What is A1C?

What is A1C?

A1C, or Hemoglobin A1C (HbA1c), is considered the gold standard for managing diabetes. But what is it?

The cell wall of the erythrocyte is permeable to glucose. Exposed to this glucose, the Hemoglobin molecule becomes “glycated.” The naming convention for HbA1c derives from Hemoglobin type A being separated using cation exchange chromatography. The first fraction, considered the pure Hemoglobin A is designated HbA0. After that comes HbA1a, HbA1b, and then HbA1c respective of their elution. Hemoglobin exposed to a normal level of glucose has an average glycation. As the glucose level rises, so does the fraction of glycated Hemoglobin, in a predictable way.

The average lifespan of a red blood cell is about 120 days before the cell membrane starts showing signs of wear and tear and they get shuttled off to the spleen, liver, and bone marrow for breakdown and recycling. The A1C therefore is a picture of the AVERAGE blood sugar over the previous 2-3 months. As an average, it cannot tell the difference between someone with tightly controlled blood sugar and a person with wildly fluctuating highs and lows. Neither does it identify episodes of hypoglycemia or periods of critically high blood sugar values. It’s great for population management but too crude a tool to manage an individual patient.

In the chart, we see a day in the blood sugar levels of three patients. All three have the same average blood sugar, but patient number 1 and patient number 2 have wildly fluctuating levels throughout the day. Patient 1 spends more time outside of range than inside, but her A1C would be normal.

The A1C coupled with the patient’s daily blood sugar record gives a more complete picture for individual patient management. Other shortcomings in the A1C happen with patients with high or low blood cell turnover.  Patients with kidney disease undergoing dialysis have especially high turnover of red blood cells due to the process of filtering the blood. Their A1C would be abnormally low. Cirrhosis of the liver decreases blood cell turnover leading to higher A1C levels. Certain types of anemia and blood disorders as well as some vitamins and medications can affect the accuracy of the A1C. If you hang your hat on the A1C for all your treatment decisions, you will be misled.

So, what is the A1C good for? The American Diabetes Association has the following guidelines to be used in the diagnosis of diabetes:

 

A1c Level What It Means
Less than 5.7% Normal (minimal risk for type 2 diabetes)
5.7% to 6.4% “Prediabetes,” meaning at risk for developing type 2 diabetes
6.5% or greater Diagnosed diabetes

 

Following it over time allows for risk evaluation for complications arising from diabetes. There’s a strong positive correlation between high A1C numbers and diabetic neuropathy, kidney disease, and eye disease. Diabetic specialists use the daily blood sugar levels to formulate an individual plan for each patient to drive the A1C numbers lower over time.

Understanding the A1C and what it does and does not tell you is important. It’s a great starting point, but not an accurate tool for individualized diabetes care.

Reflex Syncope: What You Need to Know

Reflex Syncope: What You Need to Know

You gave your patient a shot and he or she passed out! What did you do wrong? Nothing.

example of reflex syncope

No patients were harmed in this photo.

Vasovagal syncope is one of three related syncopes that share a common pathophysiology. Together, they are called reflex syncope. The three are vasovagal, carotid sinus, and situational. Vasovagal is what just happened to your patient. Pain, seeing blood, emotional reaction, and prolonged standing are triggers of vasovagal syncope. Situational is triggered by urinating, coughing, or swallowing. Carotid sinus is triggered by stimulation of the nerve bundle located in the carotid sinus of the neck.

These neurologically induced losses of consciousness are brief and resolve without specific treatment. They are usually preceded by feeling dizzy, sweating, tunnel vision, odd feeling in the chest, or feeling very hot or very cold. The pathophysiology is an abrupt slowdown of the heart rate and a dilatation of the blood vessels leading to hypo-perfusion of the brain. Basically, the pump can’t get blood to your brain and you pass out…and you fall down.

First of all, it’s important to NOT PANIC. There is nothing you can do to fix it. Prepare for it by observing your patient immediately after giving an injection or drawing blood because these are prime times for a vasovagal episode. Make sure the patient is already seated and if you notice your patient is getting pale, sweaty, stuttering, or acting odd, gently guide your patient to a lying position with the feet up. Sometimes the loss of consciousness comes with muscle twitching that looks like a seizure.  Unlike a seizure, there is no prolonged postictal period, muscle clenching, or incontinence. While the loss of consciousness will resolve as soon as the patient lies (or falls) down, he or she will probably pass out again if he or she gets up so keep the patient under observation and lying down. It’s a good idea to get serial blood pressures so you can document the resolution. Every five minutes is fine. Your first blood pressure will be low with a heart rate in the 60s or high 50s. Over the next five to 15 minutes the vasodilatation and bradycardia will resolve without intervention but if you let the person stand up…boom! Don’t let the patient get up until they have a documented normal BP and HR. You can bring them a blanket, a drink of water, some juice, anything you like. Nothing is going to make it resolve any faster.

How do you know it’s vasovagal syncope? Easy: Did you just give this person a shot, draw blood, or let them see a bloody bandage or wound? If so, did they then get pale and sweaty and fall down? When they were horizontal, did the loss of consciousness resolve? Yes? That’s it! The only thing you can do wrong is try to stand them back up again!

So what do you do if this happens to your patient? To recap, don’t panic, make sure the patient is safe, call for help, get serial blood pressures, and observe the patient until the BP and heart rate are normal. Usually there is no need to call for an ambulance unless the patient actually fell down and hit his or her head or the symptoms are not resolving.

Remember, it’s a common occurrence and patients that are prone to it will probably do it again. You didn’t do anything wrong!

Are You Mentoring Someone?

Are You Mentoring Someone?

One of my greatest pleasures in life is being a mentor to the next generation of nurses (not all of them, obviously!). I’ve learned over the years that the mentor/mentee relationship should be taken seriously. Mentoring relationships have often grown organically in my career. Though they are informal in nature, they provide a touchstone, an outlet, and a path for success to the mentee.

One thing you have heard in this career is that nurses eat their young. I’m not convinced that this is unique to the profession. Look around you and you’ll see someone in need of a helping hand in their life, and I’ll bet you have something to offer.

Here are 10 ways you can make the most out of your mentoring relationship.

1. Start by taking inventory of yourself.

What are your strengths and weaknesses as a nurse? With experience can come bad habits, corner cutting, and sloppiness. You don’t want to pass those on as wisdom. Conversely, I’ve gained deeper insight into the process of nursing, how to work within a system to promote change, how to put patient safety and outcome at the top of my priority list. These are the things I want to share.

2. Model the behavior you want to see.

I hate to say it but anyone can talk the talk. Oddly enough, I found that hand washing is a great silent instructional tool to model the correct behavior. There are plenty of nurses modeling bad behavior, but it only takes one person to do the right thing for it to catch on.

3. Be quick with praise.

The new nurse often works in a vacuum of praise. They are just expected to always be correct. I point out the correct behavior when I see it. That moment of reinforcement will last a lifetime. I’ll bet you can think of a time when someone praised you.

4. Don’t let a bad habit take root. 

Gentle correction like, “You are doing great. I can see why you did it that way, but let me show you the right way… and here’s why.” The trick is to give constructive criticism in a way that works to change behavior without humiliating the receiver. One humiliation can sour a relationship. I never give correction in front of other people. I just don’t do it. Gentle correction in private is the way to go.

5. Be willing to learn.

Medicine requires a lifelong commitment to learning—and not just doing CE’s to renew your license every few years. Every day I find some new facet of my practice where I don’t know something. How does this medicine work? What is the natural course of this disease? What is the meaning of this lab value? Modeling to my mentee that I’m a learner encourages him/her to be a learner as well.

6. Be comfortable enough to share your mistakes.

We’ve all made them. I let my bad experience be a learning tool for my mentees.

7. Show the wonder of medicine.

Enthusiasm, excitement…these things can die if not frequently watered and fed. We have so much pressure on us as nurses that we can forget to see that caring for another human is a wonderful experience. The human body is an awesome machine for carrying around our mind. Even in great states of stress or disability, it can surprise us with its tenacity. It can also surprise us with its fragility.

8. Invest time in your mentee.

Time is all we have on this good earth. It’s my most valuable gift and when it comes to mentoring, I give it freely. Someday, one of these young nurses is going to be caring for me, and I want the compassion that I have for my patients and my craft to be reflected in the next generation of nurses.

9. Have fun.

If you aren’t laughing, you aren’t alive. Caring for the sick and injured at the bedside is tough cookies. Having a ready joke, seeing humor in difficulty, smiling…these are valuable coping tools that I use daily.

10. Finally, be compassionate.

It’s our most valuable asset. Having compassion for our fellow humans sharing this journey of life helps give us meaning. Compassion leads to love, and kindness, a desire to understand the plight of others, to intercede in tough circumstances, to be a good servant to mankind. That’s what we should want to pass on to the next nurse.

Don’t let a mentoring opportunity pass you by. You’ll find, like I did, that being a mentor is fun, rewarding, and a two-way street. I get 10 times as much as I give.

Understanding Patient Sexual Orientation, Gender Identity, and Expression (SOGIE)

Understanding Patient Sexual Orientation, Gender Identity, and Expression (SOGIE)

How often should a man get breast and cervical cancer screenings? Should a woman get screened for prostate cancer? The answer to these questions and more depends on knowing if your patient is transgender.

The Williams Institute estimated the transgender population in the United States to be 1.4 million in 2016. A recent study in Minnesota of 9th and 11th graders found nearly 3% of students identify as transgender or gender non-conforming. When it comes to health care, are we ready to meet these patients’ needs? Several cases where a transgender or gender expansive person was not properly identified or their provider simply was not aware of issues regarding transgender individuals have been in the news lately.

My county hospital is rolling out changes to our HIMS to try to capture this complete information on all of our patients, including transgender and gender expansive patients. These questions are called SOGIE, which stands for Sexual Orientation, Gender Identity, and Expression, and we ask them at intake:

  • What is the sex listed on your original birth certificate?
  • What is your gender identity?
  • What is your sexual orientation?
SOGIE

Source: Benny O’Hara, Office of LGBTQ Affairs, County of Santa Clara

Our initial goal is to capture 10% of our patient population with rolling increases as we move forward. In the hopes of meeting all of our patients’ needs we will ask these questions just one time over the patient’s lifetime. However, the patient can initiate changes at any time in the future.

Our LGBTQ patients can have health issues that are occult if we don’t have correct data. A female-to-male, or FTM, person with residual breast cancer did not know he needed breast cancer screenings. By the time it was diagnosed, the cancer was advanced. Another patient, male to female, or MTF, did not discover her prostate cancer until it metastasized to her bones.

What are the barriers to care for transgender patients? The first is the patient’s comfort with disclosing information about their sex assigned at birth and current gender identity. For a variety of reasons, transgender and gender expansive patients might not trust their caregiver or the health care system in general. A person who has transitioned has spent a great amount of personal capitol to live the life they need to live. It’s not a lifestyle change. It is the core of a person’s being.

A 16-year-old patient who has made the transition from female to male tells me, “I’m not transgender. I’m a boy.” He does not identify as transgender. Practitioners find this a common outlook in their transgender patients. Some transgender individuals may feel that they have always known their gender, and that it was society and other persons who incorrectly assigned or perpetuated a gender identity on their behalf – one that did not ring true for them.  Sharing of this information with a caregiver who is not familiar with the patient might not happen if the patient is not trusting or believes the information is not germane to the situation. For a primary care provider not in the know, this creates problems with preventative care with serious consequences. The SOGIE questions start a conversation that might not otherwise have occurred.

Another barrier is on our side of the street. Are we comfortable asking a patient if they are gay and/or transgender? While rolling out our new SOGIE questions, we find push back in unlikely places. Care providers and nurses at our in-service had these objections:

“My patients will be insulted.”

“Patients of some cultures will be offended if I ask that.”

“Some patients will not understand the difference between sexual orientation and gender identity.”

“This will take too much time.”

For some, a supposed patient objection is a mirror of their own feelings. “I would be offended if someone asked me if I’m gay.” For others, cultural taboos of their own might get in the way. Are we projecting our issues onto our patients? Personally, I’m excited to see my patients’ reactions to the questions and I look forward to educating them on the meaning of the terms. It’s a valuable tool to identify health care needs and an opportunity to destigmatize a subject that might seem uncomfortable.

You can’t tell if a patient is gay, straight, or anything else just by looking. The original birth certificate does not indicate the patient’s current sexual orientation. Often, a transgender person will legally change their birth certificate to reflect their correct gender identity. We just don’t know by looking at a person or their documents what gender identity or sexual orientation they are. Health issues can’t be addressed if we don’t know.

Annette Smith, a nurse at Santa Clara Valley Medical Center in San Jose with 35 years of experience, has insight into changes in practice like the new SOGIE questions: “At the beginning, there is a lot of push-back. ‘The sky is falling! The sky is falling!’ But after a while, the process becomes normalized and it’s not a big deal. We end up wondering what all the fuss was about!”

East Meets West in the Bathroom

East Meets West in the Bathroom

A patient needed assistance in the bathroom.  An elderly, obese, female with Lupus affecting her legs and hips needed help transferring from her electric wheelchair and some assistance with hygiene and buttoning her pants. It’s something I’ve done a million times and I didn’t think twice about it. What happened later made me think about the differences in cultures between India and the United States and how to approach these differences when they come up with someone in the workplace.

After the job was completed and the patient gone, the episode came up in conversation between the patient’s doctor, who is from India, and myself. While she didn’t exactly dress me down, she was very firm that clinic nurses were not supposed to help patients in the bathroom. She gave me several reasons:

“The patient takes care of herself at home. Why do you need to do it here?”

“If the patient has a caregiver at home, where is the caregiver now?”

“What if you get injured, who is going to take care of you?”

“If you help her in the bathroom this time, she will expect help every time she comes.”

I thought about this conversation for a long time. Without a doubt, I was correct to help the patient. This I know. It’s required by the nursing oath, and it’s required by my own moral code. Why did this doctor see things so differently?

Indian society is rigidly stratified by religious and socioeconomic class. At the bottom are the untouchables who work with waste. This stratification was formalized during British rule with some 60,000 different classifications. With this in mind, I realized that my doctor was actually trying to protect me from performing work outside my caste, which would be degrading to me. From my point of view, all people are created equally. As a nurse, when someone asks for help, I don’t have to decide if that person is worthy of my help or if performing a task is outside of what is permitted by my caste. I just do it.

From the doctor’s point of view, I was performing a task outside of what is permitted by my caste and performing it for a person who is of lower status than myself. I was breaking social norms, degrading myself, and degrading the clinic and other nurses whom she expected would not perform such duties. After doing some thinking, I can now appreciate her point of view, but it is not my point of view. The tricky part is how to address it in the future in a culturally sensitive manner. I don’t want to insult my doctor. She is in a position of power over me. I don’t want to break my nursing oath or my personal moral code to always offer assistance when someone asks. In this case, I’ve decided to simply not bring it up again. I will continue to perform my nursing duties as I always have without mentioning it. I will respect my doctor’s culture by simply avoiding the subject in the future. In a perfect world where I’m king, I would explain to the doctor my point of view and expect her to change her point of view to suit my own. However, the world is not perfect, and I’m not king. So respect, cultural sensitivity, and work relationships will win out over my personal feelings.