I sprained my knee. That’s how I found out my 14-year-old daughter was struggling with her gender identity. I was combing the house for an ace wrap and found it in the dirty clothes basket in Karen’s room. It looked like it had been through a war. No elastic left. Karen had always been a tomboy. She wanted to mow the lawn, play with bugs, play sports…she was always moving and had zero interest in “girl stuff.” I took her to Claire’s in the mall a few times and she looked totally lost as I picked out headbands, earrings, and miscellaneous froufrou. I guess she was sending signals for years, but I wasn’t picking up the phone.
I don’t know how it dawned on me that she was binding her breasts. It just came to me and so I asked her, “Are you binding your breasts?” She started crying.
“I was born in the wrong body!” She said between racking sobs.
I’m ashamed to say it, but my first thought was, “Why me?” I took her to the pediatrician. She told me that this is just a phase. Karen is hanging out with the wrong people. Monitor her closely. Watch her friends. Ignore it and it will go away.
I was already pretty obsessive about who she hung out with. On play dates I would make sure I went in the house and met everyone involved. When I took her and her friends to the mall, I quizzed the friends about their home life and their grades. I thought I was doing everything right. Over the next year, our relationship deteriorated. I found marijuana, vape pens, bongs…she became a stranger to me. It was all yelling and grounding and taking the phone away. She didn’t do homework. She hated me. So much for the pediatrician’s advice.
I reached out to one of the pediatricians I had worked with and respected and asked him to recommend a doctor who worked with transgender teens. I made an appointment. Dr. Mitch spent an hour with Karen…without me in the room. When Karen came out of the appointment, a weight seemed to have lifted from her shoulders. Later, Karen told me the nurse had given her a shot to “make my period go away.” I was beside myself. I called the office and demanded to speak with the doctor. My rights as a parent had been violated. How dare he give my child something without discussing it with me first. I wasn’t against the shot so much as being cut out of the decision.
Dr. Mitch called me back that afternoon and spent an hour on the phone with me. Can you imagine? An hour. He patiently discussed what Karen was going through and informed me that children over 12 can get birth control without parental consent. I had no idea. He explained that Karen had gender dysphoria: The constant feeling that her body was the wrong sex. Karen had anxiety, anger, feelings of hopelessness, and diminished self-worth. My child was in pain. Thus, started my education in transgender children. I knew by now that it wasn’t a phase but, I have to admit, I was still hoping that it would go away. My own feelings of self-worth had taken a hit, honestly. What kind of a parent was I? How could I let this happen?
WPATH (www.wpath.org) is the World Professional Association for Transgender Health and they write the standards of care for transgender health care. Dr. Mitch suggested I look over the information on the website and I did. It answered a lot of questions. Dr. Mitch assured me that there was nothing wrong with me and that Karen was always going to be my child. He suggested that if Karen wants to dress like a boy, it’s not permanent. He suggested I just back off and let her do what makes her comfortable. Of course, I was terrified that she would start taking hormones and have permanent changes that she would regret later. Dr. Mitch told me that Karen needs to live as a boy for a year and see a therapist every week to discuss her journey to make sure it’s the right thing. He wouldn’t prescribe hormones until Karen has been living as a boy for a year and his therapist signed off on the treatment.
Karen started seeing therapists who specialized in transgender teens. Insurance was a constant battle. The quality of the therapists was spotty. Karen, now Tony, was angry and impatient. He wanted testosterone now, now, now. He went to group meetings with other transgender teens and I think he saw how many of them struggled with no parental support. I remember seeing a young boy with long lanky hair and a defeated demeanor at a couple of his pizza party groups. I saw him, or her I should say, walking there and walking home. I really felt sad for this kid who wanted to be a girl so much. Tony told me the girl was grinding up DVDs and eating them because she heard the plastic works like estrogen. I really felt terrible for her. I determined that I was not going to be like her parents. However, I was not going to let Tony make any irrevocable decisions until we both were sure this was the way forward.
That year was a bit of a blur. Lots of appointments, Tony being angry. Kids and teachers at his school wouldn’t get with his name change and preferred pronoun. I blew it myself many times. I was so used to Karen, my daughter…not Tony my son. Problems at school came to a head and Tony pulled out of high school in favor of going to an alternative school. Things got better and worse, better and worse. I was at my wits’ end. All Tony wanted was to be seen by others as he saw himself, as a boy, not a girl. He bought some binders online and that worked, but they were uncomfortable and over time, left him bruised and misshapen. His girlish hips and curvy legs were problematic.
When he finally got the go ahead to start testosterone, he was so excited. Looking back, I think he thought that once he started hormone therapy, he would magically change into another person. It wasn’t like that. He still had problems with his old friends misgendering him. He still was behind in school. He still had all his old problems. That first year was the angry year. From my perspective, things got worse once he started testosterone. The doctor assured me that it wasn’t the hormones, it was just teenage angst. Tony went from twice a month dosing to once a week, halving the dose. I don’t know if that made things better or worse or didn’t do anything. I was scared, Tony was miserable.
Over that first year of testosterone, Tony gradually got more stable. I guess it was probably two years all in all before Tony got the body he wanted…or close enough that he can live with it. He’s 18 now and looks very boyish. He doesn’t bind his breasts anymore, but he does hunch his shoulders and tape his nipples flat when he goes out. We’ve discussed top surgery and I think the conclusion is that he can live with a small chest for now. There’s no talk of bottom surgery. I think Tony is finding a new middle ground between being a boy and being a girl. I tell him he doesn’t have to be binary, either/or. He can just be himself and I’m cool with whatever that self is. He is OK with being a boy with breasts. I know that given a choice he would choose not to have them. However, for now, the discomfort and risks of surgery are not worth the benefit.
Being a teenager is difficult in the best of circumstances. Tony is an adopted immigrant from Vietnam with a white single gay parent and born in the wrong body. Is it a surprise that his teen years were stormy? Not really. Tony worked all summer long at Chipotle and saved up his money. He bought his own car. He works two jobs. He’s smart and responsible. He’s good with money. He’s still afraid of school. He was tormented in high school and I think he has a lot of anxiety about going to college. I gently nudge him, but there is no hurry. He’s just about as perfect a person as I’ve ever seen. The trauma of those years of his transitioning is with us both, but gradually fading. I’d say he is a success story. He’s my son.
The 57-year-old woman is standing in the hall outside of the exam room. She is agitated. “I’m waiting for the doctor. I’m freezing! My back is killing me!” I note she is pale, unable to stand still, and has a sheen of perspiration on her forehead. She is in withdrawal. I get her a blanket and ask her to wait in her room. The pain clinic nurse is downstairs at the pharmacy getting the patient’s prescription for Suboxone for induction. Induction is the process of starting the patient on medication and finetuning the dose.
An hour later the patient is back in the hall calling me, “Thanks for the blanket!” She is smiling. Her color is back. She is clear eyed, calm, and collected. What happened? Suboxone. Suboxone is a combination of buprenorphine and naloxone that is used to treat opioid addiction. Buprenorphine is a partial agonist of the μ-opioid receptor with a high affinity and low rate of dissociation from the receptor. In English, the buprenorphine molecule sticks to the opioid receptor in the brain, but only partially activates it. Then it stays there for a long time, blocking it from opioids, before dissociating. What this means for the addict is that they get enough opioid receptor activation that they don’t get sick from withdrawal. They can function normally with less of the problematic effects of a full agonist like morphine or heroine.
The addition of naloxone, a full opioid antagonist (blocker), keeps the Suboxone pills from being crushed and injected. Though naloxone has a strong effect when given parenterally (by injection), its effect when given by mouth is negligible because it is poorly absorbed sublingually. Suboxone disintegrating tablets are given under the tongue.
So, what is this wonder drug all about? In 2000, federal legislation (Drug Addiction Treatment Act of 2000) made office-based treatment of narcotic addiction with schedule III-V drugs legal. Until then, the only option for addicts was abstinence-based treatment or methadone clinics. The ever-increasing rates of drug overdose deaths in the United States showed this was not working. At first, only MDs specially approved by the Department of Health and Human Services could prescribe medications to treat addiction. In 2016, President Obama signed the Comprehensive Addiction and Recovery Act allowing nurse practitioners and physicians assistants to prescribe schedule III-V drugs for the treatment of addiction. Previously, they could prescribe these medications to treat pain but not to treat addiction.
What does this mean for the addict? For starters, Suboxone and similar drugs are now more widely available. Until recently, the only way for a heroin addict to keep from getting withdrawal sickness was to use more heroine. These patients were considered toxic to regular doctors because their disease lead to ever-increasing doses, seeking medications from multiple providers, decreasing levels of health, and ultimately death. Now that there is an option other than going cold turkey, the addict without some kind of pain diagnosis can get access to health care whereas before they would avoid it because of the stigma of being an addict. Because Suboxone is a partial agonist with high affinity to the μ-opioid receptor, it decreases the ‘high’ if the patient continues to use narcotics causing the patient to lose interest. It offers the benefit of allowing the addict to function in life, decreases the likelihood of death from respiratory depression, and increases the quality of life because there is no need for the addict to ride the wheel of withdrawal—drug seeking, using, running out, and then seeking again to the exclusion of every joy of life.
What happens when a person starts buprenorphine? After a largish battery of tests, the prospective recovering addict will be asked to abstain from narcotics before induction to Suboxone. How long before the first dose the addict has to abstain depends on the person’s addiction. Longer acting drugs like methadone could be 24 hours. Shorter acting drugs like morphine could be as little as six hours. The person should be in the early stages of withdrawal. The reason for this is the “partial” part of partial agonist. The buprenorphine molecule will muscle other narcotics off the receptor site where it was fully activating the receptor. Now, the higher affinity buprenorphine is sitting there doing half the work that the heroine was doing and this leads to symptoms of withdrawal. Giving a person a drug that puts them immediately into withdrawal will turn them off to it completely. You won’t see that person again. Higher success rates are tied with higher levels of symptoms of withdrawal before induction. Now instead of precipitated withdrawal, the person has relief from symptoms of withdrawal even if they are not getting high.
A person who has been successfully inducted to Suboxone therapy will find almost immediate relief. The terrible body aches, muscle pain, abdominal pain, depression, diarrhea, and cravings evaporate. Our patient might just have found a new way to live, free from the constant need to find more narcotics. She can focus on her life instead of her disease. Most of the clinic patients have jobs. They want desperately to be productive members of society for themselves and for their families. Buprenorphine therapy coupled with lifestyle interventions provided by mental health professionals, self-help groups like Narcotics Anonymous, and patient-initiated interventions (like taking a class or going back to school) are part of the success story of a growing number of recovering addicts.
What’s it like to come off Suboxone? Eh, probably a lot like getting off heroine. Same withdrawal profile or pretty close. Patients wanting to get off all narcotics, including Suboxone, can be weaned off gradually depending on their desired treatment goals. Someone facing a jail sentence or travel overseas that needs to detox from opioids quickly may be on a tapered dose of Suboxone for just a few days or weeks. Other people may decide that the burden of staying on Suboxone is worth not having to go through withdrawal and choose to stay on a maintenance dose for the rest of their life. The addiction specialist will help guide the patient through the decision process. Many patients decide to stay on the medication as a hedge against relapse since buprenorphine has a higher affinity for opioid receptors than street drugs. This coupled with the very slow rate of dissociation means that a person would have to stop the buprenorphine well in advance of restarting heroine or other opioid in order to get high.
What does this mean for health care? For one, at least some addicts who eschewed health care in the past can now get treatment for this disease. At some point, most addicts will desire to get off narcotics. Having a real treatment option available instead of a far-away methadone clinic or withdrawal will work to drive these patients into recovery. Another thing is that it’s possible that some of the stigma of addiction will be lifted, at least slowly, as treatment becomes available and success stories become commonplace. As the DEA and FDA work to get a handle on the 70,000 overdose deaths per year by educating doctors and enforcing distribution laws, these drugs will become harder to get. During the 12 months prior to July 2017, overdose deaths fell in 14 states for the first time during the opioid epidemic, according to the Centers for Disease Control and Prevention. In the rest of the nation, at least the numbers have leveled off. Greater access to Narcan (brand name of naloxone, one of the drugs in Suboxone), and more treatment options for addicts will hopefully drive these numbers lower over time. It’s not time to celebrate, but at least there is a glimmer of hope. The priority is to keep addicts alive until they can (or they are ready to) get treatment for their disease.
First described by the Egyptians in 1550 BC as “sending forth heat from the bladder,” the urinary tract infection (UTI) is a frequent diagnosis seen in urgent care and doctor’s offices. Burning upon urination, urinary frequency, urinary urgency, smelly urine, and new or changed discharge—these are the hallmarks of a UTI.
Cystitis is an infection of the lower urinary tract. Pyelonephritis is an infection of the kidneys. UTIs affect about 150 million people every year with women greater than men. During any one year, about 10% of women will have a UTI and half of all women will have a UTI in their lifetime. Risk factors include sexual intercourse, diabetes, obesity, female anatomy, and family history. Although sex is a risk factor, UTI is not considered a sexually transmitted disease and a female can get a UTI even when a condom is used. E. coli is the most frequently isolated organism, though other coliform bacteria or yeast could be the culprit.
Most UTIs are caused by bacteria entering the bladder from the urethra. Bacteria then ascending the ureters into the kidneys causes pyelonephritis. Bloodborne pathogens can also lead to pyelonephritis. The urethra is shorter in women so the path to infection is shorter. Use of antibiotics can increase the risk of UTI, probably because the normal flora of the vagina or external urethra in men is disrupted. Indwelling catheterization is also a strong risk factor for UTI from organisms ascending the catheter and the normal complete emptying of the bladder is impossible due to the design of the catheter inlet opening above the balloon. It is estimated that for every day a patient is catheterized with a balloon catheter, the risk of UTI goes up 3-10%. Between the ages of 20 and 50, there is a 50-fold difference between female and male infection rates with that number decreasing over the age 50 and favoring males due to prostate enlargement, decreased bladder emptying, and increased rates of catheterization. Other risk factors are incontinence, poor hygiene, systemic disease, and hospitalization.
The gold standard of diagnosing the uncomplicated UTI is the presence of symptoms and isolation of a pathogen by culture of the urine. In reality, most uncomplicated UTIs are diagnosed clinically and with the aid of the multi-reagent urine dipstick. There are various algorithms used in diagnosis with varying levels of sensitivity (true positive) and specificity (true negative). The presence of nitrite, a product of bacterial respiration, along with leukocyte esterase and/or blood in the urine are strong indicators of a UTI and usually enough to warrant treatment with an antibiotic. For some practitioners worried about overuse of antibiotics and the resulting problems with resistance, a prescription is given with instructions not to start until the culture comes back, usually 48 hours unless symptoms progress.
Gram-negative bacteria often associated with UTIs convert the nitrate in urine to nitrite as part of cellular metabolism. This test isn’t particularly accurate because other organisms (Gram-positive) and yeasts that cause infection do not possess this trait. You can’t hang your hat on this test alone.
Leukocyte esterases are found in certain leukocytes normally associated with bacterial urinary tract infections. They are not found in normal leukocytes, epithelial cells, and bacteria of the healthy urinary tract. Certain conditions like trichomonas, chlamydia, and interstitial cystitis/nephritis can evade detection with this test so it is indicative only.
Blood in the urine can come from trauma (kidney stones) or bacterial mechanisms that lyse red blood cells and so blood can be detected either as whole blood cells or as hemoglobin, the molecule within the cell which has been spilled out by the bacteria. A dipstick positive for blood, nitrite, and leukocyte esterase in addition to one or more patient symptoms (frequency, urgency, pain, or discharge) has a high specificity for a UTI. It’s important to note that the presence of stones is also a risk factor for infection.
A complicated UTI is considered any UTI in a child, presence of a structural or functional urinary tract obstruction, recent urological surgical procedure, or a comorbidity increasing the severity of infection such as uncontrolled diabetes, chronic kidney disease, or the immunocompromised patient.
An uncomplicated UTI is usually treated with a short course of antibiotics such as nitrofurantoin, Trimethoprim/Sulfamethoxazole, or a fluoroquinolone. Some resistance is seen for all of these medications. Complicated UTIs may require longer courses or higher concentrations using the IV route. Many institutions now automatically perform a culture and sensitivity (C&S) when a urinalysis is positive. This identifies the organism (culture) and which antibiotics it is susceptible to (sensitivity).
Pyelonephritis is more serious than cystitis, sometimes necessitating hospital admission. Back pain, fever, malaise, and nausea can accompany kidney infection and this patient often looks and feels very sick. The treatment is a longer course of oral or IV antibiotics along with supportive care. The renal capsule is a tough fibrous material resistant injury. When the kidney is infected, the pressure within the organ rises and it becomes acutely sensitive. One diagnostic test for pyelonephritis is Murphy’s percussive test. One hand is placed over the costovertebral angle of the patient’s back and the other hand thumps it, causing the kidney to vibrate. Pain during this test or immediately afterwards, especially unilaterally, is highly suggestive of pyelonephritis in the patient with flank pain and fever.
If your patient is “sending forth heat from the bladder,” you should definitely do a point of care multi-reagent dipstick and send the urine off for a C&S. Flank pain, costovertebral angle tenderness, and fever should elicit a careful work up and diligent follow up.
“I feel dizzy” is a common complaint in the ER and triage nurses sometimes use the shorthand, IFD, when describing the patient’s complaint. Finding a diagnosis for this vague symptom can be challenging. One thing the nurse can do to speed up the process is to drill down to a more firm description than dizziness.
Dizziness is a complaint that can include four separate symptoms, sometimes overlapping. A careful history will reveal one or more of these: vertigo, disequilibrium, presyncope, or lightheadedness.
Vertigo is the feeling that the room is spinning. Often, there is a false sense of movement. Sometimes vertigo is accompanied by nausea, vomiting, sweating, and/or nystagmus. It gets worse when the patient’s head is moving. The question the nurse can ask to differentiate vertigo from other forms of dizziness is, “Do you feel like the room is spinning or moving around you?”
Vertigo has relatively few causes. Benign paroxysmal positional vertigo (BPPV), Meniere’s disease, and labyrinthitis are the most common. Less common are brain tumors, brain injury, stroke, MS, and migraines. You can see that they divide into central and peripheral causes; central causes involve the brain and peripheral causes come from the middle ear. Anything that causes inflammation in the structures surrounding the organs of balance can lead to vertigo. Often the patient will have a cold or sinus problems. Tinnitus, hearing loss, and feeling of fullness in the ear can accompany vertigo. There is a rapid compensatory process when things go wrong with the organs of balance. Usually the course is self-limiting and resolves within a few days.
BPPV is caused by loose granules of calcium carbonate moving in the semicircular canal. It can be diagnosed with the Dix-Hallpike test and can sometimes be effectively treated with repositioning movements called the Epley maneuver. BPPV does not present with hearing loss.
Meniere’s disease involves episodic vertigo along with hearing loss and a sensation of fullness, usually in one ear. There are few treatments and the disease is poorly understood. The course can last from 5-15 years before the episodes stop and the patient is left with mildly disturbed balance and decreased hearing.
Labyrinthitis is believed to be caused by a viral infection of the inner ear and can result in permanent symptoms of dizziness.
Disequilibrium exhibits itself in the patient’s gait. A stumbling or shuffling gait can be a sign of stroke, a life threatening emergency that calls for immediate activation of the emergency medical system. Other causes are Parkinson’s disease and peripheral neuropathy. Alcohol and drug intoxication frequently lead to disequilibrium. In older people, poor vision can accompany disturbances in gait, leading to falls. Benzodiazepines and tricyclic antidepressants can also lead to higher incidences of falls in the elderly.
Presyncope is a problem of circulation and is most commonly described as feeling like one is going to pass out without actually losing consciousness. It’s either a pump or a fluid problem and exhibits as orthostatic hypotension. When the patient stands up, he or she gets dizzy. It can be caused by dehydration (fluid problem), arrhythmias, myocardial infarction (pump problem), multiple medications, or debilitating illness. The nurse should ask the patient if he or she gets dizzy when standing up from a sitting position.
Lightheadedness is often associated with a psychiatric diagnosis and/or hyperventilation. Anxiety is the number one factor predisposing a person to lightheadedness. It is reproducible with voluntary hyperventilation.
Asking the patient a few extra questions and taking a careful history can assist the provider in making a diagnosis. Dizziness is not a very good descriptor of this problem, so drill down a little.
Nine years ago, I was so happy to have my first article published in Minority Nurse. The article was a discussion on whether or not it’s OK to be out at work as a gay person. Looking back at the changes I’ve seen over this time period, I decided to put together a few thoughts.
The county hospital where I work is rolling out some new intake questions for our electronic health record system. The impetus is to better serve our LGBTQ patients. A transgender person with residual breast tissue did not know he could still get breast cancer. An MTF person developed prostate cancer. These patients slipped through the cracks because they lived their true self but had body parts susceptible to illness that the caregiver was not aware of. By next month, we hope to have 10% of our patients properly classified using our new Sexual Orientation and Gender Identity (SOGI) questions. As the program rolls out, we will capture more and more of our population so caregivers can better serve them.
As a gay man in my 50s, I have seen great changes in my lifetime on LGBTQ issues. There was a time when just being out was a danger. But we bring some unique perspectives to our job that shouldn’t be overlooked. We know what it’s like to be the underdog. We cherish family because we worked so hard to have our families recognized. Respect for minorities come easily to us because we have suffered discrimination. Fairness in treatment under the law was not free for us or other minorities so we always strive to protect our patients’ rights. We know that being gay does not give you AIDS, but we also know what those risk factors are and we are able to educate our patients on the facts without judgement.
Now that we are rolling out a campaign to identify our patients’ unique needs regarding sexual health, reproductive issues, and mental health, we are working to destigmatize these issues in our community. Just asking these questions can be a litmus test of our own feelings. When the program was being explained in an employee meeting, there was pushback. “Our patients will be insulted.” Or, “Our patients won’t understand the terms.”
It occurred to me that we might be projecting our own feelings and, in some cases ignorance, onto our patients. Of course, there are what seem like valid issues when trying to tease this information out of patients in the geriatric clinic. My feeling is that you just throw the questions out there and you get what you get. The elderly are just as much part of the world as the young (and in between).I can’t wait to get some real world experience in asking these questions:
- What is the sex on your original birth certificate?
- What is your gender identity?
- What is your sexual orientation?
Some explanation might be needed with some patients. Sexual identity is not your sexual orientation. Sexual identity cannot be inferred from your birth certificate. We are looking forward to the rollout but with a bit of trepidation because we are not used to asking such personal questions. But,if you want to better serve this population, you have to identify them. The FTM person who never got a breast cancer screening because his caregivers never informed him of the risk—that can be preventable with better understanding of our patients. More information is better than less.
I take away two points from the SOGI questions that excite me. The first is that caregivers are going to be more aware of the disparities in health care that can occur with our LGBTQ patients. We are charged with the care of all our patients, not just the ones that fit into neat boxes. Just being aware of the differences makes us stop to weigh implications that might have been missed in the past. The second is that by normalizing this conversation, both patients and caregivers can talk openly about a subject that was once taboo. It’s OK to be gay or lesbian, FTM, MTF, something in between, or nothing at all. We all have health care needs.
Annette Smith, a nurse and coworker with 35 years of experience, has insight into changes in practice like the new SOGI questions: “At the beginning, there is a lot of pushback. The sky is falling, the sky is falling. But after a while, the process becomes normalized and it’s not a big deal anymore. We end up wondering what all the fuss was about!”
There was a time when just talking about sexual orientation was not even considered. Now we are required to ask! This destigmatizes the whole subject. To revisit my first question: It should never be a question of whether it’s right or wrong to be out at work. It’s just a question of you being comfortable enough in your own skin to let other people know.