What Do You Do: ICU Nursing, Hour One

I’m an RN in a 18-bed Med/Surg ICU. Intensive Care units are for the sickest patients in the hospital.  You get sicker than we can handle the only step up is to meet your Maker or have said Maker do a miracle.

This is our Mantra:

We care for people in Septic Shock, with CVAs, DKA, decompensated heart failure, post cardiac arrest, COPD exacerbation, ARDS, drug overdose, and the post-ops of every discipline (except the open hearts who have their own CVICU).  We manage treatment modalities like CRRT (continuous dialysis), hypothermia protocol, and LV assist devices like the Impella and balloon pump. Highly technical and lots of variety, which is what attracted me here.

I originally was going to write about an entire shift in the ICU but found that the first hour of a recent shift gave a decent representation of what we do. Not terribly eventful or comprehensive, just typical. 

Hour One went as follows:

I walk on the unit for the first of my three 12 hours shifts.  Check the board for my two assigned patients, find the nurse who had them for the day and plop down next to her.  Yes, only three shifts, and yes, only two patients.  Trust me, it’s enough.   

The “Day Babe,” as we night shift nurses affectionately call day nurses (do they have a name for us?  The walking dead……) fills me in on each patient: history, hospital course, treatments, status of each body system.  I fill out all the little boxes on my report sheet in an attempt to grasp an entire patient’s health and plan of care in less than five minutes in a way that somehow qualifies me to be responsible for them.  It’s always astounded me how short, random, and unregulated this process is.

Hemodynamic monitors placed around the unit display heart rhythms and vital signs on each patient. They alarm and flash with increasing levels of dismay when something is out of range. This varies from little peeps and flashes for something minor (O2 sat probe is off) to the From Hell noise that awakens your hindbrain to mortal danger (your patient’s heart has stopped beating.) 

Both of my patients have heart rhythms that are compatible with life and no alarms.  Yay. I fill out a quick little schedule for myself for each patient and then go to see the sicker one first.

Patient One:  Small bowel obstruction status post Exploratory Lap, went into respiratory failure on the hospital floor after developing pneumonia. Came up to us to be intubated, diuresed, and get IV antibiotics until the invading organisms are killed to death.  She’s in septic shock on several pressors, Cardizem and heparin drips for AFib, fentanyl for sedation.

I assess her, making the million little observations that tell me if she is really doing as well as the monitor might lead me to believe. Vital signs can be very deceiving, nowhere more than ICU.  Lung/heart/bowel sounds, ET/OG tubes, pupils, hand grips, pulses, skin integrity, IV access.

She’s severely edematous. Her flesh puckers under my finger like that green brick material flowers are arranged in.   I wonder what she does for a living, if she has kids, pets, if she’s married?  Read any good books lately? Details of personal life are UTA (Unable to Assess) when the person is I&S (Intubated and Sedated) and there’s no family around.

I ensure all her drips are running correctly and calibrate the arterial line, which tells me her MAP is 68.  Beautiful. Only as much Levophed as she needs, no necrotic fingers and toes for her. She looks good. Stable-ly unstable, we call them, when their vitals are normalized on medicated drips.

Patient Two:  Older gentlemen, VFib arrest, visited the Cath lab for a variety of stents then hypothermia protocol.   He’s past all that now and has just been extubated.  The day nurse told me he looked good respiratory-wise.  I don’t agree. 

He’s tachypnic taking shallow breaths. Weak cough that isn’t getting the job done.  He’ll be reintubated within 12 hours if he keeps this up.  I call my friends in Respiratory Therapy for ENT suction.  It helps, but he HATES it. He asks me why I like to torture him.  I tell him that I don’t, that I’m trying to get him better.  He scowls. He’s over it.  I don’t blame him.

The rest of his assessment is WNL, and that’s not “We Never Looked,”  it’s “Within Normal Limits.” Because I looked.   Except…….I can’t help but notice that he doesn’t move his left side as much as his right, and his hand grip on that side is just a tiny bit weaker.  Am I imagining it?  His pupils both react to light but don’t look exactly the same…..and he’s not really answering my questions. He’s probably just being difficult….right?

Come on man, don’t do that.  Let’s not take an emergent trip to CT and do TPA protocol right now.  Fast as I can, track down the NP.  He has a history of right CVA with residual left-sided weakness.  The day nurse didn’t tell me that in report. 

I push some IV hydralazine for his BP of 180/70.  He asks for a beer.  I feel foolish for worrying about him so much a few minutes ago. 

The hydralazine helps for only a few minutes so I chase it with 5mg of metoprolol, pushed over two minutes because I don’t want to stop his heart, just slow it down.  I make peace with the fact that I’m going to be chasing his BP with IV meds all night long.

I set the bed alarm.  Dude’s awake now and I don’t trust him, even as weak as he looks.  You know how 100 lb. moms can lift cars when their kids are in danger?  Elderly patients can do astounding things when the delerium sets in.

Overall a pretty easy ICU assignment.

I leave his room and hear a plea for help from a nurse at the end of the hall.

I know this patient, Heroin OD.  Tattoos everywhere.   When I say everywhere I mean it.  Many of the nurses had speculated about whether or not certain tattoos look differently when certain body parts were in certain anatomical configurations. If you know what I mean.  If you don’t, don’t think about it too much.  

We don’t mean to belittle people or treat them as objects.  We can’t help but think these things.

The nurse called for help because he’s been on tube feeding for over a week and his Dignicare fell out.  You can imagine the consequences.  If you can’t imagine them because you don’t know what a Dignicare is don’t worry about it, innocence being bliss and all.  I help her get things straightened out. She grateful.  I promise to help her with his bath later. He’s a big dude.

Quick stop at the Accudose, grab my meds and waste Versed and Fentanyl for another nurse.  We chat and make fun of the NP who’s working on the other side of the glass, not noticing us.  We’ll tell him about it later.

I give Patient One’s meds after deciding that they’re all safe and appropriate for her.  A few IV pushes, hang an IV antibiotic, crush up the pills, mix them in some water, flush down the OG tube. 

I most definitely never pretend I’m a wizard making a magic healing potion when I do this. That would be childish and I’m a professional.

Her MAP is 64.  Borderline but I’ll ride that out another 10 minutes before titrating her Levophed; you learn after a while not to micromanage your pressors……

Then the monitor starts alarming THAT alarm, the hindbrain one.  Bed 24, and judging from the trace on the monitor it’s legit VTach.  I start to run to the room but two steps in the alarm stops.  Just a run of VT, not sustained, 20 beats or so. 

I grab the rhythm strip that’s printing out and go to the room to give it to the nurse, a friend of mine who just got back from maternity leave.  She turns to me and takes the strip. 

I don’t know this patient.  Septic on CRRT, came in yesterday.

  “She looks like shit, ” my friend says.  She does indeed.

Now that’s not some random or insensitive insult.  It’s a thing we ICU nurses say when we get that vague unsettling feeling in our perceptive gut that even though this patient looks okay on paper or computer screen they’re going to go downhill, soon. And now here she comes with the increasingly-long runs of VT.

“I told them,” she says, shaking her head.  I tell her to let me know if she needs anything, I have my unit phone. 

Then I go get a unit phone and sign into it since I forgot to do it earlier. My manager runs a report every week that tells her when we forget to sign into a phone within five minutes of starting our shift. I’ll get a strongly-worded email.

Check the monitor, Patient One, MAP 72. Hah!  Peek in on Patient Two.  Still in bed.  BP 200/103.  Awesome.  Bust out the IV labetalol.  Take THAT.   Back down to around 180/70. Sigh. NP says to give it a half hour. 

Grab the aide, both patients get repositioned.  Sit down to chart.  Barely get logged on.

Good buddy nurse sticks her head outside the curtain and gives me The Smile. She’s helped me so many times, she knows I’ll do anything for her. Not that I want to go into that patient’s room.  I do not. But we’re nurses, and we do what needs to be done.

I enter the room of the patient who solidified my belief that ultimately ICU nursing is not for me.

Now, I love intensive care.  I love helping someone right in the moment they need it most. I’m good at my job and I love using my head and my heart to do it.  But I can’t stay here.  I’m willing to walk with a patient through difficult and painful treatments to get them better but I didn’t sacrifice my time with my family and go to nursing school to put people through hell for no meaningful recovery.  I have an ethical aversion to a good 40% of what I do at my job now and that percentage only seems to be growing.

Her history is too long to recount.  Her body had lost the ability to heal a long time ago.  Every organ failing, even her skin. Her skin would break under our hands no matter how gently we would move her.

Her BKA stump has been infected for months.  The flavor of this month was Pseudomonas.  The nurse was asking for help changing the dressing. We remove the old dressing to find her stump disintegrating into the telltale light green of raging Pseudomonas infection.  It looked like pea soup.  We were keeping this woman alive so she could turn into pea soup before our eyes.

I couldn’t look at her face anymore.  When I had first taken care of her I had paid very close attention to her face, trying to read her expression for anything I was doing that she found painful since she was nonverbal at baseline after massive stroke.  Eventually I figured out everything we did caused her pain. 

We still warned her of what we were going to do, still apologized.  The family had instructed that no pain medicine be given “because it makes her less interactive with us.”   The family wasn’t even here. Sorry she can’t entertain you like you want because of the tremendous pain she’s in. I try so hard no to judge them as I’m sure they’re are suffering too.  But I fail every time and every time I get angry. 

Ethics consult was “pending.”  Meaningless, we have no teeth, no real influence. If the family says treat, we treat.  What does “treat” even mean, then?  If all we do is…..

I stop myself from going down that mental road, again. It simply isn’t up to me. What is in my power to do for this woman, right now, that will help her?  I can think of nothing but to treat her gently and say a prayer for her relief.

I don’t know if it helped.

Dressing done, I leave the room with ice in my gut and go back to charting.

A few clicks done before Bed 24 alarms again.

VTach, really fast and not stopping this time.  Everybody runs for the room.  I’m first so I go to grab the cart with the Resus meds and Life Pack but it’s not there because my friend with the bad feeling already has it in the room.  She’s been feeling for a pulse while we ran to her.

“No pulse,” she says as I walk in.  I start CPR while she digs out the defibrillator pads.  She puts them on around my hands and starts charging the Life Pack.  “Clear!,“ I back off, she discharges the shock.

(Ahhhhh sorry. I can’t help it, it’s exactly what we’re doing when we shock someone.)

Sinus rhythm restored.

“Maternity leave didn’t slow you down, did it?” I say to her.  She shrugs.  Intensivist walks in and starts barking orders about STAT labs and electrolyte replacements.  “Need something, call me,” I say as I walk out.

Check the monitor.  Patient Two’s BP is 190/90.  *sigh*

All things considered, not a bad hour. My scrubs aren’t covered in anything.  I didn’t get any indecent proposals. Nobody tried that hard to die.

Eleven hours to go.

What Do I Do? High School!!

Ik this was supposed to be a submission thing for people in the medical field but I don’t know how much people appreciate what us high school kids interested in medicine do for the medblr community. We may not know much, but high school students like myself are constantly striving to learn as much as they can about the medical profession through volunteer experience and taking related classes (Anatomy and Physiology, my school even offers IB sports medicine) 

So here’s a bit more about what it means to be a teenager interested in medicine.

High school is a full time job. From what I’ve heard, it’s gotten a lot harder since my parents were kids. I go to school for 7:30 to 2:30 every day, spend 4-5 hours working on homework (If I’m lucky, it’s usually longer) and another couple hours studying for any upcoming tests. On a good day, I get to bed around 11:00

Now, most of you have probably been to high school, but I want to shed some light on my high school experience. From BSing essays to sucking up to teachers

First things first, a little bit about what being in High school means.

It means you’re going to work harder than you’ve ever worked before. You’re going to write essays and red them over after having no idea what they mean. You’re going to skim through classic literature that makes no sense and barely pass english tests because you can’t listen to Holden Caulfield whine for an entire novel. You’re going to drop classes you hate, you’re going to continue to take classes you love.

You’ll torture yourself through pointless graduation requirements and important courses you really should take but don’t want to.  You’ll make lots of new friends, you’ll be sad when they graduate. You’ll discover who you are and what you enjoy through painstaking social trials.

You’ll learn things you’ll remember up until they day you die, and things you’ll forget the second you leave a class. You will get a bad grade, you will pass something you thought you would fail., you will fail something you thought you would pass.

You will kiss the butt of a teacher to get them to bump your grade up, you will get in stupid arguments with stupid teachers who can’t do their jobs. You’ll also meet teachers who you’ll cry for when you leave their class. 

High school is an emotional roller-coaster, forcing your academic life into your social life and ensuring you only get the minimum amount of sleep you require to function. But you’ll have a lot of valuable experiences that’ll help you later on in life. And hey, if you don’t do it, you’re not going to be able to get a job.

Now, how does being interested in medicine affect my high school life? Well aside from affecting the classes I take, (ex. AP bio instead of AP World History) it affects how a lot of people see me.

To start, my teachers…

When you tell your teachers you are interested in medicine, they will use this information against you.

I cannot tell you how many times my math and chemistry teachers have tried to link completely arbitrary things to medicine. Some stuff could be useful, but I’m literally a child, I don’t need to be psyched out about not getting in to medical school because I suck at thermodynamics.

Second,

extracurriculars

In high school, there is a huge emphasis on extracurricular activities. Not only because the more you have, the better it looks on college apps, but also, if you play a lot of sports, you’re automatically super cool. Also, that’s where all the school’s extracurricular funding goes. Sports is all anyone cares about in high school. Your interest in the intellectual world of medicine is nothing compared to sweaty boys throwing lemon shaped pig-skin at each other. So if you’re not a sports person, and you’d rather do science or music like me, you’re essentially screwed. 

Also, friends

Because I run a pre-med club at my school, I’ve met a lot of people with similar interests. It’s always fun to talk about your interest in medicine with someone who shares that passion. I’ve made lots of friends I may have never talked to otherwise through a common interest in medicine. It’s lovely to have people to hang out with who are as enthusiastic as I am, and I’m lucky my friends who aren’t in to medicine are so patient with me when I break out the science guns.

On that topic, I do get asked for medical advice by a lot of my friends. “Medical-af, this cough I’ve had for a week isn’t going away! Am I dying?”

There always comes times where I have to remind people I really don’ know enough to diagnose your problems and I am nowhere near having that capability. I say, “talk to me when I graduate medical school.”

I know I have a lot to do and learn before I become a doctor, but I’m up for a volunteer internship at a local hospital, I’m training to be an EMR, and I’m taking classes that will help me as a pre-med in college, so I’m gaining all the experience I can while I’m at this tender age. 

I may not bring much experience or information to the medblr community and the wonderful staff here at PMTH, but I do what I can, sharing my journey with everyone, taking things one step at a time. 

Keep your “What Do I Do’s” Coming!

Up tomorrow: Pre-premedding in high school from @medical-af!

Ah, thems was the days. Things seemed so hard in high school. We had no idea back then what it was going to be like pushing forward. Enjoy, my little premedlings!

~Dean Wayfaring

What is occupational therapy? (Part 2)

So, as we talked about last time, occupational therapy is a therapy focused on the specific aspects of what makes you, you—and we call those your “occupations”, the things you find important and spend your time doing.

When you come into occupational therapy with an impairment of some sort, OTs will take that and come up with a two-pronged approach to therapy:

First, we get an immediate, short-term solution to the problem. This is a modification, an adaptation. Second, we start figuring out how the patient can work, learn, or exercise in different ways to strengthen, stretch, or otherwise adapt their body to be able to do the thing they want to do long-term.

When one of my professors (an OT) was very young, she decided she wanted to be a physical therapist. Her mom wanted to encourage her, so she set her up with a volunteering gig at a local therapy place. Her job as a volunteer was to wheel elderly people in from the waiting room to their therapy, then wheel them back out. As she wheeled in one particular lady, who was recovering from a stroke, the physical therapist asked, “How are you doing today, Mrs. Smith?” Mrs. Smith admitted she was not doing very well. The PT responded something like “Well, no pain, no gain, right?” and continued on about therapy as usual. (Most PTs aren’t like that, hopefully!)

After the PT session was over, the volunteer was supposed to wheel her to OT which was just down the hall. When the occupational therapist asked, “How are you?” Mrs. Smith responded the same way. The OT stopped and pressed her for more information. Eventually Mrs. Smith reluctantly disclosed that she had been unable to put her bra on in order to leave the house, and she was embarrassed and upset at having to ask her husband for help with such a simple thing. The OT immediately reformulated the structure of her entire therapy session. First, they re-fitted her bra with Velcro in the front and adjusted it and practiced until Mrs. Smith could put it on herself. Then they began to address the issues of her limited shoulder mobility. There was a lot of work yet to do, but Mrs. Smith was wheeled out of the office with a smile because they had addressed what was specifically important to her.

So what do you do if the patient’s preferred occupation—their own personal goal, the thing they want to spend time doing—doesn’t have direct therapeutic value for addressing their impairment? That’s where artistic media can sometimes be brought in, like I mentioned briefly in part 1.

Let’s imagine an elderly woman who more or less goes around chatting with people at her assisted living facility all day long—all she wants to do is chat. But, since she’s having difficulty using her fingers for fine movements (like dressing herself, brushing her teeth, feeding herself), we want to do occupational therapy for strengthening her fingers. Sure, we could force her to do a boring activity that she doesn’t connect with: squeeze on a stress ball for 10 reps, practice picking up small items over and over again…or, we could incorporate an activity here. Have her make a pot out of clay that she has to pinch and shape. Have her make a mosaic by pressing tiles into air-dry clay. And while she’s doing that activity, she can chat, and when the project is done, she has something to tell other people about and show off!

Creative media are so useful when it comes to getting people engaged. Mr. Jones is a grumpy retired veteran who tends to be labeled noncompliant: you’ll get so much better results if you teach him how to make a leather wallet than if you try to force him to pick marbles out of some putty. Bobby is a little boy with Down syndrome who has a single mom and multiple siblings: get him interested in a therapeutic game on his iPad, and he’ll be much more likely to do therapy in his free time than if you prescribed an intervention that required hours of uninterrupted one-on-one time with his mom. Mrs. Miller has high anxiety about regaining full use of her arm: show her a soothing, repetitive craft like knitting or crocheting that will strengthen her hand and also help calm her down. Seriously, the possibilities are endless.

So hopefully you understand a little more about how OT is unique. It fits into every practice setting: there’s OT for acute care, home health, nursing homes, outpatient clinics, schools, pediatrics, geriatrics, and everything in between. I personally want to be a pediatric OT and work with children with special needs, which looks like gaining as much independence as possible for that child’s particular challenges: can they learn to feed themselves? Dress themselves? Communicate with an iPad? Maybe they can learn to walk with a walker; maybe they can learn to walk independently; maybe they can learn to use a wheelchair, maybe they can control the wheelchair with the movement of their eyes. How independent can this child possibly be? How empowered can we possibly get him/her?

It’s a fantastic profession, despite being little-known. If you’re interested in a medical profession, but you have no idea which one, consider occupational therapy when you’re making your decision! If you’re a medical provider already, hopefully this may give you some ideas of the use of prescribing OT for people. In many places, it’s considered an “emerging practice” and we’re trying to spread the word about how important OT can be, so keep an eye out at wherever you work or see how you can help drum up support for including OT in your profession!

What do you do? Occupational Therapy! (Part 1)

Hi everybody! Occupational therapy first year second year student here to answer the question, “So, what is occupational therapy exactly?”

Many people in the medical field may have heard the name or have some vague concept about what occupational therapy (commonly abbreviated OT) is, but others may have not, and certainly there are a large number of people not in the medical field who have no idea what this is. In fact, it’s probably easier for me to start by explaining what OT is not:

Okay, so those are probably the most common misconceptions about what occupational therapy is not. So we’re back to our original question, what is occupational therapy? That’s a good question, and in fact, the American Occupational Therapy Association is currently in talks to agree upon a simple definition encompassing exactly what we do, which will be announced at the 100th Birthday of OT happening in 2017. 

In the meantime, we’re having to get by with our own simple definitions, and here’s mine:

Occupational therapy is therapy that focuses on an individual’s ability to enjoy life the way they want to as a measure of success.

That means that, for an occupational therapist, the most important measure of whether they are succeeding in providing therapy is whether or not their patient is able to participate in the things they want to do. Right now, if you’re in the medical field (or even if you’re not), you might be scratching your head and saying “uh, isn’t that what every medical provider wants?” And the answer is, yes and no. 

So let me break this down a little further.

The reason the name “occupational therapy” confuses people (see: not career counseling) is because in our society, our “occupation” specifically means our job. But in occupational therapy, an occupation is defined as any meaningful activity that a person does to occupy their time. Under this definition, your job is definitely still your occupation, but so is being a parent, going to school, playing with your pet, engaging in your hobbies, participating in leisure activities, and so on. 

It encompasses all the roles in your life (employee, parent, sibling, student, child, friend, volunteer). And, here’s the most important part: your occupations are totally different than somebody else’s occupations. You may be the same age, live in the same area, and have the same diagnosis as someone else, but your therapy will be totally different because it’s going to focus on the crucial aspects of what make you, you!

This is not at all to say that other medical professions don’t care about you as a person, or that they don’t know how to adjust their tactics to fit their patient’s personal needs. Not at all! Good medical professionals in every field will have elements of this holistic viewpoint in their practice. But at the end of the day, if a surgeon has a guy open on his operating table, it doesn’t matter whether this guy uses his knee to play basketball, to perform martial arts, or to dance at the grocery store and embarrass his kids; all that matters is that the surgeon needs to replace the knee. (Cue kneeologists correcting me in the comments.) 

But when the guy is recovering from surgery and learning how to do things again, his occupational therapist will be the one taking that into consideration.

We’ll look more at how OTs do that in Part 2 of this series!

Have you missed us?

Unfortunately Dean @wayfaringmd and the Deans Emeritus @cranquis and @morebaffledlessbrooklyn have been busy doing real-life things like working and sleeping. But PMTH is not gone! 

PMTH is a group effort, guys! Submissions are always appreciated! 

We’ll be starting a new series tomorrow called What Do You Do?

If you work in healthcare or are training to work in healthcare--in any capacity--and you wish people appreciated your job more, send us a submission telling us all about your job and how cool it is! Spread the word about your job and maybe you’ll inspire someone to be just like you!

Stay tuned for a 2 part post from @kylermartyn starting tomorrow!

Dear Sir or Madam: In recent months we have noticed that some Princeton-Plainsboro patients are declining to be treated at PPTH and instead coming to your facility. Our patients have informed us that you are advertising unproven alternative medicine therapies and poaching patients from us. We cannot tell you how to run your business, but we wish you to know for your own protection that PPTH has friends in the Princeton Department of Health who can be called upon to inspect and investigate those who stand in our way. Our CEO is a personal friend of the state governor so you should not expect any relief from that quarter. Today our town has two hospitals with empty beds and physicians to pay. This cannot continue indefinitely. We were here first, and we will be here last. We are Princeton-Plainsboro and we are defending our hometown and our livelihoods. Our patients need real evidence-based medicine, and you will get out of the way or you will be crushed. Our earlier offer of merger and acquisition shall remain generously unchanged in case you decide to accept reality. Sincerely, Greg House MD Chairman and CMO, Princeton-Plainsboro Teaching Hospital

Reply from the PMTH Board of Directors: 

Oh yeah? Well... we’re rubber and you’re glue! What you say bounces off us and sticks to you!

Also...  

PMTH’s new Bruncheopathy Department

Princeton-Medbloro Teaching Hospital proudly announces the opening of it’s new Bruncheopathy department. The launch of the new department, nicknamed “the Brunch,” was spearheaded by medical student ermedicine. “I just felt like it was time to teach the world—and my fellow med students—about the therapeutic nature of brunch,” ermedicine stated at the groundbreaking ceremony.

“This project grew out of my summer research on the effects of fancy breakfast food on medical student burnout,” he added, “which showed that difficult-to-cook egg dishes and morning consumption of moderate amounts of alcohol had significant positive effects on medical student well-being. We hope that phases 2 and 3 of the project will yield similar results for residents and attending physicians.” 

With the expansion of the bruncheopathy research, the department is now in search of two medical students, a resident, and an attending physician who would be willing to donate some of their valuable time for the cause of emotional and gustatory invigoration. Apply in the Submissions box. 

The new department’s construction has been funded by grants from Simply Orange and Moët, and from a very generous donation from the Butterworth family, proprietors of the local restaurant Hugs ’n’ Quiches. The wing, located adjacent to the endoscopy suite, will include a small bistro featuring teppanyaki-style grill tables where diners can enjoy watching PMTH cafeteria “chefs” cook their eggs Benedict and french toast before their very eyes.

Given the relative novelty of the bruncheopathy specialty and PMTH’s limited funding at this time, The Brunch will open with limited hours initially. “We’re starting with traditional brunch hours of 10am to 1pm, Friday - Sunday, but we hope to open up daily if our study data from next quarter look promising,” ermedicine adds.

The Most Invasive Therapy: Diet Change

Surgeons like to boast that they have the most invasive therapies to change a patient’s life, but what they don’t realize is that surgery is a one-day thing. Most people retain all of their social support and internalized coping skills after surgery. No, if you really want to rock someone’s world, change their diet. And not for a couple weeks as prep for a test.

Change it FOREVER. 

Food allergies are on the rise, though the good ol’ standby allergies of cow’s milk, eggs, nuts, shellfish, corn and soy still hold about 85% of the “problem food” market in the united states. There’s no cure for food allergy either- the only treatment is avoidance. As a bonus, some environemental allergies are cross reactive with food reactions. A person with say, a birch pollen allergy would be reasonably expected to have some food allergy symptoms when consuming carrots, celery, and apples.

The whole IgE mediated allergy component doesn’t even touch on sensitivities, which may occur by non-IgE mechanisms like IgG and IgA. The symptoms of food sensitivities are essentially anything.

Weird rash? Change their diet. Toe hurts? Change their diet. Ear infections? Definitely CHANGE THEIR DIET!

Got someone who needs to see test results before they let you eviscerate their eating habits? There’s an IgG and IgA serum test  but the gold standard for diagnosing food allergy or sensitivity remains The Elimination Diet, aka the Diet of Tears. The diet involves eliminating anything that tastes good for about 4-6 weeks, and then each food that was eliminated  is added back in individually. That means if your patient took out wheat, eggs, sugar, and dairy, you can’t start off with adding back a donut, which contains all of those things. The patient would start off with one of those things, like an egg, for 3-5 days. Then you can try adding something else back in. It’ll take them months to get back to eating a donut. (At PMTH’s cafeteria, they can eat my newly introduced Donut Substitute, featuring spirulina and flax seeds, while they learn about their dietary intolerances!) 

The elimination diet is the perfect way to demoralize. It’s a long list of things people shouldn’t eat. 

Once the patient starts removing foods from their diet, they may notice that they’ve become That Person at parties. You know, the gluten free soy free vanilla latte with stevia person that won’t stop talking about how good they feel and how much weight they’ve lost since they eliminated about a hundred weird food combinations.  Then the party invitations will stop coming, as their previous friends can’t cope with their ever evolving dietary needs. Your patient will stop going out to eat, unless they’ve got great access to an autoimmune paleo-type restaurant, and then they’ll start instagramming their homemade food, #Whole30. Once they fully embrace the conversion, they will make new friends, start a paleo pinterest board, and start running “for fun." 

They may also experience a complete resolution of whatever symptom initially brought them in. Remember, almost any symptom justifies the use of this therapy, but not all patients can handle it! Eliminate responsibly, and keep a box of tissues in the office on days you anticipate explaining the elimination diet.

PMTH Welcomes our Newest Attending

descantforhope!

PMTH welcomes Dr. Descant as head of PMTH’s new Clinical Herbology department. Dr. Descant primarily did her training at the very prestigious Fruits & Nuts Institute in rural Oregon, though she did several clinical rotations as a student here at PMTH!

She will be available for consults on inpatients and outpatients starting August 15. Her office is located adjacent to Labor & Delivery...well, you’ll find it...just follow the aromatherapy smells. 

Message from Dr. Descant: Effective immediately, the hospital snack bar soda fountain will now carry health tonics and feel-better herbal teas. Poultices and salves will be available for purchase in the hospital pharmacy starting September 1. 

Rotation Feedback

Your name: mashupofmylife Rotation Title: hyperbaric chamber clinic Rotation Supervising Attending Name: Ariel the Little Mermaid

Feedback on Rotation Attending’s teaching methods: use of songs as teaching aides—excellent. doesn’t always have the right word for medical instruments and resorts to calling them thingamajigs–can be confusing at times. 

Feedback on Quality of Bathrooms and Snacks on Rotation: so are we actually supposed to pee in the water or not? no one ever did tell me where the actual bathroom was. suspicious lack of goldfish crackers. food that is not waterlogged would be awesome.

Complaints, Gripes, or Love Notes for Residents on Rotation: having a resident who only had fins made some procedures….interesting, to say the least.

Suggestions for Improving the rotation for future students and residents: issuing a drysuit would be nice. or, you know, just letting us know that you’re not joking when you start to talk about underwater medicine.