S3 and More!

S3 can be related to age and congenital  issues.  In adults it can be found in patients with heart failure.  pregnancy and hypertension.  It is best heard with the bell of the stethoscope and not the diaphragm,  over the apex.   It also sounds like, "What the hell" or the -ky in Kentucky  It is also better heard at the apex if the patient is laying on their left side.

S4--- Best heard in the Apex with the bell of the stethoscope.  It can be heard in patients with MI.
It can be heard before the Lub.  It sounds like the Ten in Tennessee.  It is caused when the atria contracts forcefully as it tries to overcome a stiff or hypertrophic ventricle.

The best way to become comfortable with heart sounds is to listen frequently.  There are a ton of website with great examples.  Just remember there is never a dumb question.  If you aren't sure what you heard, ask someone else to listen!  UCLA has a great site The Auscultation Assistant.  It covers some of the most common heart sounds as well as lung sounds.  

The Auscultation Assistant

When All Else Fails!  There's An App For That! 

3M Littmann Sound Builder is available for free from apple apps store.  

iStehoscope Expert is a free download t

Heart Sound Challenge from The University of Michigan is $2.99.  It offers a way to test your skills.

Heart Sounds Made Easy!! S1 S2

At one time or another heart sounds were or still are confusing to everyone who has ever listened to them.  While most of us know what the normal S1 S2 sound like, sometimes there is some funkiness that throws the norm through the loop and into the realm of the "what the heck was that?". 

Location-- Location

Different landmarks tell us different information.  Plan and Simple! 

S1 is heard louder than S2over the apex when the MV and TV close. 

S2 is heard louder over the 2nd right and left intercostal spaces, when the AV and PV close.

Other Than Normal S2----

Loud Sound: Dilated Aorta, Dilated Pulmonary Artery 

Soft or Absent S2:  Aortic Stenosis, Pulmonic Stenosis, COPD

A Place at the Table

I had a chance to see the documentary "A Place at the Table", tonight after my 10 year old went to sleep.

The movie opens showing a flyby over several cities and breathtaking countryside .  The soft lyrics and gentle music tapped into my heart, then the story of our poverty, America's poverty, begins.  In Colorado a 5th grade girl explains her hunger pains.  As the story evolves the viewer is introduced to a struggling single mom in Philadelphia who is trying to get off of public assistance and get her life into a secure situation.

The common thread of this story was that many of these families from around the county had income coming in which wasn't enough to sustain their families, yet they made too much to qualify for public assistance.  This put them in a bracket called food insecurity.

The incidents of obesity and the rising number with childhood obesity is directly related to food insecurity and the inability for families to afford fresh fruits and vegetables.  Processed food items are cheaper than healthy whole foods by about 40%, therefore the cheaper foods can be purchased in larger quantities. So while farm subsides were meant to help family farms, the majority of the $20 billion in food subsidies are allotted to subsidize large corporate farms growing the key food items (corn, soy, rice and wheat) for cheap processed food, less than 1% goes towards farming fruit, vegetables and whole grains.

In addition to food costs that have limited the poverty stricken families' food choices there is also the issue of the fresh foods not being geographically located in close proximity, which is known as a "food desert".  In inner cities such as Newark and Philadelphia or poor communities there is a lack of large grocery stores and when the families do not own cars this makes it extremely difficult for people to get proper food to feed their families.  According to the film 75% of food desserts are in urban areas.

So What Are Food Stamps In The USA?
Food Stamps or (SNAP) is available for impoverished people, it amounts to about $3 per day.  A family of 3 must have an income of no more than $24,000 per year.  If a person is working they often lose their food stamp eligibility.

Bill Shore from Share Our Strength states, "1 out of ever 2 children in the US" will be on food aid at one time during their lives in the US.  That is a staggering number.

Malnutrition has a huge impact beyond the moment or day that hunger is occurring.  A young girl, Rose, describes her inability to concentrate in school because she is thinking about food.  So here are these children who cannot focus and learn.  Additionally it is extremely important that children have adequate nutrition during their development so that their bodies grow strong but also that their neurological systems have the nutrients needed for myelination.

The Child Nutrition Act was developed to improve the nutrition of school children during the Johnson Era.  While the quality of food in public schools has only recently changed, the amount of money that has been budgeted for each child is only about  $1 per meal per actual food cost.  In 2010, Congress agreed to raise the amount of each child's meal but it was only raised $0.06.  In order to pass the bill Congress cut the availability of food stamps.  Congress refused to cut tax breaks on large companies, and elected officials were unwilling to stand up to big agriculture.  Prior to the 2010 increases per child meals had not been raised since the 1970s.

So how did the US wind up in such a bad situation?  During the 1970's hunger was nearly wiped out in America, but during the 1980's when economic recession took hold and farms were crippled, remember Farm Aid, the US government cut spending on public assistance.  Charitable food centers began taking on the burden even as the need continued to grow steadily.  When the recession began 10 years ago, families found themselves with less money to make ends meet, and  the amount of hungry people grew yet again.

The poor statistically  have more comorbidities that are strangling health care and that is killing our ability to have a healthy future for America.  Processed foods high in fat, sugar and sodium lead to obesity, high blood pressure and diabetes which lead to chronic expensive health care and premature death as well as the inability to work and contribute to the tax bases, which will impact every single American along the line.  Additionally chronic poor nutrition is affecting the ability for children to learn, who are our future leaders, captains of industry and investors.

Mississippi has the largest population of food insecurity in the county.  Their elected officials voted against most of the food polices that would benefit the poor and reduce hunger and food insecurity.
http://www.foodpolicyaction.org/state.php?stab=MS

For more information please visit the A Place at the Table website http://www.takepart.com/place-at-the-table

"You Is Smart, You Is Kind, You Is Important"

I was watching "The Help" a couple of days ago with my daughter.  The movie has so many strong depictions of love and acceptance in a complex world that has a lot of barriers.  There were racial, sex, age, class and socioeconomic barriers depicted throughout the movie, most of which my daughter at the age of ten just couldn't understand.  At first I really didn't think about the relationship the movie could have to the field of nursing, but then it dawned on me that there are still many barriers in nursing today that do apply.

I started to think about the way Hilly and her friends treated the other characters, Celia, Skeeter, Minny, Aibileen, Mae Mobley and even Missus Walters.  The harshness of their comments and their deliberate actions all while looking the poised part.  This is how some new nurses are treated when they enter the profession, there is that same bitterness and the "eating of their young" that is unfortunately exhibited.  That ugly way the characters treated "the help" was handed down generationally, it was ignorance then and it continues to be today.

The help, like new nurses were not empowered, they were pushed down, talked down to, treated as second class citizens, talked about and threatened.

For me one of the most emotion and important scenes of the movie occurs when Abilieen and May Mobley are alone in the nursery when May Mobley repeats back the valuable words her "real momma", Abilieen, tells her, "You is smart, you is kind, you is important".

I believe that new nurses need that same reinforcement, guidance, reassurance and love.

While there are many change agents in the story, the collaboration between Skeeter and the help, standing up together brining light to the treatment these women endured is encouraging.  With so many nurses entering and leaving the workforce there is a changing tide and attitude.  Now is the time to remind our peers that: "You is smart, you is kind, you is important".

Health or Poverty? Hospital Brass, Congress, and Lobbyists Are Killing Health Care!

Time Magazine featured a gripping and informative article by Steven Brill called "Bitter Pill, Why Medical Bills are Killing Us", that every health care consumer and nurse should read, .  The article was the longest in the history of Time, and in my opinion a nauseating look into how health care policy and pricing guts Americans.

Mr. Brill explains how nonprofit hospitals and for profit hospitals are price gouging patients on everything from a $7 alcohol wipe to $400 per hour nursing care (not 1:1 ratios either).  His article is supported by patients' stories and their medical bills.

He delves into the way that Medicare is able to contain some of the costs of care, such as pricing for CTs which have no price regulation nor consistency hospital to hospital, charging upwards of $6,000, where Medicare has been able to negotiate a charge of $500.  As for other insurance companies they have their own negotiating numbers, which are discounted from the hospitals' chargemaster.  Brill explains that each hospital has a charge master which is a listing of what each item costs, and that the patients are billed and sometimes over billed for these items. The chargemaster also prices lab tests and other diagnostic tests.  When Brill asks hospital higher ups about the charge master they responded as though it wasn't a concrete or important component of pricing, but again and again he provides evidence that everyday patients are charged enormous amounts of money for inexpensive items.

Medicare is the largest insurer in the U.S. and holds a good amount of leverage, but it is not absolute leverage.  While cost savings have been negotiated with hospitals for tests and services, congress has banned Medicare's ability to negotiate with big pharma over drug costs and the cost for durable medical equipment.

Congress has very little reason to do the right thing for their constituents when lobbyists out number the members of congress and spend millions of dollars to get them reelected.  According to Brill in 2012 the American Hospital Association spent $1,859,041 on lobbyists while other healthcare lobbyist have spent $5.36 billion since 1998.  Brill points out the during the same time lobbyists for defense spent $1.53 million and the petrol industry courted Washington with $1.3 billion.

While health care reform has come to the aid of some, the fundamental broken parts of health care are still very much intact, an internal anaconda, squeezing the wellness out of health care from inside the hospitals themselves.  If we are to take health care reform seriously we need to have a fair market value system. People generally don't choose to go to emergency rooms, they often have no choice, its like a hostage situation.  Do you want to live, then you take what you are given and hope the ransom isn't too high, or you leave without care and possibly die.

http://www.time.com/time/covers/0,16641,20130304,00.html

http://nursingrantsandraves.blogspot.com/2013/02/dont-choke-nurse.html

Don't Choke the Nurse

Hospital ER's have become the dumping grounds for drunks.  Unfortunately ERs also act as the holding place for mentally ill patents waiting for a disposition (either being admitted to a psych facility or discharged home).  Often our intoxicated patients have underlying mental health issues which can make a bad situation worse.

A few months ago a known "drunk" with a psych history got dropped off at our ER by an ambulance squad. He was assigned a stretcher.

A few minutes later he got up and headed over to another patient's bed and started yelling and threatening to kill him because the other patient was the guy who tried to steal his wallet at a bar (the patient wasn't even at a bar earlier).

I managed to calm him down and divert him away from the other patient.

A few minutes later the drunk got up again.  He began walking towards another patient bed, where a patient with a traumatic brain injury started screaming and flaying about. Seeing what was about to happen and the crazed look in the drunks eyes, a male nurse and myself positioned ourselves so that he could not attack the other patient.

I calmly talked to the drunk patient attempting to redirect him, but it wasn't working.  My co-worker, a male nurse also attempted to talk him down with no avail.  In the blink of an eye the drunk man lunged at my co-worker enclosing his hands around his throat.  Two visitors, myself, and a lab tech attempted to free this drunk psychotic man's hands from the nurses throat, my co worker was being choked.  Two other people came to the assistance.  The lab tech pulled the man's elbows back, myself and another nurse tried to pry his fingers off, while visitors secured his legs from kicking.  Our secretary called security, paging them nearly 10 times with no response, she finally had to call the local police.  We finally got the nurse free from the choke hold.  I ordered for someone to get the leather restraints and bring a stretcher closer.

We wrestled the man onto the stretcher.  From the look in his eyes there was no remorse.  He continued to fight as we moved him to a private room.  He attempted to bite, spit, punch and head butt the staff. Security looked stunned.  As I began drawing up Ativan I told security to put the restraints on him, they continued to just stand there looking at me.  "Put on the damn restraints" I ordered again.

Just as they began doing their job a very tall intimidating police officer entered the room.  The patient immediately knew that the game was over.  Security looked at the officer, but they were working at a snails pace. The police office looked at the security guys saying, "any day now".

The patient remained  in the ER overnight until he was sober.  While the charge nurse filled out an incident report the nurse who was choked did not press charges.  The incident was not debriefed, nor did the head of security ever meet with the staff that was involved.

While one nurse was choked, luckily in view of others who could come to his aid, another nurse was punched int her face.

I wish that my friend who was choked had pressed charges.  My profession for some reason just lets this stuff go.  Being assaulted is not part of the job description but we have adopted it as such.

Perhaps we should have let the patient go, let him attack the other patient.  If that should have happened then there would have likely been a lawsuit, and possibly a change.

As if rubbing salt in the wounds, a few weeks later, I was talking to some of the security guards about the incident.  One of them responded, "I don't get paid enough to get hurt", as he was looking at his Facebook page on the hospital's computer.

Safety in the workplace is an issue for everybody.  It doesn't matter how much money you earn.  I work in two ERs one in the inner city, and one in the suburbs.  I can assure you that I am far safer in the one in the inner city.  Our security there is top notch.

Nobody wants to go to work and get hurt, just as nobody wants to go to work and see someone getting attacked.

When Is Enough, Enough? Compassionate Care

In the past 18 years I have witnessed more people dying than I could ever recall.  The sound of the last wet breaths, the modeling of their skin, the cloudiness of their eyes.  When people are terminal, dying, they have "that look".  It is the look that I know as a nurse, but sometimes my patients' families don't understand.  Many time the family of the dying is holding out hope, and they are paralyzed, unable to make a decision on when enough treatment is enough and when compassionate care should begin.

A few years ago after my father's chemotherapy failed, actually it was is body that failed the chemotherapy, his oncologist came into his hospital room.  My mother and I were sitting in the plastic chairs to the side of his bed.  My father, weak, but alert, laid in bed as his doctor told him chemo was no longer an option, his weak heart couldn't handle it.  The doctor's eyes hardly met mine.  She danced around the subject of what the next step was.  But I knew the next step, it was hospice, and it would be soon.

When the doctor left the room my parents were left with the impression that my dad should return to the rehab facility.  When I left my dad that evening at the hospital I kissed him goodbye and I knew that he would have a long night of trying to sort out what he was told.

The next morning I spoke with my mother.  She had said she was going to look at rehabs.  But I already knew that the man who couldn't stand, go to the toilet, the man with lung, bone, kidney and brain cancer was not going to thrive in rehab.  He was miserable there before and now he had nothing to work for, his oncologist told him the cancer had won.

About a week later my dad was still in the hospital.  He was just waiting.  Waiting for the end.  

Originally my mom thought he could do hospice at home, but the set up of the home really wasn't going to be easy.  Fortunately the reality began to set in, and she visited a few hospices, eventually finding one, that when she walked in she knew he would like it, and he didn't have much time.  By the time she found a peaceful place for him his AICD had been turned off per his wishes.  His lung had collapsed.  He was slipping away.  

My father arrived in hospice on a Wednesday evening and died that Friday.  

Sometimes doctors don't like having "that" conversation with the patient or their families, and I find it selfish.  When there is little to no hope and someone is struggling it is unfair to hold information from them.  When they are drowning in their own fluids and their terminal disease had taken the life from their body patients deserve the respect of knowing how ill they are, so that they may plan the way they would like to be cared for.