Even more to learn!

12/27/2012

Even more to learn!

     Some of you are wondering why I blogged about the CHAP program. The health aides are people I interact with on a daily basis. As the “first call” provider for the ER, I am also the medical control for 22 village clinics and about thirty community health aides. The aides are very well trained, their CHAMs (Community Health Aide Manuals) are very detailed, but unfortunately they can not cover everything. This is the point in the process where I come in.

     Every week day, the CHAPs are contacted for “radio traffic”. The term “radio traffic” is a throwback to the days before Alaska had a statewide telephone system and all communications with the village clinics was by two-way radio. Today it is actually a phone call. Because of the frequent outages of land based phones and power outages there are three different phone systems available in each clinic. A dedicated IT line (like in the city where you only dial 4 digits to connect to an extension), a land based telephone line provided by the local telephone provider, and a satellite phone.

     Each village clinic has a basic stock of common medications: amoxicillin, Augmentin, Levaquin, Bactroban ointment, Tylenol III, etc. Their CHAM provides diagnosis/appropriate medication guidelines that the aides are required to follow. About now this is beginning to sound like a real “no brainer”.  Could one of these “magic manuals” make your life as a provider easier?  Several of you are already writing me an email wanting me to get you a copy of these “magic manuals”. Your “Ralph” is asking you, “what could be easier?” He has it all figured out, the scenario goes something like this:

Patient presents with bilateral ear pain.

Physical exam reveals bilateral otitis media.

CHAM tells you to prescribe amoxicillin.

     Ralph figures all you need is a CHAM and a street corner. As usual, Ralph did not read all the way to the end of the “otitis section”. What if you patient is allergic to penicillin (you know the real anaphylactic kind), CHAM tells you to contact me (your medical control). What if the TM is perforated, the CHAM tells you to call me. What if, as for the past several weeks, the weather has prevented village supply deliveries which include the medications to restock the clinics, and the clinic has no amoxicillin?  You guessed it, the CHAM tells you to call me.





     While we are playing “what if”, let’s make it really fun.

      The CHA calls in on the phone with this patient presentation:

62 yo female in the clinic with her family members complaining of increasing weakness over the past several weeks. Denies cough, SOB, fever/chills, NVD, swelling, recent changes in medications, no recent sick contacts.

Pertinent  PMH: chronic anemia

PE:

General: Well developed elderly female, NAD, ambulatory with assistance from her family, no staggers, speaking in clear-complete sentences.

V/S: B/P 88/62, P 64, R 20, T 91.8 (recheck of temp in other ear 92.1)

HEENT: PERRLA, EOMS intact, TM pearly gray bilaterally, no redness or pus in the throat, moves head around and shows no stiffness in the neck, no stridor, thyroid not palpable

Lungs: BBS clear and equal, no retractions or accessory muscle use

Cardiac: RRR, no extra heart sounds, no murmurs

Abdomen: good BS

Ext: no edema CRT <3 sec

Neuro: CAOX4, no motor changes, thoughts appropriate and complete

Hgb in clinic today = 8.2 (you quickly reviewed the patient’s previous labs and find this is their norm)

So now the big question is WWRD (what will Ralph do)?

Remember, you have a patient 232 miles away in a remote village. There are no roads; rivers are frozen; only transport is by airplane.

Now to make it interesting, I am going to let you think about this a while. You are the one sitting here at the desk. You have the telephone you are talking on; you have a Polycom system, and EHR access.

What questions are you going to ask?

What differentials are you formulating?

Does the patient need to come to Dillingham?

If you think you can treat the patient there, what are you going to do?

If you think the patient needs to come to Dillingham, how are they going to come?

Your options for transport are:

1)      In matters of life and limb = Emergent MEDEVAC by fixed wing aircraft by the Hospital (flight crew would include pilot, co-pilot, two RNs, and yourself) The cost of aircraft operations for this flight is about $4200.00, plus team members salaries and expendable supplies.

2)      In other matters = Transport to Dillingham via commercial airline. (Cost of patient’s ticket and companions’ ticket, about $215.00.

     Post your ideas in the comment section. I think it will be an interesting challenge; at least it is for me.

    

CHAP is not something cowboys wear!

The Community Health Aide Program (CHAP) consists of a network of approximately 550 Community Health Aides/Practitioners (CHA/Ps) in over 170 rural Alaska villages. CHA/Ps work within the guidelines of the 2006 Alaska Community Health Aide/Practitioner Manual in assessing and referring members of their communities who seek medical care and consultation.  Alaska CHA/Ps are the frontline of healthcare in their communities.

About the Alaska CHAP Program

The Community Health Aide Program (CHAP) was developed in the 1960s in response to a number of health concerns, including: the tuberculosis epidemic, high infant mortality and high rates of injury in rural Alaska. In 1968, CHAP received formal recognition and congressional funding. The long history of cooperation and coordination between federal and state governments as well as Native tribal health organizations has facilitated improved health status in rural Alaska.  

CHAP now consists of a network of approximately 550 Community Health Aides/Practitioners (CHA/Ps) in more than 170 rural Alaska villages. CHA/Ps work within the guidelines of the 2006 Alaska Community Health Aide/Practitioner Manual, which outlines assessment and treatment protocols. There is an established referral relationship which includes midlevel providers, physicians, regional hospitals and the Alaska Native Medical Center. In addition, providers such as public health nurses, physicians and dentists make visits to villages to see clients in collaboration with the CHA/Ps.

The Alaska Area Native Health Service (AANHS) has the responsibility of providing medical and health related services to Indian Health Service beneficiaries residing in Alaska. These services are provided by tribal organizations within the Alaska Native Health Care System. The village based CHA/Ps are a vital link in the delivery system.

CHAs are selected by their communities to receive training. Training centers are located in Anchorage, Bethel, Nome and Sitka. There are four sessions of CHA training, each of which lasts three to four weeks. Between sessions, CHAs work in their clinics completing a skills list and practicum. After successfully completing the four-session training curriculum and a clinical skills preceptorship and examination, the CHA qualifies as a Community Health Practitioner (CHP). CHA/Ps at any level of training may obtain certification by the Community Health Aide Program Certification Board (CHAPCB).

The CHAP model is currently being to develop programs in the areas of dental care, behavioral health and elder care.

http://www.akchap.org/html/home-page.html

Some pictures from Kanakanak Hospital

I will be posting a hodge-podge of photos as I go along. The native crafts are indescribably beautiful and intricate.

So much to learn!

12/17/2012   

 Well I made it here and survived my first two days, which were “orientation”. As usual, orientation at a new facility consists of filling in the blanks on seemingly thousands of pages of paperwork, getting an abbreviated tour of the facility, meeting the department heads, and genuinely feeling overwhelmed. I complete my orientation knowing that over the next few days  I will feel lost and confused as I get settled in here in Dillingham.

     I will experience several episodes of Ralph induced frustration that will probably go something like this:

Me: I need to get a medication from the pharmacy.

Ralph: Are you sure there is a pharmacy here?

Me: Well yes I know there is a pharmacy here; after all it is a hospital.

Ralph: Ok big boy, where is it then, you are so “intelligent”? (And yes I hear the snickering in his voice)

Me: I went past it on day one of my orientation, it is on a long hallway, and is next door to the lab.

Ralph: CONGRATULATIONS! You have just remembered that the pharmacy location is in the building…… I was afraid you thought it was in the middle of the parking lot.

Me: I wonder if anyone would notice colored magic marker arrows on the walls with directions for next time.

And so the saga continues for another 10 minutes, as I eventually patrol every hallway in the facility, I find the pharmacy (and as you probably guessed, it was very close to where I started my adventure). But you can bet that I know its exact location for next time!

By the end of day one, I not only knew where the pharmacy was, but I eventually found, the lab (remember it is next door to the pharmacy), the housing office (where I got my linen from on day one, wow found it two times in less than a week), medical supply, the medical staff office (where my desk is located and the location of daily rounds, and I was on time for rounds…. well only a little late the first day), the cafeteria, and several restrooms.  To you this may not seem like much of an accomplishment, but remember, I have to learn the service locations and their capabilities at several new facilities every year.

Throughout all my exploration, the entire staff here is friendly and very willing to point lost souls like myself in the correct direction.

I made it to Anchorage, now what?

     When I landed in Anchorage, I had been instructed to see the gate agent who would direct me to my connecting flight to Dillingham. Guess what; when I got to the gate desk there was no one there. I looked around the other gates and they too were unmanned. So I did the next best thing, I went to the departure board to see where my next flight would depart from. As I scanned the postings, I could not find my next flight. This is also about the time Ralph woke up from his nap. I believe his words were “you’re screwed, it is 35 minutes toil your next flight departs, you don’t have a ticket and you have no clue where to go or what to do”. My response to Ralph I can’t post here, after all this is a PG blog.

     Having never been to the Anchorage airport, I truly had no idea where to go. I found a sign that said ticketing and off I go. I eventually found an airport worker who was very helpful informing me that 1) I needed to go to the Penair ticketing desk to get my ticket 2) I was not the only person who this had happened to, in fact it is a daily occurrence, and 3) if I intended to make my flight I needed to move my butt. As I dashed off in the direction of the Penair ticketing desk I heard my name over the public address system informing me that I was needed at the departure gate immediately if I intended to have a seat on this flight. I found the ticketing desk and informed the agent that I was the person being paged and I needed a ticket and directions to the gate. They handed me my ticket and pointed toeward the gate that, thankfully, was within sight.

     As I announced my presence to the gate agent, she explained the urgency of my page. The airport in Dillingham had been closed for 2 days due to severe icing and Penair had added two additional flights this evening in an effort to get everyone that had been delayed to Dillingham. Needless to say, I understood why seating was at a premium. I boarded the Saab turbo prop and folded myself into the seat and enjoyed a very uneventful flight to Dillingham.

     On my arrival at Dillingham, I had been flying and running through airports for about seventeen hours. Having finally arrived at my destination, I mistakenly presumed (I defer from using the word assume due to its hidden implication) my adventure was over. Boy was I wrong.

     Through email, I had been instructed by my contact in Dillingham to take a cab to the hospital and report to the emergency room for the key to my lodging and further instructions/directions. Being the professional that I am, on my entry to the terminal in Dillingham, I contacted the local cab company. As I was waiting on my cab (as instructed), I was chatting with a fellow passenger who was waiting on his ride. A couple of ladies walked past that obviously knew the person I was speaking with and even politely said hello to me. After the ladies got in their car and were pulling out of the parking lot, my new friend inquired where I was going. I informed him that I was going to the hospital. His next comment came a a great surprise to me. He said “you should have just ridden with Sue (not her real name) she works at the hospital”. In fact, Sue was my contact person at the hospital who had told me to take a cab. Now I was really confused. About this time my cab arrived and for a fiver it took me to the hospital.

     When I arrived at the ER, as previously instructed, I presented myself and received looks from the staff like I had a bugger on the end of my nose. They knew nothing about my arrival, had no keys, nor any instructions for me. As they attempted to help me with this confusing situation, the DON, who happened to be in-house, graciously asked me if I had eaten. When I replied no, but if I could get some milk, I would make a protein shake and go to bed. Needless to say by this time I was beyond tired. My new “bestest” friend that had offered to feed me, looked high and low and was only able to find chocolate milk, which really sux when you want to make a vanilla protein shake.

     After several calls by the gracious staff, it was determined that the reason I had no keys was because someone had been sent to the airport to pick me up. Since the airport had been closed for two days and three flights coming in instead of one, and they had one person arriving on each flight, the plan had changed during the day. As I was traveling, there was no way they could have contacted me to let me know. My contact person did have a recent photo of me that was submitted in my credentialing packet, told me the next day “because you were so calm and not frazzled I didn’t recognize you”.

     After a brief time, I received my keys and was taken to my very nice apartment. It is a townhouse layout with two bedrooms and a bath upstairs and kitchen, living room, and dining room downstairs. I got in and carried my luggage upstairs, noticing that there was no linen on the bed or in the bathroom. I unpacked and went looking for sheets to put on the bed. You guessed it, there weren’t any, nor were there any towels. There is also a telephone upstairs and one down stairs, neither of which had a dial tone. I did find a blanket nicely folded on the sofa. I also found several rolls of paper towels in a kitchen cabinet.

     If there had been a hidden camera in the apartment, I probably would have won the $100,000.00 prize. I was so tired and exhausted, I took a shower and dried off with paper towels (I always carry a bar of Dial soap) after which, I laid the blanket on top of the bed and made myself the filling in the taco. I awoke the next morning at 3:30 am (which was 6:30 am according to my internal clock) refreshed and ready for new challenges.

     Now before you ask, the folks here did not have a vendetta against me. They actually are some of the nicest, down to earth folks I have met in my travels. I was the “victim” of an unusual set of circumstances. My contact person and everyone here have been so apologetic and actually look like little whipped puppies about my experience that I don’t even tease them about it. This facility has an enormous amount of personnel moving in and out on a daily basis and some things just happen. I am actually glad that it happened to me rather than someone who could not laugh about it.

    

Alaska here I come! 12/12/12

     The day is finally here to start my Alaska adventure. While I have been to many places in the lower 48, this is my first trip to Alaska. I “think” I know what I am getting into, but until I am actually there I have no way of knowing if I am truly prepared. Did I pack the correct clothes? Is there anything I need that I won’t be able to get in Dillingham? How will the native people receive me? And the questions from “Ralph” (that little pesky voice living inside my head) come fast and endlessly.

      Now for those of you that travel, you already know that there is no “travel fairy” that waves a magic wand and everything about your trip is hunky dory. I have prepared myself over the years to expect the unexpected and pride myself in the fact that I am fairly self-sufficient and can deal with most travel related issues while still smiling. However, Ralph is constantly trying to instill doubt and frustration in my life. I am determined that Ralph will never win, but he is occasionally able to temporarily gain a slight advantage.

     I awoke this morning at 3 am. I put the coffee on, brushed my teeth, and at 3:30 am I woke the “princess”. As I have mentioned before, I have the “bestest” wife in the world (who else would get up at this ungodly hour to take me to the airport?). While she dresses and prepares her 2 (yes two) cups of coffee (one for going to the airport and one for the return trip), I put my bags in the truck and start the engine so the cab will be warm when I, er she, gets in. I remove the heavy frost from the windshield and      return to the kitchen where I inform her “your chariot awaits”. Unfortunately, she did not find this statement nearly as humorous as I did at “oh my god thirty” in the morning.

     We arrived at the airport about 4:15 am (for my 6 am flight), I unloaded my bags, had a prolonged “good bye, hurry your ass back home hug and kiss” and she departed as I entered the Memphis airport terminal. As I crossed the threshold of air travel, the comedy of errors began and I realized this was going to be a LONG day.

     I was unable to check in online because my flight had “too many legs”. My itinerary was: Memphis to Atlanta; Atlanta to Seattle; Seattle to Anchorage: and Anchorage to Dillingham. Now in my “prepared” state I know that the airline recommends that you arrive for domestic flights 90 minutes prior to departure, it even says it on the ticket. With my inability to check in online I allowed myself a few extra minutes to check in and get my boarding pass. Now I should have suspected something when the TSA check point was unmanned and had heavy steel gates pulled across the entrance with a sign advising that they would open at 4:30 am. Great, I have fifteen minutes to get checked in before I go through TSA screening. Funny thing Delta doesn’t tell you is that their ticket agents don’t even show up at the ticket counter in Memphis until 4:45 am. About this time I tell Ralph to be quiet as I wait in line with about 20 other passengers that did not know Delta ticket agents got to sleep in. There was a “very unhelpful” Delta lady in a red jacket that walked up to the line I was standing in and told us that we should be checking in at the kiosk. I and several others informed her we had tried, and the kiosk told us we had to see an agent. With this information firmly grasped in her little mind, she smilingly informed us that we would have to wait to see a ticket agent. Thanks a lot lady in red!

     At exactly 4:45 am, the gentleman in the blue Delta jacket finally got his computer turned on and the line began to inch forward. When it was finally my turn, the gentleman informed me that he could only ticket me to Anchorage; I would have to get my ticket for the last leg when I got there. Seems like we have a plan and can go forward, Ralph has gone back to sleep and all is well. The time is now 5:20 am. The TSA screening process was uneventful and I got to my gate just as the last of the first class passengers was entering the jet way. I boarded without difficulty and was ready for a day of flying. As we departed the gate, the pilot informed us that we would be slightly delayed for take off due to the fact that we were in the de-icing line. I silently chuckled to myself at the irony of this. I am leaving the “warm” south headed to Alaska, and before I can take off the plane needs to be de-iced.

     The timing of this trip before the holidays meant that there were quite a few families traveling and a multitude of fairly fresh babies probably on their way to see grandma for the first time. Throughout the first three legs, the children were well behaved, unlike the gentleman I will refer to as “Richard Cranium” on the Atlanta to Seattle leg who apparently is a legend in his own mind. “Richard” refused to sit in his assigned seat because there was a mother with a little one in her lap in the next seat. His exact words were: “I refuse to sit by that sniveling brat all the way to Seattle!” About half way through his tantrum, Ralph woke up and encouraged me to politely step over to “Richard” and (as Ralph so eloquently put it) “knock him on his humpty dumpty ass”. This would have given me a great feeling of chivalry and satisfaction, but probably resulted in my incarceration and very large fines. I did do the next best thing and inform the flight attendant that I would be glad to exchange seats with “Richard”. She thanked me and quickly allowed us to swap seats. The young mother was visibly upset but the infant in question was soundly sleeping in his mother’s arms. I assured her that I had no problem with her or her child, advised her to forget about “Richard” and enjoy the flight. The child was an angel throughout the flight, and even let me hold him while his mother made a trip to the lavatory without vocally objecting.

     Now at the time that our friend “Richard” was showing his ass and I offered to swap seats, no one had filled the seat next to mine. Shortly after exchanging seats, a very large elderly lady “squozed” herself into the seat beside “Richard”. Several times during the trip to Seattle, she could be heard throughout the aircraft snoring loudly and smacking her lips. Now who says there is no such thing as karma?

     I arrived in Anchorage without further incident and all was well until I disembarked the plane. I’ll tell you about that in the next blog.

Don't you know it is cold in Alaska?

     After today, I have 4 more days at home before I leave for an eight week assignment in Alaska. I am scurrying around attempting to complete all my "honey do" tasks prior to my departure. My last major project is completing the back yard fence so my wife and son will not have to brave the elements while I am gone to walk the dogs (this is pretty high up on my list, if you don't believe it just ask my wife). My progress is halted due to several days of rain, thunder, and lightning. But on the bright side the forecast for Monday is clear, but the high temperature will be around forty.

     Over the past few days, I have had several friends "remind me" that it is cold in Alaska. The most recent reminder came this morning from a friend in North Dakota by way of an IM. These reminders make me chuckle (especially when coming from North Dakota). I appreciate their good intentions, but most of them don't know "where" in Alaska I will be and know nothing about the climate. They seem to forget that this is "not my first rodeo".

     Now I consider myself a fairly well educated individual, after all I have completed a doctorial program and earned the right to put Dr. in front of my name and most of the alphabet after my name. I am reasonably computer literate (just don't ask me about programing or what ever is on the inside of the thing) and have access to the internet. Before I accept an assignment, I research the area and the facility thoroughly. I currently reside in the Memphis, TN area. I lived for two years (2010 & 2011) in North Dakota, and have traveled extensively through out the United States. I am very familiar with the terms "cold, "wet", "humid", "torrential rain", "dry", "blizzard", and "hot".  Let me share with you what I have discovered about my Alaska assignment.

     My first reference for a new place is City-Data (www.city-data.com). Here I can find information on the climate, cost of living, housing, government, tourism, and yes even the number of registered sex offenders. Let's look at a comparison between Dillingham, AK, and Oakes, ND.

     Dillingham, AK:
Population in 2010: 2,329. Population change since 2000: -5.6%

Estimated median household income in 2009: $76,481 (it was $51,458 in 2000)

Median gross rent in 2009: $976

Mar. 2012 cost of living index in Dillingham: 110.5 (more than average, U.S. average is 100)

According to our research there were 18 registered sex offenders living in Dillingham, Alaska in July 2011
The ratio of number of residents in Dillingham to the number of sex offenders is 129 to 1.
Average climate in Dillingham, Alaska

Based on data reported by over 4,000 weather stations

     Oakes, ND:

Population in 2010: 1,856. Population change since 2000: -6.2%

Estimated median household income in 2009: $36,772 (it was $30,263 in 2000)

Median gross rent in 2009: $473

Mar. 2012 cost of living index in Oakes: 81.1 (low, U.S. average is 100)

According to our research there was one registered sex offender living in Oakes, North Dakota in July 2011
The ratio of number of residents in Oakes to the number of sex offenders is 1856 to 1

Average climate in Oakes, North Dakota

Based on data reported by over 4,000 weather stations

     As you can see, Dillingham's temperature extremes are not as hot nor as cold as Oakes, ND.

     I also search for local newspapers, radio stations, and city web pages for the area I am investigating. This research allows me to properly pack and gives me an idea of opportunities for adventure while on an assignment. There are many other great sites with information on cities and areas, these are some that I use.

     And for my friends in North Dakota, "don't ya'll know that it is cold there?"

All I need is some Rolaids!

     Many times in the emergency room I have nurses that "think" they know what is wrong with a patient. Too often I hear comments like, "why don't you just discharge them (the patient), they were just here yesterday with the same complaint!" I look at these patients with the approach, "what did they miss yesterday?"  Some times their "thinking" is correct, unfortunately many times it is not. As the provider, I can not afford to "think", I have to "prove" my diagnosis. If I miss a life threatening or debilitating injury it is my fault. If the nurse "thinks" wrong, it really does not matter because the ultimate responsibility is mine. I make this statement as preface to a case study. This case had a positive outcome, but hopefully you will see how it could have been a disaster.

     The patient is a 67 yo caucasian male that presents ambulatory to the ER accompanied by his wife. They had eaten at a local restaurant about 40 minutes prior to coming to the ER. About 15 minutes after eating the patient developed "heartburn" and belched a few times. He denies any chest pain (other than his
"heartburn"), shortness of breath, sweating, nausea, diarrhea or other complaint. He has had no recent fever, chills, cough, or other symptoms of illness. He reports having "frequent indigestion". He advises that he only came to the ER because so his wife would leave him alone, he has Tums at home.

     He had a complete physical exam 6 weeks ago that included labs, EKG, and hemocult (all results were with in normal limits and there were no EKG changes). He takes a multivitamin, fish oil, and a baby aspirin daily. He is an only child, father died at 93 from "natural causes" and mother died at 88 from complications of a hip fracture repair.

     General appearance: CAOX4, NAD, speaking in clear complete sentences, ambulatory with out assistance.
     Initial vital signs were: BP 132/80, HR 72, RR 18, SaO2 98% on RA
     Lungs: BBS clear and equal with adequate air exchange
     Cardiac: S1, S2 RRR, no murmurs, rubs, gallops, or extra heart sounds
     Extremities: No edema

     After my initial assessment, I ordered EKG, portable chest X-ray, CBC, CMP, Troponin, 3-81mg ASA chewed, and an INT.

     Pertinent labs: WBC 13.1, Troponin I 0.00, electrolytes WNL   

     The EKG showed:

    

     The patient was having an inferior MI (STEMI). Marked ST elevation in Lead II, III, and AVF.

     While he was in out ER, he received IV morphine for pain control (nitroglycerin use in inferior MIs has a tendency to cause marked HYPOTENSION), 5000 unit heparin IV bolus followed by a heparin drip (all dosages were weight based per the hospital heparin protocol), and after consultation with the receiving cardiologist TNKase. He was transferred emergently to a tertiary facility where he underwent cardiac catherization. The cath revealed a 100% occlusion of his right coronary artery. He received angioplasty and stenting which resulted in total re-profusion.

     This is an example of why we treat everyone like they have the worst case scenario, then do everything we can to prove they really did just need "Rolaids". 

Somebody loan me some fashion flags, QUICK!

     I want to first clarify the fact that I am NOT the poster boy for GQ. I am old, wrinkled (all of which I have earned), and prefer the t-shirt/shorts/flip flop look any day to "getting dressed up". However, I do enjoy watching people which does result in my abundant dispersion of "fashion flags".

    Every time I take an assignment, it means getting on a airplane. If I get on an airplane to go to an assignment, that means I must get on an airplane to get back home. Unfortunately, this means two adventures through the TSA screening process. While you are in the TSA line it is easy to tell who travels frequently, who has never flown, and who thinks there are there to impress someone.

     When I fly, I attempt to make myself TSA friendly. I wear Merrills, usually wear jeans and a golf shirt, don't wear a belt, check my pockets several times, and place my watch/ring/wallet in my computer bag before I enter the line. I check the TSA site (http://www.tsa.gov/) frequently for any changes or updates in carry on regulations. And yes I put my liquids in a one quart bag. This does not mean that I am immune to the "random" hand and shoe swabs for explosive residue, an occasional "pat down", or having my bags "sniffed" by Fido.

     Last Friday I was standing in the TSA line at 6:15 am. A female (I think) entered the line wearing dangling metal ear rings that touched her shoulders, thigh high boots (with no zippers), a tank top with metal stars covering the front, a jacket with rhinestones everywhere, belt buckle that Tuff Hedeman (3 time world champion rodeo star) would be proud of, and a large bag on her shoulder who's contents rivaled Opie Taylor pockets was about 4 persons ahead of me. The "aroma" she was emitting validated my thought that she used the $3.99 a gallon "fly spray" available at Rite-Aid, and had applied several gallons. I really could not begin to estimate her age because of the amount of make up she was wearing., If the quantity of make up she had was Bondo, it would supply a body shop for several repairs.

     As this "lady" approached the tub line, she removed her jacket and attempted to remove her boots. After struggling for several minutes, she finally asked an elderly (really old) gentleman in line behind her for help. This action would have definitely won the $100,000.00 prize. As she pushed tubs on the floor and sat down on the stainless steel table, her assistant dutifully began to tug and pull on her boot. Lets sum up this action with the words: slip, fall backwards, and busted his ass more than once. A female TSA officer finally came to her rescue and jerked them puppies off with an apparent vendetta which resulted in another "busted butt" (as the "lady" slipped off the table) and a group "laugh out loud". When the TSA officer advised her that her shirt would set off the scanner, the "lady" replied in a very loud voice, "well I don't know what you expect me to do about it, I can't take it off, I don't have on a bra". Other than being entirely too much information, the mental image that this created required an immediate application of mental bleach. When the "lady" attempted to send her bag through the scanner, it came back way faster than it went in. The TSA officer removed two bottles of water, a tray of cinnamon rolls (you know, the aluminum ones at the grocery store with eight in them), several candy bars, and a can of hair spray.

     Fortunately for me, there were 2 screening lines open and I was a participant in the other line. As I cleared the scanner without a hitch and retrieved my items, I could not keep myself from looking over my shoulder to see what was happening. The "lady" was being escorted from the line area by several TSA officers, two of Memphis's finest, and my old friend "Fido" and his handler. Boots in hand, toe socks on her feet, and screaming at the top of her lungs "I didn't do anything to deserve this abuse, I will have your jobs you ba#%*&@s".

     Needless to say I was out of fashion flags before I ever boarded the plane. At least I was entertained.
    

    

    

How do I work out while I travel?

People ask how I can work out while I travel. There are a multitude of websites that have practical information for “hotel room workouts” and “healthy eating” while on the road. Here is an example from:

http://www.criticalbench.com/workout_healthy_travel.htm

EXERCISES FOR THE ROAD WARRIOR:

CHEST

1. Push-up Variations:

- Regular Push-Ups (the normal push-up)
- Close Grip Push-Ups (hands shoulder-width apart)
- Kneeling Push-Ups
- Wall Push-Ups (standing up with your hands on wall, body at an angle)
- One Arm Push-Ups (set feet quite wide for balance)
- Feet On Chair/Bed Push-Ups (incline push-ups - increases difficulty)
- Between Two Beds/Chairs Push-Ups (hands on two objects so your range of motion is greater)
- Clapping Push-Ups - explode up and clap your hands between reps
- Luggage on Back Push-Ups (set your suitcase/bag on your back for resistance)

2. Dips

- Between Two Chairs (use the tops of the chair backs as dip handles)
- In a Countertop Corner (stand in the corner facing out and set your hands on either side of you - do a dip from there)

BACK

1. Pull-Up Rows

Lie underneath a solid object like a rail or table (not a table with only a center pedestal!). Pull yourself up underneath it like you're doing a rowing movement.

2. One Arm Suitcase Rows

These work best if you got a heavy suitcase. Use your luggage for resistance - go for strict form and squeeze your back hard as you do them.

3. Pull-Ups

If you can find something that is solid that you can hang from, you've got yourself a pull-up station.

4. Suitcase Knee Rows

For this exercise, you'll need a fairly large suitcase. Rest the suitcase end on your thigh - this end will act as the pivot point for the exercise, using the suitcase as resistance. Row the handle towards your body - the one end will stay on your thigh while the top end pivots up towards you.

5. Luggage Farmers Walk

Grab your two heaviest pieces of luggage and walk around with them for as long as you can! For a variation that works your abs, hold only one piece of luggage - this hits the obliques.

THIGHS

1. Squats or Lunges

These can be done for high reps without extra resistance or you can use your luggage or other objects around the room for resistance. High reps won't be as useful for muscle building but will definitely stimulate your metabolism.

2. Wall Sits

Maintain a sitting position with your back against a wall for as long as possible (with no support - you'll only stay up by pushing hard with your thighs). You can also hold a piece of luggage on your lap for extra resistance.

3. One-Legged Squats

These can be done on the floor or standing on a chair for greater range of motion. Basically, you stand on one leg and squat down as far as you can then come back up (you can hold onto objects for balance when you first try these).

4. Isometric Leg Curls

Most motel/hotel rooms have tables. Stand in front of the table facing away from it (make sure there's nothing on top of it). Now raise your foot underneath so that the heel of your foot is pushing against the underside of the table. Now try to push the table up. You should feel a strong cramping in your hamstring. Hold it there for 5 to 10 seconds, squeezing hard. Relax and repeat.

5. Bench Step One-Legged Squats

This exercise requires a chair, bench or even just a stair (as long as you have something solid to grab onto). Move the chair in front of a solid object, like a doorframe, that you can get a good grip on. Stand on the chair on one foot. Now, holding onto the solid object, lower yourself down into a one-legged squat. The benefit here is that you can go further down and use your arms to pull back up if you need to. This is a tough one but a good one!

SHOULDERS:

1. Luggage Shoulder Presses and Raises

Press your bags overhead or do raises (front, rear or lateral) with them. When doing presses, grip the luggage on both ends and press the whole thing directly overhead (it's a shorter range of motion). If your luggage is light, you'll need to do high reps or isometric holds at the top of the movements.

2. Horizontal Push-Ups

These are done by first bracing two chairs against a wall about 2 feet apart. Kneel down in front of them then put your hands on the chair legs. Use your legs to push your body forwards then use shoulders to press your body backwards - use your thighs to apply resistance.

Suitcases and bags all have handles. Use these to curl! These actually work extremely well because of how the resistance of the bag hangs down underneath the handle - much different than a dumbell or barbell! As you curl up, your hand will bend backwards, which keeps the resistance on the biceps very effectively.

2. Vertical Pull-Ups

If you've got a place you can do pull-ups, try keeping your torso completely vertical while coming up. This throws more tension onto the biceps.

TRICEPS:

1. Close-Grip Push-Ups

These are done like a regular push-up only you will set your hands about shoulder width apart. Keep your elbows tucked in beside your body as you do these.

2. Body Tricep Extensions

This is a great exercise that can be done using a dresser, chair, table edge or railing. Stand in front of the object (make sure it won't roll back - brace it against a wall). Step back a few feet. Set your hands on the edge. Now, keeping your body stiff and straight, lower yourself down so that your head ducks under the edge of what you're grasping.

3. Bench Dips

These can be done on a chair or bed. Sit on the chair and set your hands on the edge under your butt. Set your feet a little forward. Now move your butt off the chair and lower yourself down. Use your triceps to push yourself back up. This exercise can also be one arm for those who are stronger - set your feet wide apart for balance, keeping your legs straight. Your working arm should be in the center of the chair for best balance.

CALVES:

1. Standing Calf Raises

These can be done with one leg or two legs. They can be done on stairs or any other solid object. If you're in a hotel room, often a thick phonebook will work just fine.

Basically, stand with your heels off the edge. Let your heels come down then use the calves to push back up.

2. Full Range Calf Raises

In short, you combine both Donkey Calf Raises and Standing Calf Raises into one exercise. For more detail, use this link:

ABDOMINALS:

1. Crunches

The standard crunch exercise will work just fine.

2. Abdominal Sit-Ups

All you need for this one is a rolled-up towel. Place the rolled-up towel in the small of your back just above the waistband and do a regular sit-up from there. The towel changes the leverage and forces the abs to do the bulk of the work.

Strong To The Core of Your Being - Dramatically improve sports and weightlifting performance and say goodbye to lower back pain!

3. Luggage Squats

This is a variation of an exercise I call the Curl Squat. Grip your luggage with two hands (one on either end) and hold it at face level just in front of you, a few inches from your body. Be sure you're NOT holding it against your body but that it's supported just by your arms. Now squat down as far as you can and back up. Holding the luggage in that position will activate the abs VERY strongly.

While it can be a challenge to keep in shape on the road, it's definitely possible! This is just one example showing that you can train no matter what your situation.

What do I pack?

Well, it's Wednesday and I am getting ready to spend the weekend working in a critical access hospital in rural North Dakota. For this assignment, I will be the ER provider in a level V ER, the hospitalist for acute inpatients, the "on call provider" for swing bed patients,  and the "on call provider" for several local nursing homes. My shift starts Friday afternoon at 5 pm and ends at 9 am Monday morning.

So how do I decide what to pack and take with me for this assignment? This is a facility that I have been to several times, so I have an insight to what is available and the accommodations provided. This makes preparation much easier. I know that there is wireless Internet available in the apartment I will be staying in and hard wire Internet access throughout the facility.  I know that the "dress code" is scrubs. I know that once I arrive at the facility I will not have to leave the building unless I choose to. I am provided a meal ticket to eat in the cafeteria three meals a day, and there are snacks available during the night. I also know that the temperature on Friday morning in Memphis when I leave will be around 50 degrees. When I arrive at the airport in North Dakota, it will be about 20 degrees.

Now the way I pack is probably completely different than anyone else. What you need to do is get into a "routine". Just as in health care we become proficient by repetition, we can become proficient in packing by repetition. For these short trips I use a Victorinox Spectra carry on wheeled bag and a computer backpack.

First we will pack the computer bag:
  1) Laptop
  2) Power cord (yes I have gotten to an assignment without the power cord)
  3) Copies of all nursing licenses
  4) BLS, ACLS, PALS, ATLS provider and instructor cards
  5) Small digital camera and transfer cable (I use one with that requires AA batteries to eliminate a charger)
  6) iTouch
  7) iPhone
  8) Charging cords and adapters for my iPhone and iTouch
  9) Legal pad
10) A couple of current journals ( for airport and airplane reading)
11) File folder with assignment paperwork (this will vary from assignment to assignment)
12) Stethoscope
13) Sony noise cancelling headphones for inflight listening to itouch
14) Toiletry bag (one quart) w/ shampoo, deodorant, toothpaste, mouthwash (all less than 4 oz per TSA guidelines. - This can be placed in the carry on after TSA check in.

Now for the carry on:
  1) Toiletry bag w/ toothbrush, bottle of naproxen sodium, bottle of benadryl (comes in handy when changing timezones), vitamins, Rx meds, Tums
  2) Underwear (number of days gone + one pair)
  3) Socks or footies (number of days gone + one)
  4) Scrubs (three sets)
  5) Dress shirt and nice jeans or khakis (always prepared)
  5) Tennis shoes (one pair)
  6) Workout DVDs and/or movies

Normally when I travel I wear a polar fleece type jacket. Since the weather will be cold, I will still wear my polar fleece when I leave Memphis and I will carry my heavy coat with a hat and gloves in the pockets. I don't try to pack it because it takes up too much space (and it makes a great pillow while flying). I won't need it when I leave Memphis but I will need it when I arrive in North Dakota and while I am there.

By using a check list, I have found that I very seldom arrive without any "essential" items. I have another check list for extended trips and I adjust all check lists for the geographic area and time of year (if I am going south in the summer, I take a bathing suit, etc).

As always, I am not endorsing any particular products, I am just advising what works for me.

Safe travels!

Where do I start?

When someone asks me "where do I start?", I tell them with your credentials. Now "credentials" are much more than the letters after your name. Although they help, you must put together a professional level marketing plan for yourself and your services. You should also be prepared to invest in yourself. I'll explain this in a few minutes.

Let's start with the basics, you need to be certified as a nurse practitioner. Your certification (family, adult, peds, acute care, etc) will dictate where you can practice. Many states are getting very strict on making sure you practice within the "scope of your training". As far as "which" certifying exam to sit for, it depends on which state you want to practice in. If you look at the license applications from the various states, you will see that some specify "certification from a nationally recognized body", some say "ANCC", and some say "AANP". Now if you are AANP and the application specifies ANCC, don't have a come apart. So far, every state I have applied to has accepted either certification. When I called the board of nursing, they informed me that the wording on the application "just hasn't been updated", they actually accept either certification. You will find a more familiarity with a specific certifying body geographically. For instance, if the certifying body's office is in Texas, guess which certification the Texas board of nursing and facilities in Texas are most familiar with?

Now that you are a NP, you need current American Heart BLS, ACLS, and PALS at a minimum. But wait, there are many online companies that provide these classes, so why am I pushing AHA? AHA is the "gold standard" and is universally accepted. The "online, no mega code" courses all have a disclaimer that if your facility does not accept their BLS, ACLS, PALS, etc they will refund your money. From personal experience, facilities require AHA courses. If you are going to spend the time and money for a class, you should at least invest in one that is universally accepted. Trust me, it will save you grief in the future.

If you are planning on working in a rural/remote area you will definitely need ATLS as well. Now ATLS is a creature in itself. Only within the past few years was the class open to anyone who wasn't a physician. The first ATLS class I took would not allow PAs to take the final test and practical exam. It is intimidating to be surrounded by physicians staring at you while you attempt to perform a pericardial centesis on a pigs beating heart. Especially when the instructor at your station is the head of trauma surgery at Tulane, but that is another blog in itself.

I also recommend the Fundamental Critical Care Support course put on by the Society of Critical Care Medicine. Now you are probably thinking that you are not an intensivist and what the hell do I need this course for? The reason you need it is because it is a course to help you identify and correct problems that may keep your patient from needing an intensivist. Taken from the FCCS web site (http://www.sccm.org/fccs_and_training_courses/fccs/pages/default.aspx) :

Course Purpose

• To better prepare the non-intensivist for the first 24 hours of management of the critically ill patient until transfer or appropriate critical care consultation can be arranged.
• To assist the non-intensivist in dealing with sudden deterioration of the critically ill patient.

• To prepare house staff for ICU coverage.
  
• To prepare nurses and other critical care practitioners to deal with acute deterioration in the critically ill patient.

This course connects so many dots that it will amaze you.

Do you remember when you were in your advance practice program and you had to keep up with those "procedure logs"? Well guess what kids, a current procedure log is required to get credentials and privileges at many facilities across the country. Most facilities I have dealt with require a procedure log for the past 2 years. These logs are also a requirement for re-credentialing as well. They don't have to be fancy, and many times if you work in a hospital your friends in HIM can print one out for you. Below is an example of a portion of my monthly procedure log for one of the facilities I work at as an ER provider:

CPT	Count	CPT Description
10060	24	I&D ABSCESS;
10061	49	I&D ABSCESS;
10120	1	INCS & REMOV FB
10140	1	I&D
11740	5	EVACUATION
12001	46	SIMPL REPR
12002	20	SIMPL REPR
12004	4	SIMPL REPR
12011	17	SIMPL REPR
12013	7	SIMPL REPR
12014	2	SIMPL REPR
12031	1	LAYER CLO
12032	4	LAYER CLO
12034	2	LAYER CLO
12035	2	LAYER CLO
12041	5	LAYER CLO
12042	7	LAYER CLO
12044	1	LAYER CLO
12051	2	LAYER CLO
12052	3	LAYER CLO
13121	1	REPR COMPLX

The CPT codes are required. Make sure that you include everything, no matter how simple or unimportant it may seem at the time.

And lastly, back to the "investing in yourself" part. You will be required to provide transcripts and official documents from certifying agencies for licensure and credentialing. The fees for these items can add up very quickly. Additionally you will have a license fee for an advance practice license and prescriptive authorities in each state you work in (I currently spend about $500.00 every 2 years to renew my advance practice licenses and prescriprive authorities). If you live in a compact state (such as Tennessee) you will not have to have an additional RN license in another compact state (such as North Dakota). But if the state is not a compact state (Alaska), you will be required to purchase a RN license as well. And some states (ex. Alaska) require you to have a business license. Now don't forget that you are required to have a DEA number for each state you prescribe in as well.

*Pharmacies, hospitals/clinics, practitioners, teaching institutions, and mid-level practitioners register for a three-year period. The current three-year registration fee is $551. The new fee for the threeyear registration period would be $731.The three year difference is $180, or an annual difference of $60.

You need to allow 6-8 weeks for each new license you apply for as well as 6-8 weeks for a DEA number.

I have just adressed the highlights, if you are considering the "rental life" and have specific questions, send me an email and I will try to help you find the answer. If you have general questions, please post them in the comments section so we can share them with everyone.

Now go make it a great day!