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Research: Anesthesia causes jet-lag

A press release from the University of Aickland dated April 17th, 2012 described a recent study done there that linked anesthesia to a feeling of jet-lag following surgery.

The researcher, Dr. Guy Warman, noted,  “Our work shows that general anesthesia effectivly shifts you to a different time zone, producing chemically-induced jet-lag.  It provides scientific explanation for why people wake up from surgery feel as though very little time has passed.”

Dr. Warman goes on to state, “It’s been known for sometime that after anesthesia, people’s biological clocks are disrupted and this can compromise their sleep pattern and mood as well as wound healing and immune function.”

This interesting work was done on honey bees which are known to have a keen sense of time.

Click here to read the original press release

CRNA Wellness: Wake-up call

My humorous Native American name for my younger daughter was Face In The Soup.    When she was tired, SHE WAS TIRED, and by the 6:00 p.m. dinner hour, her face went down on the table and it didn’t come up.  As a young mother, I learned quickly to make sure she had received all of life’s necessities before OUR dinner time because no matter what happened in my own life, at 6:00 p.m. her curtain was going down.  If she were now an anesthetist on the job, her adopted name could be Dies on the Table or Puts Patients at Risk.

Chuck Biddle, CRNA, PhD, chief editor of the AANA Journal and multi-published author of sleep deprivation articles, quotes another anesthesia industry sleep expert, June J. Pilcher, when he reports that:  Fatigue caused by lack of adequate sleep results in diminished cognitive function, impaired vigilance, decay in problem-solving ability, degradation in memory, and eroded motivation.
Click here to read the article.

Okay, so I can’t tell you anything that will make the surgeon close that thoracic cavity in time for you to be eating dinner by 6:00, or to watch Dancing With The Stars, or to shower off the sounds, smells and stress from the OR and still drop into bed by 10:00.  But I can give you some simple fitness suggestions for making sleep more useful when your head makes contact with the pillow-top.  People who are fit and healthy sleep better than those who aren’t.  Simple.  True.

Physical exercise is way at the top of ways in which to elevate energy but tire the body in such a manner as to make sleep deeper and easier.  Although it is a personal choice as to what time of day you should do your cardio or tote that bail, you can figure it out in just a few morning or evening trips to the gym, or on the elliptical in front of your Netflix pick.  Morning cardio elevates your metabolism and your heart rate which energizes you for the better part of the day but fatigues you in a pleasant way by or before gall bladder number six.  Doing your cardio before bed does the same thing to metabolism and heart rate so you probably want to take a bit of down time between cardio and vespers.  Some of you may prefer to do a lunchtime cardio on the days it’s possible, a great substitute for pop ‘n pizza.  Try to create some routine so that your body says, “It’s time to cardio; it’s time to eat; it’s time to don the scrubs; it’s time to let down; it’s time to sleep.”

Stretching and crunching before bed is another great way to relax and create routine before the sandman comes.  Tom S. Davis, CRNA,  MAE, likes to say, “Every day that I don’t make time to stretch is one day closer to the day I won’t be able to.”  If you don’t have a designated work-out area at home, keep a Pilates mat, a towel and a 55cm fitball (inflatable stability ball) in your bedroom so that it’s easily available every evening.  Do various crunches that access all areas of the abs followed by a thorough five-minute stretch routine that leaves you feeling loose, relaxed and calm.  Wind down by finishing your toilette routine.  Then crawl in and let go.

Eat dinner right before bed…and you’ll sleep poorly.  Drink coffee right before bed…and you’ll have to interrupt your sleep to offload.  Consume alcohol in excess…and reflux, insomnia and restless sleep will be your companions.  Wear a belly to bed that looks like an eminent delivery, and you’ll wake yourself up with your own snores, not to mention that you’ll be sleeping alone. In short, what you put in your body all day is the very same thing you’ll put into bed that night and your sleep will thrive or dive because of it. Lower the bad fat in your diet, especially lower the sugar, decrease the volume of intake and put down the fork, fingers or chopsticks between every few bites.  Intentional eating of reasonable kinds and amounts of food are your fitness friend, and quality sleep will become a close relative.

Finally, stay away from negative news, time-consuming e-mails, family complaints and anything else that puts your head in a quandry and reduces your tranquility.  Say, “Good-night,” to your honey, calmly go through your affirmations, prayers or meditation minutes and put out your lights.  Six hours, seven hours, preferably eight hours later, your fit, healthy Self will be refreshed and ready to take your life back. Then go pop into the OR bright-eyed and bushy-tailed and clip on your nametag:   Saves The Lives of Others.

Other Tips
Take a power nap during your break.
Don’t stop for restaurant food on the way home.
Don’t drink alcohol.
Avoid drugs and sleep aides.
Get extra sleep BEFORE call.
Avoid arguments.
Split your cardio into morning and evening.
Eat very lightly if it’s late.
Read relaxing lit.
Do Yoga.
Meditate.
Say, “Good-night, Gracie!”

You can visit Liz during your waking hours at www.bdyfrm.com.  Read the motivational, entertaining Lizlines Monday through Friday and watch for her original Lizlimerick once a week.   Ms Liz

Fitnotes
Chuck Biddle, CRNA, PhD, is a professor and staff anesthetist at Virginia
Commonwealth University, Richmond, Virginia. He is editor in chief of the AANA Journal. Email: cbiddle@hsc.vcu.edu.
Tom Davis, CRNA, MAE is chief nurse anesthetist at Scott and White Medical Center, Temple, Tx and former assistant professor of nurse anesthesia at University of Kansas.  He is the owner of and consultant for Procrna.com.  Email:  tom@swcrna.com

Clinical Topic: Patient Safety, The Helsinki Declaration

The European Board of and Society of Anesthesiology have adopted the Helsinki Declaration for Patient Safety in Anesthesia and have made recommendations for standards that further improve patient safety.

The authors state that patient safety has 3 components; a set of guiding principles, a body of knowledge and a collection of tools.  The basic principles are the tendency for things to go wrong is both natural and normal, rather than an opportunity to find someone to blame; safety can be improved by analyzing errors and critical incidents, rather than pretending they have not happened; and humans, machines and equipment are all part of a system, the component parts of which interact to make the system safe or unsafe.

The following Abstract was printed in the European Journal of Anesthesiology:

Anaesthesiology, which includes anaesthesia, perioperative care, intensive care medicine, pain therapy and emergency medicine, has always participated in systematic attempts to improve patient safety. Anaesthesiologists have a unique, cross-specialty opportunity to influence the safety and quality of patient care. Past achievements have allowed our specialty a perception that it has become safe, but there should be no room for complacency when there is more to be done. Increasingly older and sicker patients, more complex surgical interventions, more pressure on throughput, new drugs and devices and simple chance all pose hazards in the work of anaesthesiologists. In response to this increasingly difficult and complex working environment, the European Board of Anaesthesiology (EBA), in cooperation with the European Society of Anaesthesiology (ESA), has produced a blueprint for patient safety in anaesthesiology. This document, to be known as the Helsinki Declaration on Patient Safety in Anaesthesiology, was endorsed by these two bodies together with the World Health Organization (WHO), the World Federation of Societies of Anaesthesiologists (WFSA), and the European Patients’ Federation (EPF) at the Euroanaesthesia meeting in Helsinki in June 2010. The Declaration represents a shared European view of that which is worthy, achievable, and needed to improve patient safety in anaesthesiology in 2010. The Declaration recommends practical steps that all anaesthesiologists who are not already using them can successfully include in their own clinical practice. In parallel, EBA and ESA have launched a joint patient safety task-force in order to put these recommendations into practice. It is planned to review this Declaration document regularly.

The original article by Staender et al is a “must read” for all providers who sincerely seek to improve patient safety.  Click here to read the original article.

Return to procrna.com to share your thoughts with your colleagues.

Clinical Forum: Sevoflurane with RSI in Obese Patient

With the growing Obesity epidemic in America, anesthetists are continually facing the risk of induction and intubation with a potentially difficult airway.  Many theories are in the literature about the “best” technique for safe induction of the morbidly obese patient.  Pre-oxygenation is essential and proper positioning increases the odds of successful airway management.

A recent article by Toso et al. published in the European Journal of Anesthesiology (Eur J Anaesthesiol. 2011 Nov;28(11):781-7. described adding a component of inhalation anesthesia to the rapid sequence induction technique for morbidly obese patients.  In this study, the authors positioned and pre-oxygenated patients.   When ready for induction, the researchers turned on Sevoflurane and after 30 seconds of breathing the agent, they followed with a rapid sequence induction using propofol, alfentanil and Succinylcholine.  All patients were easily intubated on the first attempt and there were not occasions of desaturation.

The authors demonstrated that adding Sevoflurane to the RSI sequence provided conditions for a safe and controlled induction of anesthesia.

Click here to read an abstract of the original article.  Return to Procrna.com and share your opinion with your colleagues.

 

CRNA Wellness: Nutrition

Gary, Gary, quite contrary
How does your garden grow?
With onions, tomatoes,
Vine-ripe sweet potatoes,
And lima beans all in a row.

April is the time to plan ‘n’ plant the garden.  The delightful thing about your garden is that it will provide a solitary escape after a 50-hour work week.  Or it will serve as a dual retreat for you and your partner.  And, it’s sure to be a family affair in which everyone can select some favorite veggies to coax and encourage to fruition. When you grow things, you grow, and when you grow, your body heals.

Sweet potatoes are an amazing garden food, big on nutrients and huge on color.  There are lots of varieties but pick one that grows well in your soil.  Beta carotene has enjoyed solid mag’ rap in the last ten years having been praised and criticized nearly equally.  The truth about  sweet potatoes is that in addition to the starch and sugar, the abundance of A, C and beta carotene make every sweet sensation worthwhile.  I recommend that my clients consume at least one serving of a variety of sweet potato each week.  Prepare it clean – bake without butter, boil and peel, microwave in a potato bag and slice, cut into strips and bake as fries.  You don’t need salt, fats, or seasonings of any kind to enhance the flavor of this already sweet, generous source of nutrients.   Click here to learn about Sweet Potato nutrients.

Green beans provide a rich supply of vitamins A and C that do not stick to your ribs or add unwanted calories to your spring plate.  You can plant pole beans or traditional snap beans in a raised garden.  But if you have room for rows and rows of snaps, haricot verts or favas, go ahead and plant the seeds, fertilize, water, watch for worms, harvest and enjoy.  Eat them fresh-steamed next to your grilled tuna, or stir fry them with onions and mushrooms.  Cut and drop raw into veggie soup or snip, steam and eat them with your fingers in front of HGTV.  If you get at this early in the season, you may have time to plant a second crop.   Click here to learn about Green Bean nutrients.

Yellow zucchini is becoming more and more expensive to purchase, so you may as well grow your own and eat the best.  Like sweet potatoes, the vines take up some space but vertical gardening is always a space-saving option.  Packed with vitamin A and plenty of C, this vegan delight is so low in calories that you can eat a bowlful of sunshine several times a week.  Stir fry it, steam it, slice it and grill it with olive oil or flavored Pam, and use the leftover slices on a fresh veggie sandwich.  Watery and lightweight, zucchini begs to be undercooked.  Your lean machine will love both  yellow and green.  Click here to learn about Zucchini nutrients.

Tomatoes are a thing of beauty in your diet and on your table.  By now most guys know the health benefits of lypocene to the prostate, and both genders are continually reminded through research studies of the cancer preventative capacity in a snappy tomato.  There is some proof that cooked tomatoes are a better option than raw but all kinds, sizes and methods of prep are tasty and healthful.  Think A (B) C then go ahead, prepare a big old ground white turkey burger, slap on a thick slice of Beefsteak tomato, put on a layer of avocado and support it all with an unbuttered whole wheat bun and some leafy lettuce…serve steamed broccoli florets as a healthy side, and indulge. You’re a Garden Gourmet!  Click here to learn about tomato nutrients.

Mary, Mary, quite contrary,
How does your garden grow?
With orange, green, yellow, red,
A rainbow in the bed,
With rich vitamins all in a row.

Gardening is an art form that delivers pleasure to every sense. Feel the cool rich earth slipping between your fingers, see the tiny sprouts and watch them flourish, hear the sweet songbirds nearby, then smell and taste the results of your labor.  There is no place on earth like a garden for feeding both mind and body.  This, you understand, because you’re a healer.

Read Liz’s daily column lizlines at www.bdyfrm.com

Chief CRNA: CRNAs as OR Leaders

Across the Nation, Chief CRNAs are probably among the most under utilized group of talented health care providers.  In addition to developing the work schedule and assuring that providers are present to support the posted schedule, Chief CRNAs know the strengths and weaknesses of the staff members and are in a unique position to guide the work flow to optimize patient care.

An original article Written by Sabrina Rodak details why Anesthesia providers are well positioned to guide the work flow in the operating room.  Click here to read the original article.

Three experts on anesthesia services explain why anesthesia providers are best positioned to lead the operating room of a hospital.

1. “The perioperative leader should be an excellent communicator with a deep knowledge of OR management in order to successfully make the necessary changes required in carrying out the hospital’s overall goals. As anesthesiologists are present in the OR every single day, it is important that the anesthesia chair takes on this role to promote consistency across the board through this time of change,” says Leo Penzi, MD, executive vice chair of the department of anesthesia at North Shore University Hospital in Manhasset, N.Y., a member of the board of directors of North American Partners in Anesthesia and assistant professor in the department of anesthesiology at Hofstra North Shore-Long Island Jewish School of Medicine.

2. In a case study presented by Surgical Directions, a hospital recruited anesthesia providers to drive perioperative performance by granting them leadership positions and aligning incentives. The anesthesiologists received financial rewards for increasing patient volume and a stipend for fulfilling certain service standards, including increasing the availability of regional blocks, accommodating add-ons and participating in the OR’s daily huddle, a process in which the OR team discusses issues from recent cases and prepares for the next day’s schedule. Anesthesia leadership was an important element of the hospital’s success in perioperative services.

3. Proper anesthesia leadership in the OR is a key element of integrated delivery of care. Robert Stiefel, MD, a principal with Enhance Healthcare, defines this as “healthcare professionals and supporting facilities working towards one goal: optimized patient care that is more efficient and cost effective.” Integrated care in the OR depends on the coordination of hospital administration, OR staff, surgeons and anesthesiologists. Anesthesia providers’ involvement in all aspects of the OR makes them prime candidates to oversee this coordination. “Anesthesia providers are the most consistent component of the entire perioperative experience,” Dr. Stiefel says.

Chief CRNA: Delivering value

As Anesthetists, delivering quality anesthesia care is foudational to our work.  As Chief CRNAs, we must ensure that developing and delivering value also includes delivering value to our Hospitals / organizations as well as our patients.   The following information was Posted by William Hass, MD, MBA in Anesthesiareviews.    Read the work below or click here to go to the original posting by Dr. Hass.

Developing and delivering value is part of business strategy.  This concept can be used for an entire organization or any of its parts or functions.  Usually the focus of the value proposition is externally toward customers, but a locally owned and operated anesthesia service cannot provide external value unless its support functions are providing internal value to the group.

Support services for a community anesthesia services can be incestuous.  In-laws, family friends, and childhood acquaintances may be providing some or all of its support services including billing, benefits, accounting, and legal services.  These inbred services are quite variable in cost and quality ranging from well-priced high quality services to high priced poorly functioning pseudo-payoffs.  The value proposition of a group’s support service becomes important when there is subsidy request.

Why should a facility pay for your poor management?
Can you produce superior clinical services without adequate support?

This is where anesthesia management companies (“AMCs”) and physician practice management companies (“PPMCs”) have an advantage because they’re supposed to have a well-oiled administrative “engine.” Some do and some do not.

Their management may be centralized, but can provide excellent on-site management?
Can they get the “little things” and the not so “little things” right at a distant site?
Do they understand the culture of the facility from somewhere over the horizon?

Some PPMCs never really get anesthesia billing right because their experience is in other specialties.  (Believe it or not, PPMC anesthesia billing can be significantly better than the billing services provided by the lowest bidder to a facility or multi-facility corporation.)  Diligent review is required when selecting an AMC or PPMC.

There is an important problem.  The progress and development of management service organizations (“MSOs”) are being slowed by nepotism.  While an MSO’s advantages of lowering the overhead costs and expanding services are easy to understand, ending a combined friendship/business relationship with an in-law, family friend, and childhood buddy can be difficult, if not traumatic.  If attention is not paid to the business aspects of its practice, the choices for an anesthesia group may be between amputation (of nepotism) to join an MSO or execution/extinction by an AMC or PPMC.

Survival and success in business requires difficult decisions.  Anesthesia group leaders may need to make hard and unpopular decisions unless they want someone else to be making hard and unpopular decisions for them.

Take Home Points:

Nepotism can slow the development of MSOs
MSOs can lower costs and improve group management
Survival and success in business requires hard decisions
Anesthesia group leaders need to hard and unpopular decisions unless they want someone else to be making hard and unpopular decisions for them

Legal Topic: Documentation

Same Song Different Verse – If It Wasn’t Documented…..

Consider for a moment, that you or a colleague is facing legal action that, on the face of things, appears absurd.  How absurd? Well, think for a moment about the first time that you learned how to place an intravenous (IV) line.  The first thing that you were taught to do (after determining the correct patient, catheter size, and limb selection) was – clean the site.  Traditionally we used alcohol either provided in an IV start kit or provided by our facility.  How many of us thought about, or consulted the relevant science, regarding which preparation solution was actually better for patient care?

Now lets take it up notch. Consider what you do as an anesthesia provider when you are preparing to place an epidural catheter or a subarachnoid block.  Most of the kits that we used in school and current practice have supplied within them a skin cleansing preparation.  According to one manufacturer, B. Braun (bbraunusa.com/images/bbraun_usa/bbrauncatalog.pdf; F3), the supplied cleaning preparation in standard single dose epidural trays is povidone iodine.  Again, how many of us question the skin preparation solution provided in a kit by a manufacturer that our facility has chosen to select for us?  Relevant science indicates that a better skin preparation solution for neuraxial blocks is chlorhexidine.  Furthermore, this solution is optimal when used from a single use package, instead of poured from a multi-use container.

What is the importance of such minutiae?  Well, suppose a post-partum patient presented to the ER 4 days after discharge from the mother-baby unit of Smallville Community Hospital with the following symptoms: low grade fever, back ache, intermittent weakness of the right lower extremity.  During her ER workup, the on call anesthesiologist, Dr. Nurves, is consulted since the patient had an epidural for labor analgesia.  After his physical exam, Dr. Nurves suspects the patient has an epidural abscess.  He orders an MRI that confirms his suspicions.  Now fast forward 18 months.  The patient decides to file a claim against her anesthesia providers for causing the pain and disability from which she now suffers.  She suspects her current problems are from the epidural abscess…….

When an attorney is tasked to evaluate this type of claim, the attorney will seek a healthcare professional who is familiar with the standards of care surrounding the activities related the client’s labor epidural for analgesia.  Imagine the professional conundrum provided by the following clause on the anesthesia record “Sterile prep and drape” without further elaboration.  Would it make any difference if we added another detail: the epidural was placed by a trainee (either physician or nurse) and the use of the trainee was NOT noted on the anesthesia record.  Additionally, the patient, and her spouse, recalls multiple attempts at placing the epidural; this is also not noted on the chart.  So how does one determine if standards of customary practice were met in such a situation?  The use of the trainee, and the multiple attempts at placing the epidural catheter are not documented in the records.  These items are not facts in evidence.  It is a fact however, that if cultures are obtained from an epidural abscess with bacterium that are not normally found in the epidural space, AND the patient’s physical exam prior to the placement of the epidural does not specifically indicate a bacterial infection in the area where the epidural catheter was to be placed AND (perhaps most importantly to us) the modality for transmission of bacterium into the epidural space is under the exclusive control of the anesthesia provider, then supporting data can be introduced to create a scenario whereby the anesthesia providers who placed the epidural catheter caused the epidural abscess AND the related sequela.  What type of supporting data?  Standards of care regarding neuraxial blockade; sterile skin preparation; and care documentation.  Documents of professional standards, along with several peer- reviewed clinical reports regarding sterile skin preparation are readily available in any medical library (electronic or traditional) or via the world wide web.

A well researched review providing the who, what, when, where, and why of how we are supposed to practice our craft can speak volumes to a trier of fact (a judge or a jury) as to whether or not a patient’s claim has merit.  So what is the take home message: Know and adhere to your professional standards of care (review them if necessary) and keep up with the state of your science.

Pamela Chambers, MSN, CRNA, EJD
www.lexterraeconsulting.com

References
Barash, P.G., Cullen, B.F., & Stoelting, R.K. Clinical Anesthesia 3rd Ed.  Ch 26 Epidual and Spinal Anesthesia p 651 Lippincott Raven, New York 1997

Birnbach D.J. et al, Povidone Iodine and skin disinfection before initiation of epidural anesthesia. Anesthesiology. 1998; 88:668-672

Nagelhout, J. J., Zaglaniczny, K.L. Nurse Anesthesia 3rd Ed. Ch 44 Obstetric Anesthesia p 1066     Elsevier Saunders, St. Louis 2005

Stoelting, R. K., Miller, R.D. Basics of Anesthesia 3rd Ed., Ch. 12  Spinal and Epidural Anesthesia p 173, Churchill Livingstone, New York. 1994

Pamela Chambers, MSN, CRNA, EJD
www.lexterraeconsulting.com

CRNA Fitness: Decompress the stress

PROCRNA asked me to mount the March podium on the issue of stress-reduction which would be nearly laughable…except for the fact that I have so much personal experience. So here it is, the Body Firm method to decompress the stress.

Where do most of my clients turn for comfort during or after a tough day with the head, hands or heart?  Why, food, of course.  The number one method of coping with pretty much anything these days is comfort food or drink.  Some of you will turn to the box of goodies in the lounge, some of you will opt to ingest a 16-ounce cola, and some (more of you than would like to admit it) will eat two or three doughnuts pretending it’s breakfast.  But be careful of calorie-dense stress relievers.  Sugar elevates your mood very briefly before acting as the downer it really is, dropping you as fast as a plumb line, and leaving unwanted calories and irritation behind.  And in the long run, useless food  raises your stress. Instead, munch on an orange, or snack on a handful of almonds, or both.  An orange will administer quick sugar, it’s true, but it’s loaded with vitamin C and will provide nutrients along with energy.  Nuts are a great source of protein that can hold you over until a real meal or simply sustain you through another case.  Try walnuts or pecans, too, and limit your serving to a clean, even dozen.  The crunch of the munch is very satisfying and brings fast relief.

You may be tempted to just flop on the decrepit sofa in the lounge when someone relieves you in the OR, not always a bad idea.  But even better:  Walk the hallway, stop to do squats every 12 strides, stretch your calves and quads and stretch your arms above your head, jog down the stairs to 2nd floor and jog up the stairs to 4th.  Pause to do a couple of Yoga positions and bring your heart rate back to normal, then re-enter your case room with mental peace restored.

Dr. Coyote howled, Dr. Hound bit, Dr. Wolf snarled throughout the last heart case and, quite possibly, the patient’s heart is now doing better than yours.  Instead of chatting it up with staff and cohorts when you exit the room, pull out a good read.  Weird Sisters is a current hoot for chicks, and author, Olen Steinauer can capture either gender’s attention in short order.  Try reading the daily “funnies” for comic and cardiac relief, or read anything cheerful that will take your mind off the present and help restore your equilibrium and your gift for humor.  LOL.

You may not be in charge of selecting music for the gall bladder room.  Pink Floyd or
George Strait may be the surgeon’s consistent choice of genre, but when you get to choose, or when you go on a break, listen to music that relieves tension.  Relax with alternative sounds like waterfalls or crashing waves from a Narada collection.  Classical melody from Smetana’s “The Moldau” or Debussy’s “Daphnis and Chloe,” and even big Wagnerian themes from “Tannheuser” or “Lohengrin” can fill your soul and remove the excess tension.  Schubert piano solos or symphonies, unrestrained strains from LAGQ,  Chis Botti love tunes on the trumpet or any of the music you simply know and love can take off the edge, and pull you back from it.  Massage your hands and feet while you listen to music and get maximum de-fusing.

Finally, here’s one of the best stress-busters known to Venus or Mars – Meditation.  You’ll need a quiet corner for this activity unless you’re an excellent self-hynotic.  Close your eyes and preferably a door, get seated and settled with good core support, then start with slow, deep breaths in through the nose, out over the lips, switching to all nose breathing when you’re fully “centered.”  Tune out any and all distractions and focus on the breath (Toothpaste trumps garlic!); in…and out….in ….and out…”…he loves me….he loves me not….one for you…one for me…”  Relaxation is in the focus and in the rhythm.

K, I hate to wake you up, but there you have it – Body Firm’s favorite decompression session.  An anesthetist has almost no time to relax during the workday.  Morning break is not a given.  Lunch can be 11:00 or 2:00 or not at all. The comfort and outcome of the patient will always be your ultimate concern.  But put your own health next in line and treat your stress with safe, un-medicated relief.  Your patient will benefit, and it may keep you from becoming one.

Visit Liz online at www.bdyfrm.com  Read daily Lizlines and leave a stress-free comment!

Chief CRNA: OR Efficiency

The following information was provided by Jay Horowitz, candidate for AANA Region 7 director.  With the current budget restraints and emphasis on efficiency, Jay has documented the inherent inefficiency of staffing ratios  and the cost to the system.  Read Jay’s comments, link to the supporting articles and return to procrna.com and offer your comments.

From Jay: This week an article appears in “Anesthesiology, The Journal of the American Society of Anesthesiologists, Inc.” (!!): Supervision Ratios that gets to the heart of the inefficiencies, waste and fraud inherent in “supervision” and “medical direction” models of anesthesia delivery. With an average 22 minute delay in multiple operating rooms several times a day, and an average Medicare reimbursement rate of $1.43/minute X 250 working days a year X 1000’s of US operating rooms, the money adds up awfully fast! So do the savings with greater CRNA utilization models validated in the recent Health Affairs and Nursing Economics articles with NO compromise in quality of care.  Click here to read the ASA article.

I’ve been writing about these inefficiencies for some time now: Streamlining Anesthesia Care and how we might rationally fix the problem. We need to make sure that this kind of information is available to every state and national decision maker and other stakeholders.   Click here to read an article from the Herald Tribune.

Read, enjoy, and return to make a comment

 

Topic: Continuous Capnography Linked to Lower Monitoring Costs

In the age of Health Care Reform where we are all being tasked with providing more care for less money, simple ways to save are gaining popularity.  In an article published in Anesthesiology News, Dana Hawkins-Simons discusses the use of capnography in the Intensive Care Unit to save money.  In the article, she refers to an study by Courtney Rowan, MD who compared to total number of blood gas measurements done before and after the ICU began using continuous capnography on all patients.

The study showed that after beginning the policy of capnography measurement on all patients, the number of blood gas tests dropped from an average of 21.6 per patient to only 13.8.  This reduction in testing resulted in a savings of $985,130.  It was speculated that there could have also been savings due to a reduced requirement to transfuse blood in the smallest of patients where frequent drawing of blood for samples resulted in a lowered Hemoglobin level.

Click here to read the article in Anesthesiology News and return to PROCRNA.COM to make a comment and share your opinion.

CRNA Fitness: What goes Up, Must Come Down

What goes up when the rain comes down?  Answer:  Your weight.  If you thought the correct answer was “an umbrella,” then you probably heard it from your kids or grandkids.  March does bring rain, but even more than moisture, March brings a change of seasons.  And as the season changes, so do your fitness opportunities.

If you have been walking on a row of treadmills all winter, hiking virtual trails while listening to gym-girl Greta’s visions of grandeur, aka gossip, on the machine next to yours, you’re more than ready to hit the pavement, wet or dry.  Asphalt streets, dirt trails, and school tracks exist in nearly every community and only really nasty weather should send you back to Greta.  Fitness experts often claim that outdoor cardio actually burns calories faster just because of the elements of wind, breathing outdoor air, and dealing with natural changes in elevation.  Yes, on Lion days, you can go back inside and adjust your treadmill to outdoor standards, but it would be a shame to miss watching that Bartlett pear tree on the corner of Magnolia and Vine go through its spring metamorphosis. Don’t forget to take drinking water.

 Bands work-outs are a fantastic source of strength-training and once you’ve taken them to your favorite park, you just might opt to stay outside in the wind and rain if only to enjoy the freedom and flexibility of the work-out.  If you’ve been going to the gym three mornings a week to lift weights, or to do Body Pump, or to zip through the circuit of machines, taking your bands outside to a park will provide a nice break in the winter routine AND if you walk there, you can keep checking on that Bartlett pear.  When the nitrates start falling from the sky, you can always take the bands inside at home or at the gym.  Is there a fitness center at the hospital where you work?  Is there a children’s outdoor area with some poles that support swings or climbing apparatus?  Perfect for bands.  How about doors with hinges.  If there is a low-traffic area inside the hospital where some infrequently used doors with hinges are hanging around, that’s another perfect place for anchoring bands. Maybe you’ll need “permission” to use the space or maybe you’ll need the chief’s approval, but if you really want to do your work-out, you can work it out.  Don’t forget your water.

March brings a variety of weather to your exercise routine – rain, wind and even some stubborn snowfall.  You will probably need to do a blend of trail walks and treadmill, outdoor cycling and indoor elliptical, and you may need to tote the Totes.  But it’s a great time, a hopeful time of year when as the season changes, you can take advantage of the change.  Then when April arrives and the rain comes down, the only thing that will go up is your umbrella.

Learn more about the Bands In the Park work-out on mobile browser at www.bdyfrm.com.

Clarus Video System

Having trouble with insertion of the ET tube into the trachea? Would you rather see than feel tracheal rings to insure intubation?  There are a number of video laryngoscopes on the market, now Clarus has introduced the video intubating stylet.

The Clarus Video System allows visualization at the end of the distal point of the stylet (ie the end of the tracheal tube).  The HD screen of the CVS gives the intubater maximum visualization, making it simple to maneuver the tracheal tube into the airway for both regular and difficult intubations.  Also with a click of a  button, a red LED light will illuminate the airway and transluminate through the cricothyroid membrane providing additional insurance that the intubation was successful.

We would like to hear from CRNAs who have used this product.   How does it compare to the standard video laryngoscope?

Click here to go to the manufacturer’s web site and review the product.  Return to PROCRNA.COM and use the comments box to share your thoughts with your colleagues.

Clinical topic: Lower Central line infections

In the midst of the pressure to lower infection rates and meet CMS standards, is it possible to reduce the rate of central line infection to zero?  That question was addressed in an article by Kate O’Rourke published in Anesthesiology news.   The author states that new research has found that multidisciplinary team approaches are making great strides in dramatically reducing rates.  She describes a study done at the University of Massachusetts finding that involving caregivers at all levels and providing frequent, regular feedback on infection rates to hospital staff are two key elements that have made these programs a success, experts said.

The article continues by quoting Matthias Walz, MD, chief of vascular anesthesiology at UMASS Medical Center,  who said the guidelines at his facility were developed by a small task force and then approved by the institution’s Critical Care Operations Committee prior to implementation. “From the ICU physicians to the ICU nurses, respiratory therapists, pharmacy team, occupational therapists—everybody is at the table.” Because all disciplines were involved in creating the guidelines, all caregivers feel they have a stake in the process, he said.

A good infection control program will show positive results, however, for the success to be continued, participants must continue to be updated and motivated.  Ongoing education is essential.  Reducing infection rates is a total team effort by all caregivers.  Communication and coordination is mandatory.

Click here to read the article as published.  Return to www.procrna.com and leave a comment.

Feature SRNA: Adrianne Collazo

 

Adrianne Collazo

SRNA

Adriannejc@gmail.com

Mercer University

Will graduate December 2012

Click here to review my CV

Click here to review my student work

Why you should hire me: Team player, people person, eager to learn, teachable, hard worker with a good work ethic. Clinical experience in diverse cases (general and sedative) at Level one trauma center. Excited to become part of an organization that promotes autonomy and self growth.

Chief CRNA: How to balance your life

Life has many demands at home and at work.  As CRNAs, we are expected to provide first time value to patients with each encounter and we are expected to be available 24/7.  As Chief CRNAs, we add the responsibility of department management to the clinical responsibilities.  After a long day at the Hospital, we often go home to a long list of “must do” items leaving little time for rest and relaxation.  Over time it takes a toll.  As professionals, we must balance our lives if we are to avoid burn out.

In a blog posted on Rock the  post, the author presents 7 key tips for bringing your life back into balance.  The author concludes, “If you don’t have a sense of harmony between your personal and professional life, things can take a toll on you mentally and physically.”  Taking simple approaches, like those listed in the blog, can help you get your life back in balance so that you can be productive at work and have fun with your family and friends.

Click here to go to the blog and read the 7 tips.  Return to www.procrna.com and leave your comments.

Chief CRNA: Negotiate Your Salary

In business, everything is negotiable.  As a Chief CRNA, you are responsible for not only setting the Corporate climate and enforcing the standards in your work group, but you also must attend to the business of Anesthesia.  Being fairly and adequately compensated is foundational to being a loyal and engaged employee.  Negotiation is essential both when you are being compensated and when you are hiring new people to work in your group.

An article written by Linda Jenkins on the salary.com web site details some of the elements of successful negotiation.  In a negotiation, each party should fulfill the needs of the other party.  In order to do so, you must know your strengths and resources and be able to respond to the needs of the other person.  She stresses preparation prior to the negotiation.

Click here to read the article in a PDF format or click here to link to the article published on salary.com.

The Chief CRNA area of procrna.com is a forum for those interested in Anesthesia Department Management to share ideas.  If you are a Chief CRNA, please use the guestbook on this page to let us know who you are and where you work.  Please pass this web site along to your colleagues.

 

Clinical Topic: Propofol allergy in Children

Propofol is currently the hypnotic drug of choice for anesthetic induction.  With the increase in TIVA anesthesia, Propofol is also being used as a maintenance drug.  Propofol is a lipid preparation which incorporates egg lecitin, phosphatide and soy oil in the preparation.  Egg and Soy allergies are listed as contraindication to the use of propofol.  Due to the presence of egg products in the formula, the question emerges as to whether or not propoful should be used in the patient with egg allergy.

In a retrospective chart review study by Murphy A, et al published in Anasth Analg the topic of propofol use in the egg allergic patient is explored.  The authors report that egg lecithin used in the propofol formulation has not been found to have residual egg proteins.  The literature revealed only one case where an egg allergic patient reacted to the lecithin used in propofol.  Since egg lecithin comes from the egg yolk, the authors speculate that up to 75% of pediatric patients with egg allergy could tolerate Propofol without incident.  Nevertheless, the authors recommend skin testing of patients with egg allergy prior to propofol use.

Click here to read an abstract of the original work and return to procrna.com to leave a comment.

 

 

Clinical Topic: Case Presentation by SRNA

SRNA Brooks Cauley has offered some of her student work for review by the CRNA community.  Read, learn, enjoy and make a comment.  Brooks will graduate in 2012 and is available for those who seek a motivated addition to their staff.

Case Study:  Elderly patient with infrarenal AAA, Aortic stenosis and an intracrainial mass.  The review is presented as a series of power point slides with talking points regarding the anesthetic management of each co-existing disease.  References are listed at the end.  View the slides and return to this page to leave a comment.

Click here for slides

 

 

Brooks Cauley

SRNA

bcauley9@yahoo.com

Will graduate December 2012

 

Why you should hire me: People person, good personality, teachable, eager to learn, good work ethic, understands teamwork. Gaining valuable experience in providing general and sedative anesthesia in diverse cases at a level one trauma center. Excited to become part of an organization that promotes effective, efficient, and quality healthcare. Looking for an organization that promotes autonomy and self growth.

Click here to download CV

 

Meeting Review: Texas Association of Nurse Anesthetists

Who says you have to go to a big National meeting to obtain quality continuing education?  The Texas Association of Nurse Anesthetists once again has done it right.  The Texas Association Spring Meeting was held February 17-19 at the Waterfront Marriott in The Woodlands Texas.

The meeting location was a newly developed area with shopping restaurants and movies within easy walking distance.  The Hotel was first class and offered a group rate to those attending the meeting.

Speakers were exceptional.  All were extremely knowledgible and the topics were relevant to clinical practice.   The meeting room was comfortable.  The lunch provided on Friday was better than most food served at meetings.

All things considered, this State meeting was exceptional value for the money.  The Fall Texas Association meeting will be September 21-23 in San Antonio, Texas.  Mark your calendar.

If you attended this or any other Texas meeting, leave a comment.

 

 

Clinical Topic: Intubation verification with Ultrasound

As airway experts, we have all been faced with intubating the difficult airway.  We line up our toys, develop plans A, B, & C, and then go for it.  After intubation, verification of tube placement is essential.  The traditional methods of auscultation over the lung and the presence of a CO2 waveform are the gold standard.  However, with the expanded use of the ultrasound in the operating room, there are other options.

An article by Pfeiffer P, et al published in Atca Anaesth Scand describes the use of the ultrasound for verification of endotracheal tube placement.  The ultrasound can be used several ways to verify intubation.  First, by scanning across the cricoid membrane, direct visualization of passage of the tube is possible.  Several views in the neck area enable confirmation of tube passage.  Ultrasound visualization of diaphragm movement indicates proper intubation.  Finally, lung sliding with ventilation confirms tracheal intubation.

In this study, the group used the techniques described above  and compared the time to verification using ultrasound versus the traditional auscultation and capnography.  The study found that using the ultrasound for verification was reliable and equally quick as auscultation.  When compared to auscultation plus capnography, the ultrasound verification was faster.

Click here to review the abstract of the original article.  Return to procrna.com and offer your opinion.

 

 

CRNA Fitness: Circuit Training

  The Circuit Train

Working out can be whole lot simpler when you know the drill!  If you need one day a week to “relax your mind” while actually getting your work-out, try circuit-training.  There are several good things about using an established circuit and here’s just one.  You can go get a member of the training staff for a free orientation around the circuit.  Reservations encouraged.

A circuit provides a moderate level work-out and consists of gym-level machines set up in a circle, a neat little rectangle or at the very least, all on the same side of the gym.  If they are not grouped, it’s not a simple circuit, it’s a hairy maze. There will be one or two machines for each specific muscle group and in a well-thought-out arrangement, muscles will be grouped to keep you in order.  Remember?  It’s 4:30 a.m. before a 12-hour day of one heart, two gall bladders and whatever last-minute trauma is scheduled and you’re looking for a straight-forward work-out, not discombobulation.  Start with shoulders and begin working your way around the circuit.

Overhead Shoulder Press and perhaps Incline Shoulder Press will be your starting place.  If you’ve not had the orientation, you’ll need to read the instructions printed on one of the supporting braces of the press.  Adjust the weight plates, adjust the seat front-to-back and up or down, sit with “Body Firm” posture, use an overhand grip and press the contraption overhead(or angled up and outward) until fully extended.  Voila!  Rest 30 seconds between one or two more “sets” or press onward.

Note:  Adjusting the set-up options correctly and appropriately is tantamount to getting the most out of each exercise, but even more importantly, to remaining uninjured.  Too much weight can crash back down, hunching shoulders can pinch your neck, exhaling at the wrong time can challenge your heart(and not in a good way), and failing to use your abs will arch and injure your back.  Use caution and common sense.  You too, Men!

Chest Press and Seated Chest Flies will be next and, once again, read the instructions, adjust all of the set-up options – front to back, seat up or down, weight plates –  and be seated.  When seated, your feet should be flat on the floor unless there are little angled platforms for your feet.  Both of these machines are harder than you think so err on the side of caution and keep it light until you’ve found the level of exertion that challenges without causing pain.

Seated Lat Flies are the reverse of Seated Chest Flies – not to be confused with seated front flies which require elbows bent and arms to open and close like French doors – and may be part of the same machine. To work the chest, you’ll face outward; to work the back, you’ll face inward.  And the Seated Lat Row, which has three set-up adjustments, should be next.

These require feet flat on the floor, not tucked behind you so you fall forward, nor extended in front so you can row your boat.  You’re not in an outrigger canoe in Hawaii.  You’re in the gym, darn it, at 4:30, darn it, before doing a heart, darn it…feet flat on the floor, please.

Triceps and biceps are next on the circuit.  Note the work-out moving from strong shoulder exercises, to large chest and back muscles, to the smaller, but potentially so down-right gorgeous tri-bi muscles, the ones that never show in the OR but show big time on a beach…in Hawaii.  You can see what’s on my mind in February!  Biceps will be a standard Seated Biceps Curl and/or a Preacher Curl. I don’t get why this is called “preacher” but google says it’s because the arm position resembles someone praying.  You’ll actually look like someone holding a Bible or a hymnal a whole lot more than praying, but whatever floats your boat is what you should visualize.  Just do it!  Remember, the key to good biceps curls and triceps curls is the anchoring of the elbow and maintaining neutral wrists.  Curl is the basic motion, not the rolling and bending of the wrist to avoid effort.

Legs are next and last.  Expect to do Seated – or angled supine – Adduction and Abduction as well as Seated Leg Extensions and maybe Leg Curls.  You’re a lucky little guy if there is also a Seated Calf Raise and a Leg Press.  A circuit is not generally meant to challenge to the extent or even in the same way as a full-blown 45-set work-out, so three leg machines are really enough.  Lunges and squats are “on on your honor.”  Crunches can wait.

Okay, you’re done.  But if you did only one set of the circuit, take a 60-second break, not a 5-minute text conversation with your broker, and do the circuit again.  People tend to monopolize equipment at the gym, especially cardio equipment, but the circuit may be popular, too.  So you may just want to claim each machine in its turn and hang onto it until you’ve completed your two or three sets of each. Then when your legs are finished – and they WILL be – you can wobble in and out of the shower, hide your coif under a scrub cap, and take a non-circuitous route to the hospital without looking back.

To learn more about exercising with safe, efficient form, visit Liz at www.bdyfrm.com.

Read Lizlines and the weekly Lizlimerick posted Monday through Friday every week of the year.

Clinical Topic: Malignant Hyperthermia Review

Highlights of Malignant Hyperthermia

Early in our Anesthesia training, we were all taught about the dreaded Malignant Hyperthermia.  As we settle into clinical practice, we all remember that MH is a potential risk but give it very little thought.   SRNA Ola Akigbogun, from the Mercer University School of Medicine Nurse Anesthesia Program has offered the following review for procrna.com readers. The bullet format allows us to quickly review the highlights of treating MH.   Ola will graduate in the fall of 2012.  Read his profile and contact him if you are looking for a new graduate who is a motivated and committed to excellence.

Definition

  • Malignant Hyperthermia is characterized by an acute metabolic state in muscle tissue following induction of general anesthesia and in the post operative phase of anesthesia.
  • Malignant Hyperthermia is rare 1:15000 in pediatrics and 1:40000 in the adult population.
  •   Most common in pediatric cases.
  • Patients with mild to moderate MMR, King Denborough syndrome, Duchenne’s muscular dystrophy, Central core disease and Osteogenesis imperfecta are usually susceptible to Malignant Hyperthermia.

History

  • First formal description in 1960 by Denborough and Lovell
  • The first case report allowed for a very solid understanding of the pathophysiology of Malignant Hyperthermia. The patient was a young man who stated that his relatives died without any apparent cause during anesthesia.
  • This patient was anesthetized with halothane and developed tachycardia, hot sweaty skin, and cyanosis. The early recognition of this symptom saved him and lead to the further research and developments of Malignant Hyperthermia
  • In 1970 many of the clinical symptoms of MH were reported
  • In 1970 Kalow et al suggested the development of an in vitro diagnostic test which involved the exposure of biopsied muscle to caffeine and Halothane.
  • In 1975 Harrison reported that dantrolene was successful in the treatment of MH.
  • MH registry in the United States in the late 1980’s
  • In 1985, Lopez and His colleagues demonstrated that intracellular calcium concentration was increased during an episode and that dantrolene was successful in its reversal.
  • In 1990’s molecular biological techniques where applied to identify genes that are susceptible to MH.

Pathophysiology

  • Triggered by Succinylcholine and halogenated agents in greater than 80% of reported cases.
  • Why malignant hyperthermia does not occur after every exposure to halogenated agents is not fully understood.
  • Malignant Hyperthermia is believed to occur due to an uncontrollable increase in the intracellular calcium in skeletal muscle. The sudden release of intracellular calcium removes the inhibitory properties of troponin which results in intense muscle contraction.
  • Increased adenosine triphophatase activity results in an uncontrollable increase in aerobic and anaerobic metabolism. The severe hypermetabolic state created is responsible for increase oxygen consumption and CO2 production leading to severe lactic acidosis and hyperthermia.
  • It was first believed that the abnormal  ryanodine Ryr1 receptor in patients with MH was responsible, but further studies have shown that MH pts may have a normal ryanodine receptors and that abnormalities in secondary messengers such as fatty acids may be the problem. An abnormal sodium channel may also be responsible for malignant hyperthermia.

 

Triggering Factors

  • Halothane
  • Enflurane
  • Isoflurane
  • Desflurane
  • Sevoflurane
  • Succinylcholine

Signs of malignant Hyperthermia

  • The earliest sign and symptom that will present is an increase in ETCO2.  ETCO2 can occur due to other reasons, but when other problems are ruled out treatment of MH should begin.
  • Other additional early signs include tachycardia, tachypnea, and rigidity of the masseter muscle called trismus. However, trismus often occurs with pediatric patients, in particular when intubating, so this sign must be taken into consideration with all other signs and symptoms.

Late Signs

  • Unstable blood pressure, cyanosis and/or mottling of the skin, diaphoresis, cardiac dysrhythmia
  • Hyperthermia. The patient’s temperature may elevate as much as 1-2°C every five minutes.
  • Hyperkalemia, Hypernatremia, Metabolic acidosis, Hyperphosphatemia, elevated CK levels.
  • Dark red blood in the surgical field
  • Myoglobinuria

Malignant Hyperthermia Protocol

1. Immediately discontinue anesthesia, including Succinylcholine. Life-threatening surgery will be continued, but with the use of a different anesthetic agent and machine to prevent residual inhalation agent from triggering a second episode.

2. Hyperventilate 100% oxygen at a high flow rate of 10L/min. to treat effects of hypercapnia, metabolic acidosis, and increased oxygen consumption

3. Dantrolene 2.5mg/kg IV as soon as possible; given every five minutes until symptoms subside.

4. Change ventilator tubing and soda lime canister. Some anesthesia providers may still perform this action, but research has shown that it is not necessary to change the breathing circuit and anesthesia machine since the oxygen delivery rapidly clears the machine of the anesthetic gases.

5. Sodium bicarbonate 1-2 mEq/kg IV to combat metabolic acidosis due to increase of lactate in the circulatory system.

6. Ice packs Apply to groin area, axillary regions, and sides of neck – where major arteries are located.

7. Iced lavage the stomach and rectum with cold fluids to lower temperature. It is recommended not to lavage the bladder since the fluids can alter the true amount of urine being excreted by the patient and alters measurement of output.

8. Mannitol or furosemide Muscle cells are destroyed during an MH crisis and the myoglobin that is released accumulates in the kidneys, obstructing urinary flow, referred to as myoglobinuria. Diuretics are given IV to promote and maintain urinary flow in order prevent renal damage. Mannitol 0.25g/kg IV; furosemide 1mg/kg IV; up to four doses each. Urinary output of 2ml/kg/hr or higher must be maintained to prevent renal failure.**skip this step if dantrium IV is used because it contains 3g of mannitol.

9. lidocaine to treat arrhythmias secondary to electrolyte imbalances. Procainamide removed due to practitioners not beeen familiar with the drug.

10. Dextrose and insulin Treat hyperkalemia due to the release of potassium into the circulatory system as muscle cells are destroyed. Dextrose 25-50g IV; regular insulin 10 units in 50ml of 50% dextrose in water given IV.

11. Monitor urine output Insert Foley catheter if one is not in place

12. Monitor electrolyte levels Blood samples taken every 10 minutes to measure sodium, potassium, chlorides,calcium, phosphate, and magnesium levels.

13. Perform clotting studies

14. ABG Every 5 to 10 minutes

15. Arterial blood pressure Insert line if one is not in place

16. Central venous pressure Insert line if one is not in place.

17. Pt should be monitored in PACU for at least 4 hours then transferred to ICU for 24-72 hrs monitoring.

 

Dantrolene

  • Hydantoin derivative which intereferes with muscle contraction by binding to the RYr1 receptor and inhibiting calcium ion release from the SR.
  • 2.5mg/kg IV every 5 mins until episode is terminated. Upper dosage is 10mg/kg
  • Dantrolene is packages in 20mg vials and it is to be reconstituted with 60ml of sterile water. The reconstitution can be very time consuming
  • Half life is about 6 hrs.
  • Recent studies show that prophylactic use of dantrolene can increase muscle weakness and is not indicated. The anesthesia provider should proceed with the use of non triggering agents
  • 36 vials of dantrolene should be made available upon diagnosis of MH

 

References

CRNA Fitness: Calories Count

If you’re really serious about taking off those last ten pounds or just improving the way you eat, use a calorie log.   Daily calorie logs provide a source of personal accountability and  act as a learning tool.  Balancing calories IN and calories OUT will guide you to your goal.

A calorie log should include what you consume, as well as how much you consume, and how often you consume it.  And a really good log starts with what you planned to eat and then what actually passed your lips and took the dive.  There are numerous online logs to choose from, but building a calorie-log of your own personalizes it and makes it work just for you.

You can develop a short excel food log that takes no more than 15 minutes per day to fill out.  Provide spaces to note the date, the time of day that you ate, and, of course, your daily totals.  Develop your columns to allow space for food measurements and food descriptions, like poached pears, frozen edamame and fresh tuna.  Your excel program has the capacity to total your calorie intake automatically which removes the responsibility from a mind and body on operation overload.

Include a column or block for logging calorie output which applies to cardio, strength-training and power walks. Estimate a calorie per minute for all cardio and adjust upward or downward for maximum or minimum level of exertion.  Estimate half that for strength-training.  Even though your heart rate and metabolism are elevated after cardio, strength-training immediately afterward doesn’t burn calories at the same rate as non-stop, heart-challenging cardio exercise.  When you spend eight to 14 hours a day standing or leaning against your anesthesia chair and turning your head to follow a monitor, your eyes burn and your brain fries, but calories do not. You don’t get to subtract 1 calorie per minute for sitting.

Tweak your excel program to include issues unique to you.  Do you want to know what percent of your calories were wasted?  Relegate all non-fructose sugars, added fats, junk foods, non-nutrient beverages and excessive or unnecessary foods to the “wasted” column.  Then divide wasted calories by gross calories to get the % of should-have-had-something else calories.  Do you have GI issues?  You may want to have a block on your log that represents how often you fully empty.  There will be a relationship between what you eat, how much you eat and how well your GI system functions. How many meals did you eat at a restaurant or inhale on the fly?  How many desserts did you consume? Do you drink enough water?  Throw in a log block for number of glasses of unenhanced water you drink daily.  Do you walk the stairs instead of taking elevators and do you do a lunchtime walk? I have clients who wear pedometers at work in order to track how active they are, a great way to remind yourself to use stairs, to go for 15-minute walks, and to lunge down hallways between patients…unless you’re working on kids, which will keep you running all day!  Add a log block for calories burned during your normal daily activity, but don’t subtract it from your gross total.  After all, most of our bodies were designed to get a leg up.

It is generally accepted that 3500 calories equals a pound, lost or gained, so to lose a pound, you need to consume fewer calories than your body needs for function.  Since you do not actually know how many calories you require, simply take in a few hundred less per day than you usually do.   If you want to ditch 10 pounds, reduce your normal daily intake by a couple hundred.  If you are morbidly obese – isn’t that a lovely admission of sin? – you will need to drop several hundred unnecessary calories per day, maybe a 1000.  But, if you are seriously overweight, the bonus is the rapid, safe weight loss you will enjoy right up front.  Thinner people will lose much more slowly, but they get to adjust their intake less dramatically, too.  Beware of the RDA recommendations when planning your food day.  It does not take 2000 calories to run a 5’4”-female body for 24 hours.  In fact, it doesn’t take 2000 calories to maintain a 6’-male body that isn’t active.  In further fact, if you eat a nutrient-dense, mostly plant-based diet, it is nearly impossible to consume 2000 calories per day without bloating into a state of flatulent, comatose exhaustion.

At the end of each day, total your column of gross calories(food intake).  Add your blocks of expended calories(cardio, strength training, strenuous sport activity).  If you’re figuring percent of wasted calories, now’s the time.  Then subtract output from intake for the total net calories.  Your net should be noticeably less than your intake used to be, and your weekly reduction should be around 3500 to lose one pound. Eight to nine-hundred well-balanced calories is safe for most women and nine to eleven-hundred net works well for average men. Don’t forget:  Fried chicken is not the same as grilled chicken breast; broccoli with cheese is not called fresh broccoli; ¼ cup of granola is not ¼ cup plus several-bites-while-measuring; and trail mix with fruit is not an apple.  Be honest.

Using a food log gives you control over your daily nutrition plan and your weight loss.  By writing down each and every item, you take charge of what you’ve planned and responsibility for what actually went down.  The log will reveal to you what works and what doesn’t, when you’re really hungry and when you simply indulge.  And it will also give you a sense of power over an issue that used to leave you feeling powerless.  To get your power back AND lose ten pounds, count your calories because calories do count.

 

You can visit Liz online at www.bdyfrm.com where “…a fit body is a friend for life.”

Clinical Topic: Defenses to Negligence

In earlier articles, I discussed some basics about medical malpractice. Now I want to briefly review some defenses to negligence.  Keep in mind that all negligence claims are not credible; and even if a credible claim exists, there are many avenues to resolution.  If the required elements of negligence are present and cannot be contested, defenses to negligence may be considered.

One method for mounting a defense to medical malpractice is to assert that the plaintiff caused their own injury, and because of the plaintiff’s action the defendant should not be held liable for the injury.  A jurisdiction that recognizes contributory negligence would bar recovery by the plaintiff if the plaintiff is found to have contributed to the cause of his injury.  A jurisdiction that recognizes comparative negligence (of the plaintiff) would decrease any award for a plaintiff’s claim based on the amount of fault the court determines the plaintiff contributed to the injury. Additionally, if the defense can establish the plaintiff knew the risks involved in an activity and voluntarily performed the activity, then assumption of the risk might be the appropriate defense to relive the defendant of liability. Adherence to these theories is ascertained by reviewing relevant case law in the applicable jurisdiction, and review of relevant statutes in the applicable jurisdiction.

Consider this example: Priscilla Patient arrives at Sunshine Valley Ambulatory Surgical Center (ASC) for a laproscopic appendectomy.  After completing and signing all of the required forms in the admitting office, Priscilla is led to the dressing room to disrobe and to change into her gown for surgery.  Priscilla disrobes leaving only her underwear remaining under the gown. As Priscilla gathers her belonging and opens the door to exit the changing room, Priscilla’s right great toe makes contact with the door of the dressing room.  The contact doesn’t initially bother her so she doesn’t tell anyone about it.  The next day, during the follow-up post-operative call, when asked if she has any questions or concerns about her procedure the prior day, Priscilla states, “My surgery went fine, but my right big toe is really hurting where the door hit it.  Now it’s swollen and really hot.”

This example is hypothetical.  However, at this point many options can occur.  If Priscilla decides to sue the ASC for her injured toe, all of the required steps (such as fact gathering and determining if the claim is credible) will begin to be pursued by her legal team.  In a claim of negligence against the Sunshine Valley ASC, if a defense to negligence for a claim like this were considered, it is reasonable to suggest that Priscilla had something to do with the injury that she now has because she didn’t tell anyone about it when it occurred.  If a court believed that proposition, any award to which Priscilla may have been entitled to would be either barred in a contributory negligence jurisdiction, or reduced in a comparative negligence jurisdiction.  If the defense can establish that Priscilla chose to exit the dressing room without foot coverings, knew she was injured before she had surgery, and before she left the facility, and she chose not to inform medical personnel who were readily able to assess and treat any injury if any were present, then assumption of the risk might be the choice to rebut Priscilla’s claim of injury to her toe.  The legal team will evaluate the facts of the case and apply the law as indicated.

Pamela Chambers, MSN, CRNA, EJD

About the author:  Pamela Chambers is a staff CRNA a Central Texas regional trauma center and the affiliated Children’s hospital. Ms Chambers received her MSN in 2000 while on active duty in the U.S. Army; then received her Executive Juris Doctor (EJD) in Health Law in 2008 from Concord Law School. Ms. Chambers owns Lex Terrae Consulting a health law research and consulting firm and also teaches Legal Nurse Consulting for Kaplan University. Ms. Chambers is not an attorney. The information provided is legal research and should not replace consultation with an attorney or physician when warranted.  Click here to learn more about Lex Terrae Legal consulting services.