolding there. The immediate and real loss of a loved one. The events that were completely changing the world as we knew it outside those houses were background noise. People knew they should be concerned, but time and space work differently when you are in the liminal space created by the dying. 

In that space, the process of losing a loved one, the personal tragedy that is unfolding is all there is. Going through that door is entering an airlock, and on the inside there is a single focus. Other stuff exists, and has to be dealt with, but doesn't feel real. And as those who enter that space, we have to recognize and accept that THIS death, THIS loss overshadows anything else going on outside. And even if we have a connection to that person, it is not OUR loss.

So when I see yet another person who I admired has died, rather than adding them to some list of grievances I prefer to contemplate and grieve for those who are right now in that liminal space between the life that included that person and the life ahead
without them. And wish them peace and comfort going forward.

May 31, 2016

Who the Heck are You? A quick guide to medical care providers.

A visit to the doctor, to a clinic, nursing facility or hospital means talking to a dizzying number of people about medical issues. People ask for history, check your blood pressure and vital signs, take your blood, give you injections...who the heck are all these people?

Here is a quick guide to many of those letters you will see on the badges of the people you talk with.

MA or CMA - this is a medical assistant, most often seen in an outpatient clinic working with providers there. They work under the supervision of doctors and nurses. Their scope of practice in most states where they are regulated include clerical tasks, taking history, vital signs, assisting the provider during exams, taking specimens, and may be trained in phlebotomy (taking blood). Some states allow them to do additional simple procedures and operate equipment under the supervision of a physician, but they are never allowed to interpret results. What is a medical assistant?  They are usually the liaison between patients and their primary care providers, and may be mistakenly referred to as "nurse". Note that it is illegal for an MA or CNA to present themselves in such a manner. Calling yourself a nurse is a crime.

CNA - this is a Certified Nursing Assistant, most often seen in home health or inpatient facilities such as nursing homes or hospitals. CNAs work under the supervision and delegation of an RN, and provide hands-on bedside care such as taking vital signs, bathing and cleaning the patient, transferring the patient and assisting them with movement and self-care tasks like toileting and shaving. They also have the important responsibility of tracking bowel movements and skin condition in severely impaired patients, alerting the RN when changes are noted before much larger problems occur. They may also do dressing changes and daily wound care in some states. Both of the above require similar education, the primary difference is the location of their work and the tasks that are delegated to them. Both have differences in regulation and licensure (if any) varying by state. Differences between CNAs and MAs

LPN or LVN - this is a Licensed Practical Nurse or Licensed Vocational Nurse, terminology varies by state. An LPN *is* a nurse. They are licensed to provide nursing care, and are found in most places you will find doctors and nurses. They work under the supervision of a physician or RN and may have duties delegated by an RN. Limitations on practice by LPNs vs RNs are in areas that require clinical judgement, and in more advanced care settings. Many states limit the role of LPNs and do not allow them to administer IV medications or narcotics.  Working as an LPN .  LPNs are used to help keep healthcare costs down because it is much less expensive to have a group of LPNs working under the supervision of one RN than to employ RNs only.

RN - Registered Nurse. This is a nurse who has completed either an associates/certificate program or a bachelors degree in nursing, and passed the national licensure exam (NCLEX) as well. They perform all nursing tasks, supervise and may delegate to LPNS, MAs or CNAs, and may obtain advanced specialty training to increase their scope of practice in particular areas. While an RN has the broadest scope of practice of all the above listed, they also have the highest level of responsibility. The RN is responsible for not only their own scope, but they accept the responsibility of tasks that are delegated to them by physicians. An RN is responsible for ensuring the appropriateness of treatments, medications, etc that they have been ordered to give and is accountable along with the prescriber if the are wrong. Scope of practice is determined on a state-by-state basis, and requirements for continuing education vary. My specialty is Hospice and Palliative Care (CHPN). Some states allow me to pronounce a patient dead, some states require that I contact a physician to get that pronouncement, some states require the coroner to be notified, etc as an example of variations on scope of practice. As far as the other letters you will see after RN on a nurse's badge, they will generally designate their specialty certifications and may also include their education (MSN - masters of science in nursing, etc).

 APRN - Advanced practice RNs. These are RNs who have continued their education to a master's or doctorate in a particular specialty area and by doing so have increased their legal scope of practice. APRN  These providers practice medicine under their own licenses, and in most states do not require supervision of a physician to practice. The financial advantages of having a DNP versus an MD in roles that do not require the scope of practice of a physician are the same as those for hiring an LPN versus an RN. In the past, a Master's degree was the minimal educational requirement in most states for a Nurse Practitioner (APRN). Many states have changed that requirement to a doctorate, and there has been a push to make this a national requirement. So the Nurse Practitioner who sees you at the clinic may well be Doctor Nurse! http://www.nursepractitionerschools.com/faq/dnp-requirement-for-np This is similar to the change in requirements for pharmacists, who are now required to have a doctorate as well.

PA - Physician Assistant. PAs are masters degree trained medical providers who attend a specialized Physician Assistant program. http://www.nursepractitionerschools.com/faq/np-vs-physician-assistant PAs work under the supervision of a physician, and are frequently found in the same settings that you would find Nurse Practitioners. The primary difference between the two is that an NP can diagnose and treat without the supervision of a physician.

 DO - Doctor of Osteopathy. A Doctor of Osteopathy is a physician who has received their degree in medicine from a School of Osteopathic Medicine. They are licensed in each state as physicians and have the same scope of practice as MDs. DOs primarily see their practice as different from traditional medicine in the emphasis on a holistic patient-centered, versus disease-centered focus. An example: Oregon License Definitions Note that the scope of practice in Oregon is identical to that of an MD, with the addition of musculoskeletal manipulation.

MD - A licensed Doctor of Medicine, graduate of an accredited medical program and licensed by the state to practice medicine. May be found anywhere medicine is practiced. There are a vast number of specialties of medicine. A couple that regularly confuse people are Internist (a doctor with advanced training in Internal Medicine) and Intern (a medical doctor who is doing their clinical training for their licensure). Hospitalist - this is a fairly new specialty, physicians who specialize in treating patients who are hospitalized, coordinating all the specialties involved and ensuring that the patient is followed appropriately after discharge. Note that it is also illegal to impersonate a physician!

***Disclaimer: The above are the opinions and research of myself, a retired nurse. None of the above constitutes medical advice or definitive anything, is representative of the US, et cetera ad nauseum. Consult your local state medical board or nursing board for definitions, limitations, requirements and scope of practice.

NOT Nurse


April 5, 2016

New Drug Alert - Epidemic declared!*

Today we have become aware of a new, terrifying drug trend sweeping the nation. Teenagers are combining ED medications with Minoxidil for a fast, crazy high lasting well over four hours. Kids refer to this combination as "Drug X". 

Teens everywhere are succumbing to the siren call of Drug X, and health officials are declaring a new drug epidemic as it sweeps the boulevards and gated communities of our nation. 
Most worryingly, this drug is easily manufactured by simply combining the two drugs, which are often easily obtained at home. Parents may not realize there is a problem until "date night" when they discover the missing ingredient.
Public Domain, https://commons.wikimedia.org/w/index.php?curid=472336

DrugX and Addiction*

Doctors say compounds like DrugX are highly effective for treating ED. And patients are much less likely to get addicted if they use these drugs in just the dosage necessary to treat their ED.
But when a person starts taking compounds when they are not in ED, or in doses beyond what is required to treat their ED, doctors say the drugs have a different metabolic impact on the brain. In those situations, addiction is highly likely.
Many teens crush up DrugX pills and snort them to get high, getting a hefty dose of drug all at once when they are not having ED to begin with. This form of taking in the drug is much more likely to lead to addiction.

 A Pricey Habit*
DrugX is very expensive on the street: $80 for one pill. To pay for his habit, Ryan says he cashed $7,000 in savings bonds his aunts had given him on birthdays. He sold his PlayStation, leather jackets, cell phone — everything he had — just to stay high and keep from getting sick. He finally broke down and asked his parents for help.
Looking back on it, Ryan says he didn't think using DrugX would be that dangerous because it was a prescription pill — that made it seem safe. Many different kids at his high school were playing around with it, he says: "People from every sort of group — the burnouts, athletic kids, the geniuses and, like, girls playing wicked-good softball [who were] offered scholarships to places — they would be using it."
That sentiment is echoed by 18-year-old Mike, a recovering DrugX addict in Winthrop, Mass. Mike says he was always an athlete and played football. Until his sophomore year in high school, he attended a prep school with wealthier students; he later transferred to the local public school. He says that, if anything, he saw more DrugX at the prep school.
"All the popular kids — that was the cool thing to do," Mike says. "It seemed like it was cool because it was so expensive, this big rich drug. And a lot of rich kids were doing it because the poor kids couldn't afford it."
DrugX is so expensive that many teens turn to stealing to support their habit.
"I stole so much money from my parents," says Katie, 18, who is also a recovering DrugX habit. She says she and a friend both stole their parents' ATM cards to support their habits. "I stole $5,000 from my parents in two months."
Katie also wrote checks from her mother's checkbook. Katie's parents say she and her friends stole cameras and jewelry from their house. Somebody stole her father's wedding ring out of his top drawer.
"It's like someone just punched you in the stomach," Katie's father said in an interview with NPR. "You know you're never going to get it back. And what did it get used for? The addiction." 

In the face of such a monumental problem, Congressmen are being called upon to offer some solutions. After consultation with many experts and industry representatives, millions of healthcare dollars are being earmarked for education and treatment programs to address the issue. Congressman
Richard Priap responded to questions at a press conference yesterday:
Obviously, any sort of ban on the drugs being used illicitly to create this compound is impractical and does not address the root problems. Denying millions access to these needed and useful drugs solves nothing and simply creates a more profitable market for smuggling rings to fill. Law abiding citizens will be denied needed treatments while criminals continue to have access, which is always counterproductive. Prohibition simply does not work, as we have demonstrated again and again.

 Obviously the above is satire. Please note that the paragraphs colored yellow are taken from an NPR story on OxyContin that can be found in its whole and unaltered state HERE .
 As a hospice nurse, I have seen how the panics over OxyContin abuse have negatively affected patients who NEED these drugs for severe pain, with little impact on overall narcotic abuse nationwide. I watch huge numbers of people suffering the effects of bans on psuedoepinephrine based drugs in an attempt to address methamphetamine abuse, again with less effect on drug manufacturing than it has on law-abiding allergy and virus sufferers.
I picked on NPR for the *protected* satire above because the article for me highlights the reporting that goes along with issues that affect the wealthy white and educated demographic. It is an emergency, an epidemic, requires immediate action. I mean these kids are moving on to HEROIN for heavens sake! Poor people use heroin. 

So I wondered - what would happen if Richie Rich started getting high from a combination of Dad's hair restorer and impotence meds?

 Please note - this is not a real thing and if you try this then you are stupid and deserve whatever horrific mutation results. 

March 8, 2016

Nurse's musings on weight issues

Several recent Plurk conversations are gelling in my head so I am gonna think aloud here for a bit.
Discussions of the fallacy of the "average" discussions of challenges with healthcare and another discussion about the horrors of flying when obese. And I think I sometimes I come off as judgemental or unsympathetic because of the limitations of the medium. So here goes!
First, medicine (in the US) as it is currently practiced is a high volume business that makes its money via tests, imaging, labs, surgery and other interventions. All those things pay the bills, which is why so may practices do those in-house now. Providers are required to see a minimum number of patients a day, carry a large census of patients they are responsible for, and as a result visit times are brief. Medicine is essentially practiced as a game of averages. This test result usually means diagnostic code xxx, which is treated with treatment regimen y. So everyone with a blood pressure over a predetermined norm get drug A, then if that doesn't work drug B. etc. And if 900 of your 1000 patients benefit from your treatments then that is a great success rate. Unless you happen to be one of those 100.
The other side of the coin is patient expectations. We spent a lot of years selling the idea of the miracles of modern medicine. Add popular culture on television and movies to that and you wind up with expectations for healthcare and interventions that are WAY off. The ER team on TV does some chest compressions and the patient is well! Johnny wakes up from his three year coma in perfect health. If the brilliant but curmudgeonly doctor puts his mind to it they can diagnose you by the end of the 30min episode. And cure whatever it is just in the nick of time. Dying is especially elegant in popular media. Great lighting, makeup, fully conscious until you say something profound and slip away. RL is so much messier than that.
Patients often expect that if the doctor would only do ALL the tests, they could find out everything that is wrong with you RIGHT NOW (and sometimes even in the future) and fix it all today. And it doesn't actually work like that. At all.
Human beings and human bodies vary a lot in many parameters, and the idea that there is a "healthy" perfect state is a fallacy. Weights vary quite a bit, as do blood pressure, blood sugar, pain tolerance, and on and on.
Genetics plays a big role - you can have the textbook perfect weight, exercise, eat an ideal balanced diet, go to church every Sunday and still drop dead at 40 of a heart attack. Or get colon cancer at 50, or MS at 35...
Weight is an issue for a number of reasons - heart disease is a combination of genetics and damage from blood pressure, plaque buildup, high blood sugars, etc. Diabetes is the biggest risk of long term obesity, in the insulin resistant form. Genetics play a smaller role in that type. Diabetes leads to blindness, multiple organ failure, amputations, and was a very frequent end stage diagnosis I saw in hospice, usually from kidney failure (dialysis only works for so long).
Most universal issue with weight is one I personally deal with and that is joints. Joints are engineered in humans to work within a certain weight range, with body type and sex playing a role. But your joints WILL wear out eventually at any weight. What excess weight does is speeds up that process. And obviously the more weight you carry the faster it happens.
So back to provider and patient expectations. Providers need a different approach. Currently the attitude is that I am going to educate you on what you need to do in order to improve the health profiles that are outside the norm. Your goals and limitations are not even on the table in most cases.
What needs to happen is a discussion that starts where we are right now. What is it that keeps you from doing what you need and want to do? What does the provider see as a big issue or concern? What is available to help you as a patient meet your goals, if your goals are unreasonable then WHY are they and what would be reasonable goals? And there should ALWAYS be a nurse CM or a social worker available if needed who can direct patients to resources in the community.
As a patient, understand that everything is not fixable. And that anything that stresses your body's ability to maintain balances or does long term damage is going to have consequences no matter WHY that is. Some people CAN'T lose weight, but those people are also going to have to deal with the consequences of that. And the best way to approach that conversation is not to pass judgement. It is to acknowledge that these are the challenges we face and make plans on how we can mitigate the inevitable damage and give some really good quality of life.
Because ultimately sitting down to a nice steak or having an ice cream cone should be a delight, not a prelude to shame.

March 6, 2016

The Scourge of Adblocking software

Back in the day, visiting a website often involved being exposed to some random advertising in a banner across the top of the page.
Something like this.

Over time, online ads began to creep down pages, filling first the left margin and then the right.

I know that article I'm looking for is in here SOMEWHERE

Of course, we had been able to ignore the banner ads after a time, and eventually were able to ignore all the kibble surrounding the content we sought. So the advertisers escalated their pitches. Ads flashed, jiggled, popped up in middle of your screen, marched around over the page. Much harder to ignore, and should you break down and click on one of them it did not make them stop on your future visits. If you bought every single item being advertised there, you would still be facing that mess on every visit.

Then came the video ads. These are sneaky because they may not be there when you open the page. But the advertising feed on that page will serve them up randomly, and they play immediately. Some arsehole just woke the baby, scared the shit out of you, and froze your computer squawking about paper towels.

If that wasn't enough to drive you into the arms of your nearest adblocker, this did. Doing research, surfing, shopping, looking at newsfeeds or working on the web only to suddenly have every page you visit covered with ads related to what you have been looking at. Now conventional wisdom says that targeted advertising is much  better than just random products, and we are all pretty much aware that our web usage is tracked and reported. But having your nose rubbed in it is creepy as hell.

And do NOT get me started on commercial shopping sites that have obnoxious ads flashing and popping up all over the place WHILE I AM TRYING TO BUY YOUR DAMN STUFF.

So - THAT is why my lazy butt took the time and trouble to find and install an adblocker. Because the escalating war for my attention was actually becoming nauseating. And since webpages I have contacted about it disavow any control over their ads, I am going to have to just skip them.
Can we go back to this? This was nice.

February 16, 2016

Dreams and cogitations

As a child, she was surprised and wounded by the first rock that struck her. But she picked it up and put it in her pocket, and contemplated it later.
As the years passed, the rocks became more frequent and her collection grew. She was no longer surprised by them, but still dreaded each one. Her collection grew into a little wall that she could shelter behind when she needed it.
Over time, her wall grew into cottage where she could go for safety, a place to breathe and just be.
Decades passed and the rocks sometimes became less frequent, but were often larger. Her cottage began to take on the aspects of a Manor. There was not just room for herself there, but offer safety and comfort for those she loved as well.
By the time she was old, she had created a Castle. Within its walls she could provide shelter, compassion, and safety for any who required healing. The giant stone fireplace contained a roaring fire where she could tell stories and share wisdom. Children play in the gardens of that castle, and it is a rare stone that makes it over the wall.

Tree of Life On the Allendale Nature Trail, about 100 yards along the riverside path from Bridge End, is this carved sandstone tree set into a drystone wall. Inspired by the Celtic name Allen, which means shining water, Sarah Turnbull, aged 8, designed this tree. It is inlaid with lead as a reminder of Allendale's lead mining past, and its roots, which become rapids, are brushed with silver leaf.

Worlds and stories and songs, the strata of all that we have been and all that we believed of ourselves layered and overlapping. Pangaea, Laurasia, Gondwana, Panthalassa. Primeval forests teeming with life. Vast plains of flora and fauna competing, breeding and dying.
Dark World below Blue World below Yellow World below White World. Shambala, Eden, floodplains and mountain valleys. Deep caves with ashes from countless fires and energetic shapes dancing across the walls in their flickering light.
Vast kingdoms spreading across plateaus, blood soaked battlegrounds and rivers running red with blood. Troy, Ur, Atlantis, Pompeii, Alexandria, Timbuktu, Giza, Babylon, Teotihuacan, Cairo, Carthage.
Each layer covers the one below, and yet those beneath are sometimes incorporated into those above. A pyramid pierces them all, thrusting up into today, still reaching towards the sun. Some things are lost, and some things break out at unexpected times and places.
The strata of all that has come before sits below the plane of now.
And the World Tree, in whose shadow and branches and roots we make our way, has a taproot that extends down through every layer.