RE:Connect

Adjusting to Night Shift

I never thought I would ever admit this, but working night shift really has not been that bad. Yes I know, I whined and moaned about how I didn't think my body would be able to handle it. But, it has been 9 weeks since I came off  of Resourcingand I have adjusted to the night shift schedule. I definitely enjoy the bigger paychecks and the slower work/learning atmosphere. I get to sleep in as late as I want. The night before I work, I am not rushing to get into bed early. It has been kind of nice. I am still tired most of the time, but who isn't? Next week I have to switch back and work day shift for 6 weeks. Now, I am sort of dreading that. (I know, sometimes I just can not make up my mind of what I want!) It is sort of bittersweet because day shift is incredibly busy and I am scared that it will be way too overwhelming yet I am looking forward to being on a somewhat normal schedule. I am sure my body will go through shock next week when I have to actually wake up at 4:30 in the morning instead of sleeping till 3:00 in the afternoon. I think no matter if I work days or nights, I need to just get on a set schedule and routine and stay on it! I find that when I am on a set schedule I take better care of myself. I plan out healthy meals for the week, I make sure I get enough rest, etc. I think that is the one major lesson I have learned so far in my career, that you have to take care of yourself. After this last rotation, I will be on straight nights. And hopefully one day my body will adjust to all of this.

Taking Care of the Entire Family

One thing I have found to be quite difficult in my nursing career thus far is teaching families. I cared for a patient last week who was hit by a car while being held in his fathers arms walking across the street. The 4 year old child suffered an atlanto-occipital dislocation, then required mechanical ventilation for respiratory failure. So, basically the patients head was dislocated from his neck and he required Halo traction for stabilization. The family was incredibly difficult to deal with because they did not understand anything the team tried to teach them regarding the patient's diagnosis, necessary treatment, sedation requirements, etc. The list went on and on. I really do enjoy teaching families and supporting them in learning more about their loved ones care. However, this family thought everything was just too fast and they didn't understand why we kept messing with him. They did not think the patient needed to be intubated or have Halo traction for stabilization. This was very frustrating for the nurses who cared for this patient because it seemed like no matter how much education and teaching the surgeons and doctors did, they still did not understand why it was all necessary. A couple days into his treatment, the patient was scheduled for an atlanto-occipital fusion. The family once again did not think this was a necessary procedure and thought the surgery was too quick for the patient to have to endure. After multiple teams of nurses, doctors and surgeons talked with the family, the mother was still not convinced. So, the mother had the aunt and grandmother come to hospital to get their opinion. I could go on and on about all of the nit picky little things the mother had a comment about regarding her son's care.

But, what I think all of this really boils down to is a lack of understanding and education and the desire for some sort of control over the horrible situation. I wanted to say to the mother bluntly that "it was never too fast to re-attach your son's head to his neck again", but that wouldn't be very therapeutic, would it. Working in pediatrics definitely has its challenges. You are not only caring for the patient. You are caring for the entire family. You are caring for families that are not educated. You are caring for families that are scared, anxious and exhausted. You are caring for families with financial stressors. I have to continually remind myself of what these families go through on a daily basis. I too would be asking 5000 questions if I had never been in the hospital setting before. Sometimes families comprehend the seriousness and urgency for treatment and say to do whatever you can to save the patient. Other times, families are just too scared and confused to make any decisions and you have to try others ways of teaching like handouts, drawings, web resources, books, etc. Just like no patient is the same, no family is ever the same. But, we as nurses need to look at the bigger picture instead of the snapshot in front of us. We need to care for the patient and the entire family instead of just the problem at hand.

When I came into work the following evening, the patient finally had his surgery 2 hours later than scheduled. The patient is doing well, but has a long road ahead of him.

SWOG study results concerning race. . .

Recently, SWOG released some data indicating that genetics may pay a larger role in the disparities that exist in Afrrican-American patients with Breast, Ovarian, and Prostate carcinomas. As access to healthcare has been on a more even keel in the last few years, SWOG has gone back to the 1970's to draw conclusions indicating more than healthcare access and cultural norms, that there may be biologic/genetic factors involved.  The article can be found at www.swog.org. The press release is here:

Why Do African-Americans Fare Worse With Cancer? Access and Economics Are Only Part of the Story

 

An analysis of clinical trial data implicates biological factors behind worse outcomes for African-Americans with breast, ovarian, or prostate cancer.

 

ANN ARBOR, Mich., July 7 /PRNewswire-USNewswire/ -- An analysis of almost 20,000 patient records from the Southwest Oncology Group's database of clinical trials finds, for the first time, that African-American breast, ovarian, and prostate cancer patients tend to die earlier than patients of other races even when they get identical medical treatment and other confounding socioeconomic factors are controlled for.  The finding points to biological or host genetic factors as the potential source of the survival gap.

 

"When you look at the dialogue about the issue of race and cancer survival that's gone on over the years," says the paper's lead author, Kathy Albain, M.D., a breast and lung cancer specialist at Loyola University's Cardinal Bernardin Cancer Center, "it always seems to come down to general conclusions that African-Americans may in part have poorer access to quality treatment, may be diagnosed in later stages, and may not have the same standard of care delivered as Caucasian patients, leading to a disparity in survival."

 

The study, which will be published online by the Journal of the National Cancer Institute (JNCI) on July 7, found that when treatment was uniform and differences in tumor prognostic factors, demographics, and socioeconomic status were controlled, there was in fact no statistically significant difference in survival based on race for a number of other cancers -- lung, colon, lymphoma, leukemia, and multiple myeloma.

 

"The good news is that for most common cancers," Albain says, "if you get good treatment, your survival is the same regardless of race.  But this is not the case for breast, ovarian, and prostate cancers."

 

Even with good treatment by the same doctors, African-American patients with one of these three cancers faced a significantly higher risk of death than did other patients, ranging from a 21% higher risk for those with prostate cancer to a 61% higher risk for ovarian cancer patients.

 

The elimination of treatment and socioeconomic factors as the cause of this higher mortality "implicates biology," says study co-author Dawn L. Hershman, M.D., of the Columbia University College of Physicians and Surgeons.

"There may be differences in genetic factors by race that alter the metabolism of chemotherapy drugs or that make cancers more resistant or more aggressive," she adds.

 Hershman published a smaller study last month that found that, at least with breast cancer, disparities in survival based on race persist even after adjusting for differences in treatment.  That study, published in the Journal of Clinical Oncology, analyzed data on 634 breast cancer patients.

 

"Our study of multiple cancers is distinguished from others that have looked at race-based disparities by its size and by the source of its data," says Joseph Unger of the Southwest Oncology Group's Statistical Center, who was statistician and co-author on the new JNCI study.

 

The study analyzed records from 35 clinical trials - going back as far as 1974 - that had been conducted by the Southwest Oncology Group, an NCI-sponsored cooperative group headquartered at the University of Michigan.  Using data from clinical trials, which are already controlled for a range of potentially confounding factors such as differences in diagnosis, treatment, and follow-up, helps throw the remaining factors into sharper relief, according to Frank L. Meyskens, Jr., M.D.

 

"It's because of the similar way that people are treated on clinical trials that these differences are even detectable," he says.  Meyskens is associate chair for Cancer Control and Prevention for the Southwest Oncology Group and director of the University of California-Irvine's Chao Family Comprehensive Cancer Center.

 

The urgency of addressing the reasons for racial disparities in outcomes - both sociological and biological - is amplified by another recent study in the Journal of Clinical Oncology.  It predicts the cancer incidence among minorities will nearly double in the coming decades, increasing 99% by 2030 compared to an expected 31% increase among whites.

 

And the American Society of Clinical Oncology, the field's premier professional organization, recently issued a "Disparities in Cancer Care" policy statement that recommends a set of strategies for improving outcomes for minority cancer patients.

 

"The elimination of socioeconomic and healthcare access disparities must be a priority in the United States," says Lisa Newman, M.D., director of the Breast Care Center at the University of Michigan Comprehensive Cancer Center.  "However, Dr. Albain's landmark study demonstrates that further investigation of race- or ethnicity-associated differences in primary tumor biology is also important."

 

John Crowley, Ph.D., of the Southwest Oncology Group Statistical Center and Charles A. Coltman, M.D., of the University of Texas Health Science Center were also coauthors of the study, which was funded by the National Cancer Institute.

 

The Southwest Oncology Group (swog.org) is one of the largest cancer clinical trials cooperative groups, with a network of almost 5,000 physician-researchers practicing at more than 500 institutions, including 19 of the National Cancer Institute-designated cancer centers. The Group is headquartered at the University of Michigan in Ann Arbor, Mich. (734-998-7140). The Group has an operations office in San Antonio, Texas and a statistical center in Seattle, Wash

Cancer Hits Home for New Surgeon General Nominee

Dr. Regina Benjamin, a rural family physician, is President Obama's nominee for the next U.S Surgeon General. With a stunning professional background, accolades upon accolades, truly altruistic care and a family history of just about every major chronic disease, including cancer, she definitely understands the challenges of rural care in America.

The Office of the Surgeon General is a part of the Office of Public Health and Science within the U.S. Department of Health and Human Services, and the Surgeon General serves as "America's chief health educator," addressing topics from childhood obesity, cancer, and tobacco cessation to deep vein thrombosis, pulmonary embolism, and mental health. The National Call to Action on Cancer Prevention and Survivorship is one of my favorite publications and is a collaboration of the previous four U.S. Surgeons General.

With so many healthcare issues needing attention, Dr. Benjamin already has more than enough to accomplish. Once confirmed by the Senate, what do you think Dr. Benjamin should focus on first?

Shortage of Radio Isotopes

Being from Canada, I've heard a lot in the news in the past few months about the shut down of the Chalk River Reactor, the shortgae of radio isotopes for nuclear imaging, and the impact it is having world-wide on the healthcare system. Working in oncology, I thought I would have heard more about this issue and that it would have a more powerful impact on my daily practice, but surprisingly it seems to be a non-issue. The only people I hear about it from are the patients who see the story on the news.

The Chalk River reactor is one of five nuclear reactors in the world and supplies approximately 1/3 supply of radio isotopes used for diagnostic tests to diagnose and reassess htreatment response in heart disease and cancer. This shortage has been called the 'biggest crisis ever for nuclear imaging.' Last week it was reported that the Chalk River reactor will now be down for the remainder of 2009 and that we will begin to feel the shortage more in August.

For the assessment and imaging of cancer patients a PET scan (Positron emission tomography) scan is an alternate test that can be ordered in place of bone scans and other imaging that requires radio-isotopes. At our center, we are lucky to have acccess to a PET scanning machine for our cancer patient populations but I understand there may be an issue in the United Sattes in that the FDA has approved the use of PET scanning but in some instances a PET scan is not covered by Medicare. This poses the question of what to do? The principles of cancer treatment rely on specific timing of cycles to maximize cell kill, what happens if we are unable to perform staging tests 'on-time' because of the isotope shortage? How will this affect clinical trials who rely heavily on nuclear imaging to determine if new treatments are more benefical than our current standards of care? Will insurance companies pay for a more expensive test if we are physically unable to provide the test that has been approved for use?

In a perfect world, the world-wide shortage of radio-isotopes will remain a non-issue' but I suspect this isn't the case.

Reflections on Marriage and Cancer

This is a guest post by: Dennis Pyritz, RN, BA, BSN, practiced oncology nursing from 1987–2004 and was active in local, national, and international ONS projects during that time. In 2001 he was diagnosed with a rare cancer—t-cell prolymphocytic leukemia (T-PLL), relapsed in 2004, achieved remission again with alemtuzumab and consolidated with an allogenic peripheral blood stem cell transplant. He is currently building an active cancer blogging community at his blog, www.beingcancer.net. The blog was recently featured in Top 50 Cancer Sites & Resources.

This morning I woke up and realized that today was another of those special days by which we mark the miracle of our continued survival from cancer - the 38th anniversary of the marriage of myself and my lovely wife, Tish. More importantly is the fact this is the seventh time that we have been able to celebrate this day since my diagnosis. That I would be writing about this or even being alive to celebrate it in 2009 was not even something that I would have considered or believed during anytime from 2002 to maybe 2006.

So my first thought upon realizing that fact - actually my second thought, my first being a husband's relief at remembering that the day was his anniversary - was a natural one for any blogger - here is reflective fodder for an essay.

The diagnosis and experience of cancer can profoundly impact that primary relationship of cancer victim and spouse. A number of cancer victims have written me and alluded to less than supportive relationships in their cancer struggle. And several have referred to the fact that their marriage did not survive the cancer even though the patient did.

I remember many years ago, working as a nurse on the oncology unit, what seemed then a startling revelation, that daily family life went on despite the medical crisis. I remember a lymphoma patient who had spent a long time in the hospital and had gone through some really tough times. His wife was in the room, the two young children eating ice cream at the nurses station. The hushed sounds of a somewhat heated discussion emanated from his isolation room. Problems with the kids, the frustration and weariness of the wife in dealing with a myriad of domestic crises alone and feeling unsupported. Expectations of my patient that were perhaps unrealistic and yet keenly, uncontrollably felt by his wife.

I have witnessed the bone-tired weariness of spouses. I have seen in a hundred faces the fear that cancer will overtake the spouse, leaving the other alone, unprepared for a future that may extend for decades. This is not what they signed up for ... and yet it is - "for better or for worse, in sickness and in health", words we all recited but, on that joyful day, did not, could not imagine. In the image above a caption "Leukemia victim and caregiver" simply does not fit with the emotional message. But illness can bring out the best and, per some of my email, the worst in us. Illness challenges our notions of the steadiness and the more enduring comforts and grace of marriage, those tender mercies of a loving relationship.

In the joyful photo above of Tish and I, you can easily imagine what we are thinking, and not thinking, in that moment. We are thinking "how lucky I am", "I have never been this happy before", and "we have our whole lives before us". We are thinking about our honeymoon on the beaches of Florida, we are thinking about sexual bliss, we may even be imagining what kind of kids we might have, their sex, what they will look like, what they will become. We may even have stored somewhere the vague image of two older people, sitting in rocking chairs with little grandchildren playing at out feet. We may be wondering what kind of people we may become, what kinds of success we may achieve, what impact we may have together on the world (we are children on the sixties, idealistic baby boomers after all).

But images that do not flow through our minds on that wedding day - sitting at the hospital bedside of the other, listening to wet, struggling breath sounds, holding a hand on fire with fever. We do not imagine crying together with our young adult children. We do not imagine sitting in the quiet clinical sterility of a doctor's exam room, fearfully awaiting news of a biopsy. No, on this magic wedding day, these images are galaxies away.

So here I sit in my study, thirty-seven years later on a warm rainy morning, sharing these thoughts with a community of colleagues and fellow-travelers whom I have never met. When I first read about my disease on a cloudy cold afternoon in December 2001, when I read the words "aggressive and invariably fatal with a median survival of 7.5 months", my life changed forever in an instant, in the millisecond that it took to process the import of those words.

That day was an end of dreams. How many more Christmases, birthdays ... anniversaries might I be granted? For years I would not make plans that extended further than six or so months in the future. My life might end at any time. But, as playwright Sherwood Anderson had proclaimed, my relationships with my children, my mother, my family, my wife would "continue on, seeking their own resolution."

So this day, this June 18th in 2009, is yet one of those myriad days when I take time to count my blessings. I awoke this day almost having forgotten that the years since my diagnosis qualify as nothing less than a miracle. This wedding anniversary of ours is a stellar reminder.

So many special moments. In the year after my first remission we were able to take advantage of a speaking engagement in Norway to wander the ancestral lands of Tish's forebearers, Sweden - a trip that I thought might slip away with the rest of my life's dreams. We have been able to enjoy the promise of two beautiful grandchildren. We have gone on vacations together and witnessed hand-in-hand the weddings of our children (suddenly I have the alternate image of Tish standing alone in formal wedding outfit, clutching flowers, or telling tiny children what their grandfather was like).

We downsized our home, our income, but not our dreams. I have had to redefine myself ... as a relapsed cancer patient, as a nurse struggling to reclaim the ability to practice, as a transplant survivor, then as a half-blind disabled provider ... and with each definition, subtly redefining aspects of the marriage.

But the solidity of that relationship holds fast, like an anchor in a rocking violent sea. It could have floundered. I made mistakes, so did Tish, so do we all. And cancer can put a crushing weight on marriage already challenged by the day-to-day struggles of modern life. So in a way being able to celebrate this 38th anniversary is my second miracle. And being able to write this post solves the perennial dilemma of what to give a wife on this special day.

So darling Tisha, this is my gift to you ... and to you as well, my dear readers.

By Dennis Pyritz, RN, BA, BSN

Should We Be "Facebook Friends?"

I wanted to touch on the article Misuse of Social Networking May Have Ethical Implications for Nurses by Deborah McBride and Eric Cohen in the latest edition of ONS Connect. I remember when Facebook first started out many years ago. I was a sophomore in college at UT Knoxville and I thought the whole concept was quite ridiculous. What was the point to be Facebook friends? Well, then I joined and became addicted to "Facebooking," much like the rest of my friends. After all, you were not officially in a relationship until it was confirmed on Facebook. Now, years later Facebook is among one of the top social networking avenues for people of all ages to stay connected.

The problem with Facebook and probably many other social utilities is that people disclose way too much information about themselves to sometimes unintended audiences. Another problem is that patients are asking nurses and other health care professional to "be friends" on Facebook. I have dealt with this situation first hand and it canbecome very akward if you do not take a stand on this matter and be consistent. A sweet little 8 year leukemia patient befriended me on Facebook. At first I thought, how sweet, she wants to be my friend. But after analyzing the situation, I thought that I did not want patients and their families knowingwhat I am doing or who I am talking to outside of the work environment. If anything, it felt like a lack of privacy. I think it would have been incredibly inappropriate to be friends with patients or family members on Facebook.

Another problem I have seen with the users of Facebook is that so many people use the status update feature of facebook to vent about their boss or work in general. This is completely inappropriate and can cause major problems if certain people, like your boss see this information. I think the main point I have is to be professional. Remember that our personal lives and professional lives should always remain respectful. Facebook is not the place to vent about work or the patients you care for. Facebook is meant to be a social utility to connect people.

What are your thoughts about social networks like Facebook and Twitter? Are you "facebook friends" with your patients?

What's Next? 'Post-Treatment Letdown'

On a regular basis, I try to read the New York Times Health and Wellness section. Earlier this week, Dana Jennings, a reporter for the newspaper and cancer survivor wrote a column that caused me to have an aha! moment. In my clinical practice with lymphoma and leukemia patients, one of the best days for me is on the 10th day post their final cycle of chemotherapy when they come to see me for their final assessment and nadir blood work. I feel deeply satisfied being able to tell patients that their chemotherapy treatment is over, they have responded as we hoped and we will arrange some follow up scans in the upcoming weeks/months and see them back in the clinic to review the results. For me it has always felt like the last day of school sending the kids away for summer vacation with the knowledge that what lies ahead will far exceed anything they've gone through in the past year. The patients however always look at me with great disbelief and say "You mean that's it?" As if I would joke with them about something so important. I don't think I ever really understood what this experience must be like for a patient. Dana Jenning's column has given me much needed insight into this transitional time for patients. Although his diagnosis and treatment differs from those in my practice this is one instance when we can make comparisons between cancer patient populations.

He calls this feeling 'post-treatment letdown' and I think it is an accurate description. We are all creatures of habit and after a cancer diagnosis disrupts the natural rhythm of life we search to find a new normal. For those on treatment, a new normal involves the rules and routines of treatment. He describes the process of coming for treatment as his 'job', a place where he knows everyone's name and has come to learn the idiosyncracies of the environment and cultures from the insider's view. The act of engaging in treatment is 'doing something' rather than the alternative of the uncertainty and the waiting. The end of treatment signals an important transition period for patients and their families. This column has reminded me that as a primary nurse I must pay more attention at ths time to help patients adapt to this new time in their lives.

You can check out Dana Jenning's blog at http://www.nytimes.com/2009/06/30/health/30case.html?_r=1

Nurses as helpers, white cap wearers..........I think not!

http://well.blogs.nytimes.com/2009/07/01/nurses-helpers-angels-or-something-more/

A colleague sent me the above link to read and it infuriated me so I wanted to get some other opinions on it.  Personally I'm getting annoyed with all the negative stereotypes about our profession in the media lately with the addition of the new nurse shows (if they're worthy of being called that).  It's interesting what people think of us until they're in that hospital bed pushing the call button praying that we appear to assist them with any nursing or non-nursing need that they might have.  

What stereotype about nursing bothers you the most?