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!

Where do they ship the body?

My wife and I were talking the other day and she brought up a great point. How would anyone know anything about me, who to contact, or my pertinent medical history if something happened to me while I was traveling. To be honest, this was something I had never thought about.

Most locums companies have a health history form and emergency contact information form that you fill out when you contract with them. But, as my wife pointed out, who is going to know I am working for a locums company? What if the information is needed at night, on the weekend, or on a holiday? There is no way to get the information. In a true emergency, we all know that we need patient information now, not on Monday when the office opens.

Thus began my search for a way to carry my information with me. The issue is how to have the information available without carrying around a piece of paper with your life history and personal information on it for anyone to find. So the search began. A Google search produced several options, however the all would make my information available to anyone.

The method I decided on is called a "Road ID". It provides an easily identifiable means to obtain my information. I chose the bracelet version. It has my name, year of birth, city and state of residence, and a phone number/web address to access my information. The back of the bracelet has a serial number and a PIN required to obtain my selected contacts, health information, allergies, medications, and anything else that I deem necessary for someone to know in an emergency.

No I am not endorsing a product, I am endorsing the idea that if you travel, you need to have a means to speak for you if you can't. Or as I tell my wife to watch her twitch, "a way for them to know where to ship the body".

The Women In My Life

There are several women in my life that make it possible for me to do what I love.

First and foremost is my wife, without whom this would be impossible. She is not only my wife, but my best friend, soul mate, my biggest fan, and very often my "reality check". She is a wife, mother, part time NP, keeps the laundry done, makes sure there is food in the house, attempts 7th grade homework, makes sure our son is where he is suppose to be (occasionally on time), walks the dogs, and deals with whatever comes up unexpectedly while I am gone.
She does all these things without griping, bitching, complaining, or whining. In her spare time she trains twice a day (she is training for her next half marathon on December 1st with a goal of completing a Half Ironman next August), becoming "healthy",  not eating meat (there is a limit to how "healthy" I will ever be and no meat ain't one of them), and turning into an amazing "middle age" (her words not mine) athelete.

Next inline, yet no less important is my mother-in-law. While some of you are cringing, I am blessed with the bestest mother-in-law I could ever hope for. She is always a phone call away to help out with whatever needs to be done. She offers encouragement and does occasionally look at me with a straight face and asks me "what the hell were you thinking?" (no she doesn't really say "hell", but that is her implication). She is my wife's best friend and confidante as well as an exceptional grandmother (don't EVER call her "granny", she will get her flying monkeys after you).

The last woman in my life is my trainer, Misty. I have never been skinny and probably never will be unless I contract some terminal disease. I have been "short for my weight" all my life. A few months ago, I became very tired and didn't have the energy to get out of bed. I went in to see my PCP (no I did not try to heal myself) who slapped me in the face with the cold reality that I am no longer bullet or laser proof (if I ever was). Now understand that 14 months ago (while living in North Dakota) all my labs were fine. Dr H informed me that my triglycerides were over 500, my Vitamin D level was 6 (folks I live in the south where there is plenty of sunshine), and testosterone was something I read about in school.
So, I decided that I would make a few changes and would NOT take this news without a fight. I chainged my diet, track my food, supplement my vitamin D, started on Trilipix, supplement my testosterone, and hired a personal trainer. In the past 9 weeks I have lost a little over 30 lbs, decreased my BMI by 10, and overall inproved my cardio and strength.
Now Misty is not a Barbie look alike, nor does she wear skimpy outfits like the trainers do on TV. What Misty brings to my life is accountability and her knowledge of exercise physiology. I am smart enought to know that I am accountable only to myself for my choices and healty (or lack there of). Although I pay for Misty's services, she puts alot of time and effort into my training. She goes above and beyond what some other trainers will do. As an example, she is putting together an exercise program for me that I can continue as I travel. I rationalze that if I don't train and exercise I will be showing disrespect to her for all her tireless efforts.
With my next asignment starting next month being 8 weeks in Alaska, it is important that I can exercise without a fully equipt fitness center. She is the only woman that I allow to kick my ass on a regular basis. Oh, did I mention that she is a 5th degree Black Belt in tae kwon do?

As I begin to prepare for my trip to Alaska, today I am thankful for the women in my life. Those that accept me for who and what I am and continually push and encourage me to be better. And in Misty's case,continue to kick my ass and help me be accountable.

Why do I do it?

I often get asked why I work locums. I could come up with a plethora of reasons that sound good, but my self reflection tells me that I get board easily. I enjoy challenges. I enjoy going somewhere I have never been, meeting new people, and being able to handle whatever comes through the door. I had a full time job as a provider in a large metropolitan ER. I went to the same place twelve days a month and did the same thing each of those twelve days. I enjoyed the staff that I worked with, but after a while it lost it's challenge.

This type of work is definitely not for everyone. Let me give you a glimpse of a typical trip. Last Friday I got up at 4:45 am and left for the airport at 6:00  (about a 30 minute trip). I parked the truck in long term parking and then rode the shuttle to the terminal. Check in, clear security after having my hands swabbed for explosives and my computer bag sniffed by the TSA dog (thankfully he didn't mark it), and get to the appropriate gate by about 7:15. Board the first plane of the day and depart Memphis at 8:20. Now between this time and 10:50 I flew to Minneapolis/St Paul and deplaned at gate G 24, did a forced march from one end of the airport to gate A 10 ( which is a heck of a long way if you've ever been to this airport) to get on my next flight that was scheduled to depart at 11:25 pm and was boarding as I got to the gate. This next flight was to Minot, ND and at 12:50 I was getting into a hospital van for the one hour trip to my assignment. My shift started at 5:00 pm. I remained on call from then until 9:00 am Monday morning (you don't have to do the math, that is 64 hours). The short version of the flights home is just the reverse of my trip Friday, except I did not leave Minot until 12:30 pm. At 6:30 pm Monday evening I was sitting in Firebirds in Collierville (home) with my family eating prime rib.

And the best part is I don't work again for 9 days. That means this week when my son is out of school for Thanksgiving, I get to spend the week with him and my wife.

And THAT makes it all worth it.

How do you rent a nurse practitioner?

At the encouragement of my mentors, peers, and even my wife, I am going to attempt to share my journeys across America. I will share the good, the bad, and if it happens the ugly. If you are considering working locums, hopefully you can learn from my experienc and won't have to buy all the experience I have already purchased.

So just how do you "rent" a nurse practitioner? Well the "proper" term for what I do is locum tenens staffing. Locum tenens is Latin for "place holder".  I work in the place of a regular healthcare provider when that provider is absent, when a provider takes vacation time, when a practice is growing, or when a hospital/practice/clinic is short-staffed. To some this seems very glamorous, and at times it is. But don't think it is all glamour and glory,because it does come with it's own issues, problems, and down side.

Other nurse practitioners often ask me how they can get started working locums and quit their "regular" job. If you search google for "nurse practitioner locum tenens jobs" you will see a screen full of staffing companies that want you to work for them and fill their locums openings. Unfortunately my experience has shown that the healthcare recruiting industry has many similarities to the used car business. The recruiters are very adept at telling you what they think you want to hear. In addition to thoroughly researching the individual companies some examples of questions that you should ask in the very beginning of your negotiations with any recruiter might include:
1) Is this an employed position (taxes come out of your check and you may be entitled to benefits) or a 1099 position (you are an independent contractor and responsible for your own income taxes, health insurance, retirement, etc)?
2) Is transportation paid by the company, or are you required to pay for travel (airline tickets, rental cars, etc) and get reimbursed
3) What are the living accommodations (apt, sleep room in a facility, hotel/motel room, extended stay hotel, etc)
4) Are the accommodations individual or shared with others?
5) What is the work schedule and how do you get from the lodging site to the work place and back (shuttle, carpool, rental car)?
6) If you are provided a vehicle, can you use it on your days off?
7) What is the dress code (scrubs, lab coat, busines casual, shirt and tie, etc)?
8) Is there internet access?
9) Does your current cell phone provider have coverage in the area you will be going?
And the list goes on and on ..............
Each assignment requires preparation and research. Do not be afraid to ask questions! Remember you will be the one living in a strange place, leaving your family and friends for an extended period of time. The answers you get from the recruiter will also give you insight into the person you are dealing with.