Wednesday, 9 August 2017

Metal Nurse: Pus, slough, silver, honey and maggots

As a nurse, I flit from one passion to another. All in all, my passion for good nursing has not diminished, but subjects tend to vary from one to the other. Whilst I was a student I had a very, very acute interest in diabetes. Especially how much being diabetic can affect and impact on nearly every single aspect of your life. I've dabbled a little bit in cardiac care. I still enjoy advocating for vaccines, especially for healthcare workers, mental health still remains at the forefront of my mind, I got extremely interested in stroke if only because my first job offer was within an acute stroke setting, and so on and so forth. All in all, I do generally enjoy almost every aspect of nursing. Currently, my biggest passion involves wound care. In all its gory and gooey glory. The sloughier, the better. The deeper the cut, the more I have fun. I am not saying that I want people to get hurt... But when they do, I want to be there. To help obviously...

Wound care has gone through some major changes over the years and will no doubt continue to do so, just like any other aspect of health. Wounds account for a huge portion of the NHS budget, a study published in the BMJ estimated that wound care along with associated co-morbidities accounted for £5.3 billion. This is on par with obesity which costs £5.1 billion, a little less than cancer which costs £5.6 billion. But considerably less than health tourism.

There are several myths that persist regarding wounds. The biggest one being "Let the wound breathe", it is one of those exceptionally persistent old wives tales that every (grand) parent tell their children when they fall and scrape their knees whilst being too busy playing on their mobile devices (I jest, I jest). The idea being that the air will dry it out and let it heal faster. This is just patently wrong. The best healing environment is a moist environment. Moist environment reduces the time it takes for the wound to heal, leads to less inflammation and necrosis, and also reduces scar formation. Leaving the wound open just increases the risk of infection, slows healing rate and scars more prominently.

Wounds tend to be fairly simple in of themselves. But any healing can be delayed by a lot of reasons. Present co-morbidities, certain medications, dietary intake, mobility, smoking, alcohol drinking, etc etc. One of the biggest factors that can delay healing is being diabetic. The reason for this is because diabetes oft leads to neuropathy, which in turn leads to blood circulation, which makes it difficult for the blood with it's associated macrophages, fibrinogens and platelets from reaching the wound area.

But enough about that. Due to increased prevalance of antibiotic resistant bacteria we have now started to look more at alternative ways of treating wounds. As can be imagined antibiotic resistant bacteria will wreak havoc on wounds and will turn acute wounds into chronic ones purely because we don't have the antibiotics to give either in IV, oral form or as a topical cream. The three major components that are being used more and more of are: SilverHoney and Maggots. Oh, and seaweed. We use a lot of seaweed in wound care. Sadly due to the lack of real hardcore double blinded studies it is hard to ascertain how effective these methods are in speeding up wound healing process. Anecdotally I have come across excellent results with maggot therapy, but more mixed experience with either silver or honey. Good wound care is more based on how cleanly the dressing is done, with minimal dressing changes. Plus also making sure that the patients holistic assessment is complete, because there are so many other factors that can affect wound healing mentioned previously. The key component being actually cleaning the wound before covering it up, now here is something that I personally found interesting but every community nurse knew but needs to be reiterated, using normal tap water is just as effective as using pods of normal saline.

Now those three things that I mentioned before, Silver, Honey and Maggots are largely on the rise because of antibiotic resistance. Which was first detected when antibiotics first came on the market, but has since been on the rise. Without effective antibiotics we are looking at a very bleak future indeed, hence the need to look beyond antibiotics for infected wounds.

Silver dressings had been on the rise until fairly recently when study after study found that it was not that effective in preventing infections in chronic wounds or increasing healing rate. There had been reports that silver inhibits bacterial growth in petri dishes, but human beings are not petri dishes and this unfortunately not been replicated properly in real life situations.  In fact in some cases it seemed to delay healing times. On the other hand it is quite effective in odour control, but in all honesty I'd rather stick with charcoal dressings as they do it even better and are overall cheaper. There are of course those in the "alternative medical" business who insist on pushing colloidal silver for everything. But beware of this quack remedy. It is not natural as claimed, nor is it effective. And as a side note, ingesting colloidal silver can and does lead to a condition called Argyria. Having said all of that, when/if antibiotic resistance becomes the overwhelming reality then we will have to reevaluate the use of silver in dressings and wound care.

Honey on the other hand has been showing some benefit in real life situations. Honey had been a stable in folklore and "natural" medicine, up until the 19th century when medical doctors decided to put it to the test. Today it isn't just any old honey that is used, it is manuka honey. This honey is generally derived from New Zealand and Australia, collected by bees that forage on tea tree. The oil of which has also been found to be a fairly effective antimicrobial agent, even against antibiotic resistant bacteria like MRSA. Though again most of the positive findings tend to be in vitro. These dressings have been found to be as effective in small scale studies, but (again) large scale studies need to be done in order to establish whether they are superior to traditional dressings. But on the whole honey dressings are good because the provide moist healing environment, debridement, deodorizing and are also anti-inflammatory, all factors that assist with good healing environment.

Maggot therapy is back in vogue, and in recent years has seen increase in usage on especially wounds that take a long time to heal for example diabetic foot ulcers, pressure ulcers and venous stasis ulcers. Whilst maggot therapy had been in fairly common usage up until 1930's, the advent of antibiotics made maggots look obsolete. It wasn't until the 1980's when the danger or antibiotic resistant bacteria started truly rearing it's ugly head when maggots were reconsidered for wound care. Just to be clear it can't just be any maggots. For preference the larvae of the green bottle fly is used. These little beauties are tiny and feast on necrotic flesh, which makes them perfect for debridement of wounds. They do their stuff by secreting enzymes that break down the necrotic tissues into juices from them to drink. These enzymes also have the added benefit being broad spectrum anti-microbial, making this therapy also suited for those whose wounds have been colonised by antibiotic resistant bacteria. They can come in either a teabag or loose, and left on the wound for up to three days. Along with cleaning out the wound, the larvae also stimulate the healing process, they managed that by stimulating fibroblasts which synthetize into collagen and extracellular matrix, and by providing those elements it supports other cells with wound healing.  A small randomized study done in 2000 that involved 12 patients did indicate that larval therapy could be more cost-effective than using the standard hydrogel. But as with an study like this it makes it hard to replicate and do on a larger scale.

As mentioned previously, the dressings that I have mentioned to have their place within the toolkit of wound dressings. None should be completely dismissed unless there has been a large scale studies performed in showing either ineffectiveness or in fact make the problems worse. For example, "letting the wound breath", just stop it.

 What is most important when dressing a wound is consistency, rather than any fancy pancy dressings.

Wednesday, 22 February 2017

Metal Nurse: Health Tourism, Red Herring.

During the whole Brexit election I got into some heated debates, especially about the National Health Service. For years and years there has been this myth that the UK was being flooded with health tourists, who would take advantage of the free care provided by the NHS. Never mind that one of the founding principles of the NHS is "Free to the point of delivery" and never mind that the whole "Health Tourist" concept is a red herring. This is generally to distract people from real problems that actually affect their lives, like austerity. Because in the last couple of years mortality rate has risen, while NHS and Social Care has been getting less funding.

It should be noted that immigrants use less services within the NHS than their British counterparts. The reason for that is immigrants (like myself) tend to be younger and healthier. Even being admitted to hospital is rarer amongst immigrants.

But let's for a moment pretend that health tourism is a problem. To do that I'll just check out some numbers... Now currently the NHS budget is around £116.4 billion (2015-2016), the best estimate that the Department of Health can come up with regarding the cost of health tourists is somewhere between £110 - £280 million. Now those do sound like big numbers, and they are. But that accounts for 0.0945% - 0.24%. Are we seriously going to worry about those numbers?  Now those are for what DoH call deliberate health tourists, i.e. those who come to the UK specifically to obtain treatment. Should they be charged, sure of course they should be and most are. But on the other side of the coin is how much they bring into the economy whilst they come to the UK for treatment. Health Tourists also bring somewhere around £219 million back into the economy, by paying into hotels, shopping, transport and suchlike. All of those are VAT'd so that gets back into the economy, and those who work in the industries get paid and thus also pay taxes. So swings and roundabouts. These are people who come to the UK for specific treatments as well.

But then what to do with health tourists from the UK? Because according to this rather interesting research published by PLOS entitled "Medical Tourism: A Cost of Benefit to the NHS" they state:
Our analysis of data suggests that the UK is now a net exporter of medical tourists. While incoming medical tourists may be less likely to declare treatment as primary purpose for their visit to the UK than outbound tourists, data over time clearly shows a greater acceleration in outbound over inbound medical tourists. Despite the variations in numbers of patients visiting different hospitals and in the income per patient, the number of medical tourists was comparatively smaller than the percentage of income generated by them (7% of patients generating close to 25% of private income). These figures suggest that non-UK residents travelling to the UK for medical treatment seek high-end specialist expensive procedures, and may generate substantial revenue. Additional numbers of patients for specialist procedures may also help NHS doctors with surgical learning curves.

But let's take a case study on one of these awful health tourists. As mentioned above I got into some heated debates with a lot of racist people regarding the NHS usage by foreigners. Their favourite story was about this Nigerian lady who came to England to give birth to four children and then left with an unpaid bill. The one issue they didn't seem to understand is that Nigeria isn't in Europe, let alone in the EU. But they also either deliberately left out details or never got around to reading the full story because their lizard brains couldn't handle it. This story has since been touted by media outlets like The S*n, Daily Heil and Sky. Talking about the horror of the cost to the common man, even the BBC headline is focused on the financial cost, as opposed to the human cost. For those who need a quick update on the actual story I'll summarise it:

Nigerian woman was pregnant with 4 children. She got told by her doctors that she'd be better off giving birth elsewhere as it would be safer for her. So she decides to go to the US where a large portion of her family lives. She gets there only to find out that her paperwork is wrong. So she has to turn back, with a stop in the UK, where she has no relations. While en-route she was taken ill. As the plane lands she is taken to hospital, where she gives birth prematurely. One child died at birth, the remaining three were taken into Intensive Care. Another child dies shortly after. The patient herself got discharged after 6 weeks. Quite frankly the headlines shouldn't be about the cost, the headlines should read about how well the NHS staff did in saving both mother and children. She didn't want to give birth in the UK. She didn't want two of her babies to die whilst in a land she doesn't know and has no one in.

But then you do have those who come to travel to the UK, because you know people like to travel. And you can't always account for if you get ill during your travels or not. Now this is where it gets a little bit trickier. Because when you are travelling in a different country you don't really expect to have to get any sort of treatment. But normal use is estimated to be around £1.8 billion, still a tiny 1.15% of the total NHS budget. And most of that can be recovered through European Health Insurance Scheme (well for now anyway). Other countries do seem to be better at claiming money back for when British tourists take ill in the EU, then the NHS. But that is more due to administration costs.

Now let's compare those numbers to something that does have real impact on the NHS. According to the latest numbers I can find (from 2012) diabetes and diabetic care costs £13.750 billion. 85% of which Type 2 Diabetes is accounted for. And this is expected to be increased to £39.8 billion by 2035/36. T2DM is largely preventable through healthier living and better lifestyle choices.

Obesity is also largely preventable through healthier living and better lifestyle choices and that costs the NHS an estimated 
£6.8 billion. Within the EU the citizens of United Kingdom have the highest rate of obesity.

Alcohol costs society as a whole £21 billion per year, £3.5 billion of those to the NHS. Again this is through lifestyle choice of those who live in the UK.

Then there's smoking. Which costs the society upwards to £14 billion, with £2.7 billion costing the NHS. Bear in mind that those numbers were calculated in 2010.

In conclusion is it really worth hounding and demonising people coming into the UK for medical treatment when the UK citizens themselves take it for granted and should we not also be as disparaging to the UK citizens who leave the country to seek treatment elsewhere? In my opinion, as a healthcare professional and as an NHS employee, the fact that people actually want to come to the UK to receive their treatment makes me proud. And it should make the citizens of the UK proud because it shows that we are doing something right.

Other sources include:

Full Fact

The Conversation

King's Fund.

Thursday, 16 February 2017

Metal Nurse: Edward Jenner healthcare hero

Me in Hyde Park, with  Edward Jenner
Some time ago I went to London with my beloved to spend the weekend. Whilst there I visited Hyde Park for the first time where I came across this monument of a man who changed the landscape of healthcare indefinitely. For the better. I am of course talking about one of the great pillars of public health, Edward Jenner. The father of vaccinations. You will undoubtedly read many many ‘Alternative Facts’ by anti-vaxxers. But as usual they tend to be more confined within the fiction section of third hand bookshops. They lie about vaccines in general, but some of the lies they repeat over and over again about Edward Jenner are astounding. There is a made up story that his son died after receiving the smallpox vaccine. He died at 21 from tuberculosis, which incidentally we now have a pretty effective vaccine for. They also lie about smallpox, alternating between it being never eradicated, just renamed, or simply never that bad in the first place. Yeah, between 300-500 million people died from it in the 20th century alone (until it was eradicated of course), it had 20-30% mortality rate, couldn't have been too bad a disease.

Smallpox had been a scourge on mankind throughout written history. Ancient writings about it were found in a medical book from India, dating from as early as 1500 BC. King Ramses V had been infected by it, cases found in China dating at least 1100 BC. It made no distinction between classes, it knew no boundaries, afflicting the poor and rich alike. Those who were "lucky" enough to survive would be left with permanent scarring. It is a virus mostly transmitted via close contact and droplets coughed by the infected individual. The virus could even be spread via infected cloths, incidentally how the British conquered the Americas when General Jeffrey Amherst gave Native Americans blankets carrying the smallpox virus, quickly decimating the previously unexposed population. The afflicted remained contagious until the last scab healed. There was no treatment available. The only way it could be controlled was with vaccination. And thanks to extensive immunisation programmes the last known wild case of smallpox was in Somalia, in 1977. But it is known that there are vials of smallpox left in both the US and in Russia.

Chinese Variolation
In itself the idea of immunisations wasn't anything new, an immunising technique called variolation had been practised in China and Turkey and some parts of Africa since at least 1000 BC. That form of immunization was introduced to England by the 1700's. It wasn't a particularly safe practice, though safer than getting the disease itself. It involved drying the scabs of previously infected individuals and blowing them up people noses. (Which admittedly is awfully similar to the flu nasal mist spray we use today.) In Sudan and Turkey this practice consisted of collecting fluids from the smallpox postules and rubbing the pus into a cut on the person receiving it. Uptake of either practice in Europe was lacking because the medical establishment had dismissed the practices as witchcraft or folklore. It wasn't until the 1700's that an Italian doctor by the name of Emmanuel Timoni witnessed the practice in Constantinople and then wrote about it and got it published in Philosophical Transaction in 1714, that it received some attention from the higher classes of Europe. Mostly thanks to Lady Montagu who had been permanently scarred by smallpox herself and lost her brother to the same illness.

Edward Jenner was a doctor hailing from England. Jenner himself had been inoculated when he was 8 years old via the practice of variolation. During his medical apprenticeship he took a keen interest in cowpox and how it might possibly lead to protection against smallpox, something that had been taken note of before, specifically by another English physician John Fewster, a friend of Jenner's, and a farmer named Benjamin Jesty. They had observed and reported that milkmaids infected with cowpox were invariably immune to smallpox, this essentially started the mass immunization programs. In essence he didn't discover vaccinations, he popularised it.

Jenner first experimented on eight year old James Phipps, injecting a small amount of cowpox into his arm. After James had recovered from the inoculation Jenner attempted to infect him with smallpox. Neither James nor the children who shared his bed developed smallpox, thus discovering herd immunity. His theories were revolutionary for the time and a lot of people refused to believe them. With the advent of vaccinations came the Anti-Vaccine Movement. Because the idea was so mind blowing even the establishment initially refused to believe it, leading Edward Jenner to do further experiments with more children, including his own child.

By today's standards these were extremely unethical experiments. But thanks to these experiments Jenner managed to convince the establishment of the effectiveness of his method, replacing the more dangerous variolation. Jenner was reportedly an extremely generous man, when James Phipps had married later in life and had children of his own, Jenner gave him a free lease on a house. He refused to use the discovery to make himself rich. Instead he'd devote his time to vaccinating as many people as possible, even negotiating to vaccinate French soldiers in exchange for British Prisoners of War. By 1840 variolation was confined to the past and Jenner's form of immunisation had taken over.

In addition to his research on vaccinations he also made some great headway into research on Angina Pectoris.

Without Edward Jenner there is a very good chance that we would still be dealing with mass epidemics of deadly, dangerous and disfiguring illnesses like smallpox, measles and polio. I believe Jenner's research into vaccinations was as important as John Snow's sanitation investigation, Joseph Lister’s insistence on equipment sterilisation, Ignaz Semmelweis preoccupation with the importance of hospital staffs hand-washing and Alexander Fleming's discovery of penicillin.

Vaccines save lives.

Edward Jenner was a hero. Even Napoleon accepted that.

History Of Vaccines

BBC: History, Edward Jenner.

History of Immunology by Arthur Silverstein

Edward Jenner and the History of Smallpox and Vaccination, by Stefan Riedel.

Monday, 6 February 2017

Metal Nurse: Loss of Liverpool Care Pathway

I've tried not to be too political on this blog, for mostly professional reasons. It has happened at least once. But seeing as this is my blog I thought that this one time (and possibly more often after) I can be. Because this is one topic that really riles me and gets me going. The loss of the Liverpool Care Pathway. I have written previously about how Dying Matters, it is a fundamental part of all good nursing. How we treat the dying patient. How we help the bereaved family. Because how you die stays in people's memory.

For those who don't know. The Liverpool Care Pathway was set up in the late 90's in Liverpool. The aim of it was to provide the best possible care for those who were dying. It provided a framework on how to assess the patients condition, when to continue treatment, when to discontinue treatment and when to provide palliative care. To provide a review of whether further tests and examinations were needed, if artificial hydration should be started when the patient refused diet and/or fluid intake. In other words when to provide comfort care for those in their last hours of living, to provide them with a pain-free, and most importantly, a dignified death. It was a way to provide hospice care in a hospital.

Since 2014 we have not been able to use it. It was completely phased out with the order that each Trust should develop their own pathway, funny considering that the report that the DoH published a document called "More Care, less pathway.". This the Daily Hatreds concluded was victory for the public. Even though the review stated that that LCP was model of good practice, but because of individual mistakes it had to be discontinued. The pathway was excellent, and continually updated. But as usual human beings are fallible. Talking about death and dying is not easy, especially when the family are hellbent on that their relative should live forever. Some people had complained that it was a tick box exercise, which as usual misses the point of these documents. They are there to assist doctors and nurses in providing good care, making sure that all the best care was provided. But as with all good pathways the LCP was proactive, as the patients condition changed for better or for worse, their care and treatment would be re-evaluated. No one stayed on the LCP indefinitely, if someone made a recovery, which does happen because the human body is an amazing thing, then those patients would be re-examined, re-evaluated and and treated accordingly. It was never a "one-size-fits-all". It was a dynamic pathway like all good care pathways are.

All thanks to rags of hate like Daily Mail, Daily Telegraph and Daily Express (The triumvirate of Gentleman's Hate). These papers started reporting that there was a widespread misuse of the LCP, that healthcare professionals were using it as a means of euthanasia, and so on and so forth. The Daily Hate was especially gleeful in publishing false news about doctors withdrawing hydration of neonatal patients.  For a whole year Daily Nazi went on and on about the LCP, stating that families weren't consulted, that patients were put on it without their consent. That patients were put on it to speed up their death. For a whole year the Daily Triumvirate of Gentleman's Hatred continually on a near daily basis misinterpreted proper healthcare decisions, using their misguided (broken) moral compass on how doctors and nurses should do their work and how they should come to their decisions. Contrary to popular belief, the LCP was never misused, just grossly misunderstood.

Quite frankly the only truth was poor communication on the professionals part, which is not unusual. Talking about dying in hospital is often very hard, not just for relatives. But also for those professionals, because you don't want to be seen like you are failing in your job by letting someone die. Good communication is of course key to all good care. This comes with experience and training. It does not come from reading the Daily Triumvirate of Gentleman's Hatred. But the fallout has been such that some relatives seem to think that DNACPR and Advanced Directive are somehow Liverpool Care Pathway remade and should not be considered at all. But since scrapping the LCP we have got better at talking to relatives and patients regarding end of life care has improved, but the availability of said services have not. I know there was much rejoicing when it was scrapped, but when NICE published new guidelines on end of life care. It was all very much a rehash of the LCP, it just can't be called that now. We provided individual care to all patients before and we still do so.

And the fallout didn't just affect adult nursing, it also affected paediatric nursing. Paediatric Nursing had been trying to develop a similar pathway for years. Seeing as there was the need for one. Palliative care for children is not as well known, generally again this is not a subject that a lot of professionals want to have. They will, but no parent actually wants to hear that there is nothing that the hospital can do for their child and that they would benefit from palliative care, rather than active treatment. The need for a tool for healthcare  professionals to use in order to assist them with making those decisions and the rationale for those decisions was lacking. It's a conversation that neither party wants to have, but both desperately need.

Sometimes further treatment is just inflicting pain on children, with no hope of either cure or reprieve. Extending hope when there is none. Children, like adults, need and deserved tender loving care. And like with adults, how children die stays in the memory of those who live on. But again, thanks to the triumvirate of gentlemans's hatred, the development of said pathway for England(and Wales) was halted almost indefinitely. NICE since have published up guidelines on how manage and plan end of life care for children. Scotland have also been developing an excellent one.

As healthcare professionals we really could do without all the blame and suspicion that is cast on us by paper of Gentlaman's Hatred. It gets in the way of good care when patients and relatives judge our actions based on lies and falsehoods that are propagated by those papers. The readers and writers of said newspapers looked at the loss of the LCP as some sort of victory for the common people, when it was anything but. It was the common people who lost out on a very effective, very good tool that was made for them. It's the common people that lost out. No one goes into healthcare with the thought of making money, they go into it for fulfilment of the job. But it's hard to do the job when writers who don't know anything about healthcare cast doubt and aspersions about your reasoning for being a nurse or a doctor. My job is hard enough as it is, please stop making it harder. I want to care for my patients, not for rumours.

Wednesday, 1 February 2017

Metal Nurse: Physical health within mental health

One of the many healthcare areas that hold great interest to me is mental health. Prior to starting my nurse training I had worked in secure services mental health for 6 years. It was an eye opener. It was essentially what lead me to doing my general health training as opposed to mental health training. This article should tie with my previous article on self harm. The focus here is of course on how patients physical health should also be the focus within a mental health setting. What was often not always noted is that physical health problems can manifest as mental health issues. For example infections can and do lead to delirium, especially Urinary Tract Infections. Even constipation will cause confusion and mood swings.

Quitting Smoking
My main interest at the time though was the physical well being for those patients. The lack of physical health care for patients in long term mental health institutes has been recognised for a long time. Patients with schizophrenia are for example known to die from natural causes sooner than the general public. Hence the need for mental health nurses to be trained better in order to recognise and tackle physical health issues. The most common causes for the mortality rates are smoking and obesity.

The rates of smoking are two to three times more common within patients who have schizophrenia than the general public, two out of every five cigarettes are smoked by people who suffer from mental health problems. And people who have bipolar disorder have also been known to be 2 to 3 times more likely to smoke. Not only that but those with mental health problems smoke more than the general public that smoke. So the dangers of smoking are enhanced and the importance of smoking cessation becomes even more important.  The dangers of smoking cannot be over stressed, and the benefits of quitting smoking cannot be underlined often enough. According to a systematic review by the BMJ, quitting smoking has not only physical health benefits but also mental health benefits. And that's across the board. Or as the meta-analysis says itself: 
"Both psychological quality of life and positive affect significantly increased between baseline and follow-up in quitters compared with continuing smokers.  
There was no evidence that the effect size differed between the general population and populations with physical or psychiatric disorders. " 
Essentially. Anxiety went down, depression went down and stress all significantly decreased AFTER quitting smoking. Which all in all just says to me that mental health care facilities should place a stronger focus on smoking cessation then they already do. What should also be added is that if you are on medication for your psychiatric issues, you take less medication if you quit smoking. The reason being is that smoking increases the body's metabolism of most of those drugs. This is especially apparent in those who take clozapine. For example when the smoking ban came into effect within UK's mental health facilities the plasma serum levels went up, because of patients reduced smoking. But that often wasn't accounted for when considering the patients medication dosages.

Quitting smoking isn't easy, I know that from personal experience, and in I would imagine that those who already have diagnosed mental health problems will find it more difficult hence the need for more robust support during the smoking cessation. Which also just brings the point that nurses should also work as role models in terms of their health promotion. Seeing as there are so many nurses that still smoke. It is pretty difficult to provide good support if you aren't willing to seek out support for it yourself. We also have to smash the preconception that drinking coffee and smoking cigarette first thing in the morning is something that is okay, and think that it is a safe and effective way of getting someone to calm down when they are having a psychological breakdown. Verbal de-escalation works a lot better then the offer of a cigarette and a cup of coffee.
Learn How To Become...
As mention previously obesity is the other big(no pun intended) issue for mental health patients. It is well known that certain psychiatric medication induce weight gain and in longer term morbid obesity. Obesity leads to several physical health related issues as well as mental health. This would include,  Type 2 Diabetes Mellitus, Stroke, Coronary Heart Diseases, Infertility, Loss of Bladder Control, and many many more.

Regarding T2DM, it becomes a big issue within a hospital setting as often the health care staff looking after patients with diabetes sometimes mistake hypoglycaemic episodes with delirium or psychological breakdown, hence delay of proper treatment. With patients who suffer from schizophrenia they also often suffer from defective glucose tolerance and insulin resistance. Which makes recognising diabetic crisis hard to tell from psychological crisis, for those who are not appropriately trained.

Then there the psychological issues. Being obese can lead to depression, anxiety, body dysmorphia, low self esteem, and many more. Of course if you already do have those issues being obese will exacerbate those issues.

Since weight gain is a very common side effect of psychiatric medication, and well known by mental health care professionals,  I do wonder why rolling out weight management plans alongside starting the drugs isn't done. Because losing weight is not an impossibility like a lot of professionals seem to believe.

 The medications will increase their appetite, but that is not the only reason for it. Whilst in a secure setting patients become more idle, and their diet intake tends to be very poor. I remember watching patients eating increbile amounts of takeaway foods, sweets and gulped vast quantities of soft drinks. But on the flip side I don't remember an awful lot of healthy food stuff being promoted, like the 5 a day fruit and veg intake.Or just the whole Change4Life campaign. Or drink to water. Or even Meat Free Monday's.

In a large study published by NJEM, it was shown that with the right plan and the right intervention, patients with serious mental health problems could lose weight and not just that but keep their weight down following lessening of weight loss sessions. Even with obstructions like hospital attendence's, breakdown in mental health and so forth. Of course like with smoking, it is sometimes hard for nurses to be role models for life style changes when they also feel like they can't tackle the subject due to their own life style.

All in all, what I personally would like to see more of is further physical health training for mental health nurses, and of course vice versa for general nurses. Because all training for either will only improve both professionals healthcare practice.

Friday, 7 October 2016

Metal Nurse: The importance of the flu vaccine

In my second year as a student nurse I decided to write a blog that pretty much transformed my musings from music to health care related stuff. It was about the flu vaccine. I think it was pretty good and so did others, to the point where one of my favourite internet pages, Skeptical Raptor, reblogged it. So here I am, nearly 2 years later having been qualified for over 18 months. Still having to refute myths about this vaccine. If you work in health care there is no good excuse to refuse the vaccine. You do not have an excuse. Lets begin with a few quotes from the NMC Code of Conduct from 2015:

  • "Always practise in line with the best available evidence."
  • "Act without delay if you believe that there is a risk to patient safety or public protection."
  • "Be aware of, and reduce as far as possible, any potential for harm associated with your practice."
  • "Take all reasonable personal precautions necessary to avoid any potential health risks to colleagues, people receiving care and the public."
Those are the points that I feel are the most important. 
And of course according to the GMC Good Medical Practice:

  •  If you know or suspect that you have a serious condition that you could pass on to patients, or if your judgement or performance could be affected by a condition or its treatment, you must consult a suitably qualified colleague. You must follow their advice about any changes to your practice they consider necessary. You must not rely on your own assessment of the risk to patients
  • You should be immunised against common serious communicable diseases (unless otherwise contraindicated).

Swine Flu plush toy.
I would like to introduce the concept "Post hoc, ergo propter hoc.". Translates as "after this, therefore, because of this.". Basically it is when you want to connect one event to another because of reasons to make the world seem like a logical place. You see a butterfly, then a thunderstorm happens. That kind of thing. It's not a very rational thinking process. Okay, why am I talking about it here? One of the many many excuses I hear regarding the flu vaccine has been "My relative had the vaccine, then they ended up with a cold."
One thing does not have to correlate with the other. Especially when the common cold is caused by
coronaviruses and rhinoviruses. The flu is only caused by the influenza virus. And the flu kills. On a regular basis. According to WHO, the flu kills between 250.000 and 500.000, every year. In England in 2013-2014 the Public Health England recieved 904 reports of patients being admitted to ICU, out of those 98 died. That's a whopping 11% mortality rate. According to the European Centre For Disease Prevention and Control, the season between 2014 and 2015:

  • "In 15 European countries that report mortality data to the EuroMOMO project, an excess winter mortality rate of 231.3 per 100 000 above the seasonal baseline was observed. This excess was noted for more than 11 consecutive weeks and was the highest of the last five winter seasons."

No, the flu is not just a bad cold. It's a killer. But not just deaths that we should be concerned about it's the complications that follow having the flu, the complications that arise for those who suffer from chronic illnesses, like COPD or diabetes. For those who have pre-existing lung conditions, the flu is even more deadly. Not just deadly it also exacerbates the disease and they rarely every recovered back to baseline. But it has been found that the vaccine reduces hospitalisations of diabetics by 72%, and up to 52% of those who suffer from chronic lung disease. It reduces mortality and ischaemic episodes in those who are recovering from angioplasty. It also prevents cardiacvascular events. Some of the rarer but also dangerous complications from the flu include:
Influenza associated encephalopathy is a rare complications. But it does have up 30% fatality rate. It is most likely to affect babies from 6 to 18 months old. With one third of those affected will suffer from neurodisabilites. 

Meningitis is a complication that occurs due to a viral infection. The influenza virus being one of the more common virus that can cause it. 

Guillan-Barré syndrome, has long been associated with the flu vaccine. But there is a story behind that. All in all it's the story that sort of defines everything about science, how science develops knowledge and improves on what it knows and continues to define how we as healthcare professionals should follow the evidence. In 1976 there was a case of where it was linked to the flu vaccine, so researchers concluded that there might be a casual link between then the swine flu vaccine and GBS. The most current research fails to find any link between them. If you get infected by the flu you are at an increased risk of developing Guillan-Barré Syndrome, 17 times more likely to develop it in fact.

But why do I rail against health care staff who refuse to be vaccinated. Simple. We take care of acutely ill patients. We are around them all the time. We take care of people who are infected with some nasty nasty illnesses. One in three people who get infected by this virus are asymptomatic carriers. So the danger of infecting those who are vulnerable increases. Because you can pass on the virus without ever showing symptoms yourself. It is infectious for at least 24 hours prior to any symptoms developing and is infectious 5-7 days during the infection. Which is why herd immunity is so important, or community immunity for those who like concepts that rhyme. In a nutshell herd immunity is where there is enough people vaccinated against a contagious diseases to protect those who cannot be vaccinated and/or are vulnerable to disease that are easily spreadable. And (I will be repeating this point) healthcare professionals are a big part of that herd (or community) in hospitals. This is important to remember, there are people who rely on this. And all of them will be in our care. The list includes:

The list is of course not exhaustive.

Most healthcare workers seem to have no objections to vaccinating against other illnesses, like measles or hepatitis B. But somehow they seemed to have this blind spot when it comes to the flu vaccine.

The "I've never had the flu, so I don't need the vaccine" excuse doesn't work. For the same reason as "I never got pregnant, so I don't need contraceptives." Or  "I've never been in a car crash, so I don't need a seat belt." Don't work. I've never had hepatitis B, you can be sure that I'd have that vaccine again. Same goes for all of them. I've never had Tetanus, but you can bet your bloody arse that I'd get the Tdap if I've had a serious cut when walking around mother nature. I've never had Yellow Fever, Typhoid, Cholera, Japanese Encephalitis or Hepatitis A but yes I'd have that vaccine if I was travelling to those countries where they are prevalent.

And honestly I struggle to understand why, most of the time I think it is purely out of sheer bloody mindedness rather than actual facts. Some people see it as a form or rebellion against a higher authority. It's one small needle. Once a year. And it's there to protect us, our loved ones and those who we are taking care of. There is not beating around the bush about this. At worst we will get a sore arm, 24 hours sniffles and an immune system that will know how to battle the flu. It's a myth that you get a cold after a vaccine and it's a myth that healthy people don't need a vaccine.

I have come across people who just flat our state "I don't agree with it." What is there not to agree with? It's a low risk thing to do. Even young health people have died from the flu. In fact if you look at the greatest epidemic in human history, the Spanish flu, majority of those who died were aged between 20-50. The more I listen to people who object to it, the more I get convinced that it should be mandated as a requirement to work in healthcare, like they do in America. Require those who don't vaccinate to wear masks if necessary. We are there to take care of the patient. Not our ego. Our egos will heal, some of our patients might not because of ill-thought out refusals.

"What about my right to refuse?" Well, what about it. Yeah, sure you do have the right to refuse it. But what about the right of the patient  to be taken care of by someone who works within evidence based practice? What about the right of the patient to be taken care of by someone who takes every step to make sure that THEIR health and well-being is the centre of their care?

Is the vaccine perfect? No, sadly it isn't. But it still offers the best protection available. Currently it offers between 50% and 60% protection, which is damn sight better than 0%. Though currently there are some great developments in terms of developing a universal flu vaccine. The issue is that there is more money for pharmaceutical companies in people getting ill with the flu, rather than the vaccine. But as an organisation like the NHS, we save money on people getting the vaccine. There is a reason why every medical organisation in the world recommends that their staff have the annual flu vaccine. And it's all about protection.

Are there complications with the vaccine? Certainly, but they are rare. Redness, soreness and localised swelling are most common. 1-2% of those who get the vaccine might get a fever. Rarer side effects include hives, urticaria, racing heart and high fever. Anaphylaxis might occur in 1 case per million doses given. But 
compared to the chances of getting the flu, I'd rather have the vaccine.

We are there to  take care of and protect our patients from harm. We barrier nurse them. We gown up and use face masks when needed. We use gloves, we wash our hands. We give intravenous antibiotics and anti-virals. But a small needle that will protect you from a dangerous disease is somehow a step too far? Really? 

Thursday, 29 September 2016

Metal Nurse: Sexual Health Care for the Older Generation

Everybody likes sex. Everybody likes to read up on sex. Everyone should have sex. On some level we should be more open about talking about sex. In recent years we also have been able to open up about one ageing taboo: Old people having sex. Now, it's is something that needs to be tackled but no one really wants to talk about it. Why? Well, who wants to imagine their parents having sex? I don't. I am pretty sure that my kids don't either. But it is quite frankly beautiful to know of, that people in their twilight years are still enjoying themselves. More and more people seem to be enjoying their retirement age having lots and lots of sex. And who can blame them? Now that it's all out in the open the next thing we have to discuss is the rise of STD's in the 50+ population.

During my university years I volunteered  in the Chlamydia Screening project which was part of Best2Know. So I got to know about how common STD's are in the university student population. There's a big focus in getting the 18-24 to get tested for chlamydia and give free condoms in order to stave infections. It was interesting and fun to assist with, but since most of the people I take care of are a lot older, I started wondering how common STD's are in that age group. Turns out it is quite a lot. I had read that currently the over 55's are second highest group in terms of increase in new STD's diagnoses.

Middle Aged Spread
So now that we've managed to open the discussion about older adults having sex. Maybe we should start talking about contraception with the elderly. Some survey's done show that a lot of those who are still sexually active do want to find out more about STD's, but often don't feel like that can. In recent years cases of STD's has rise in the population aged 50 and over. According to the CDC, HIV alone as increased by 15% from 2000 to 2010 in that particular age group. Syphilis has been on the rise again, even though you would have thought that that one was gone the way of the smallpox. Gonorrhea and chlamydia have both seen big increases in the older generation.  Now the issue we have with these numbers is because it is based on people who seek treatment, so there is a big danger that the number of infected individuals is much higher.

But why is this an issue? People of that generation tend to not want to talk about it. Unless it's about bragging rights, they like to talk about being in a new relationship. But don't want to talk about the potential consequences of being in a new relationship. With a partner they might not know the past sexual history off. Women in particular after menopause think that they won't need contraceptives like the condom because they won't get pregnant. But condoms are not just there to prevent pregnancy, they are the ONLY contraceptive on the market that prevents STD's. And you are never too old to use a condom. Maybe the conversation needs to be about how to use them correctly. Because it is a myth that sex is less pleasurable with a condom, but this myth persists. Besides this generation is the one that grew up with the contraceptive pill, so the talk for condoms most likely didn't happen, and research has shown that those over 40 are less likely to use condoms. Mostly I'd imagine it is because they are just so damn embarrassed about it, they shouldn't be. They've been given a new lease of life. You can get Viagra pretty easily (just don't buy them online) to help with erections, lubricants to help with vaginal dryness and meeting new people has never been easier thanks to the internet.

What would help, as we open up and talk more often course, is if doctors and nurses started incorporating sex education into our health promotion. Or maybe GP's could include sexual health checks with their annual physical assessments. Especially if we suspect that some individuals are practising unsafe sex. Maybe it's time to introduce sex education for over 50's, there is plenty of focus on sex education with teenagers. But in reality how much do adults know about safe sex? Should we really presume that as people get older the stop enjoying sex altogether? The urge to have sex might decrease but that is not the same as stopping altogether. It isn't just infectious diseases that they could discuss, this could be incorporated with talking about erectile dysfunction and vaginal dryness. What medication they could take to alleviate those symptoms and/or what medication they are taking could cause those symptoms. Because I don't don't know how often those side effects are discussed or even contemplated when new medication is being prescribed to patients. Us health professionals also have to do our bit and confront our fears and prejudice regarding sexual health, especially with people who are old enough to be our parents.

The focus on safe sex campaigns and use of contraception has been always on the younger age group, if only because they remain the group that contract most STD's on the most frequent basis. They tend to also be the most likely to seek out help if/when they are aware that there is a problem with their genitalia. They get free chlamydia screening kits and they get free condoms given on a regular basis. The other reason of course why the focus has been on this group is because they will hopefully be paying taxes for a long time, well up until they reach retirement age, and have children. But they won't be able to do any of that if they don't get their various STD's sorted and treated quickly. Because the economical factor of neglected cases is immense. The other reason why the focus is on the younger age group is because some STD's like the Human Papillomavirus, if left untreated, can lead to people developing assorted cancers. Up to 70% of cervical cancers have been attributed to an chronic and untreated HPV infection. Up to 25% of oropharyngeal cancers have been linked to HPV.  But of course the problem doesn't just lie with cancer. Then there is also the cases of infertility, because fertility treatments are extremely expensive and time consuming.

Then there is the issues of differential diagnosis. With all this in mind various STD's should be considered as such. Gonorrhoea, Chlamydia and Syphilis, all have various signs and symptoms that go with other diagnoses.

But why neglect those over 50's? Because as the populace get older they will need more treatment for long-term illnesses, and adding something that can be both treated and prevented so easily into the mix is just going to cost the society more. As The Kings Fund has pointed out, patients with long term conditions could cost the UK an additional £5 billion by 2018. So why add untreated STD's into the mix?