Standing Up for the Right to Be Ourselves, Part Two

Standing Up for the Right to Be Ourselves, Part Two

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.

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!”