Don't worry, I won't be wearing this costume.

Happy Halloween!! 

OMGWTFBBQFDA!!1! Hyland's Teething Tablets R Poison!!

Three days ago the Food and Drug Administration issued a warning to parents to stop using a benign over the counter product which we've used with our kids a dozen times at least: Hyland's Teething Tablets. The same day Hyland's issued a voluntary recall. The tiny dissolve-in-your-mouth pills contain minute amounts of belladonna, a plant that's been used medicinally for centuries for its antiinflammatory and antispasmodic effects. It is a natural product, but in reality it does contain drugs used in Real Modern Western Medicine^TM, chiefly atropine and scopalamine.

Both of these drugs are used in varying amounts in real medicine because they are potent anticholinergics. Indeed atropine is the typical drug of this class, and the WHO lists it as one of the few basic necessary medicines needed for an adequate healthcare system. Millions of people are prescribed atropine to control bladder or gastrointestinal spasms; we use it in mega high concentrations in resuscitation efforts because it makes your heart beat faster. So you can see they are serious drugs - when purified and used in concentrations more than a thousand times that used in Hyland's Teething Tablets. It is very possible to give yourself belladonna poisoning, but I would imagine most children would have to eat at least a bottle or several bottles to achieve even the milder adverse effects.

Ironically the dose is low enough that if Hyland's was advertising that their product contained atropine, the FDA and normal medical practitioners would probably be claiming that they're nothing more than sugar pills.

Despite the well-established nature of atropine, and the fact that the "homeopathic" dose is something like a thousand times less than any medicinal use, this is how the FDA chose to inform the public about the drug:

Belladonna is commonly known as Deadly Nightshade.  It is a plant whose leaves and berries are extremely toxic.  Belladonna has been used as both a poison and a medicine throughout history.

Acting more like it's a medieval poison than a modern medicine.

The FDA isn't saying what symptoms they received reports of, or how many occurrences. On the other hand, you can readily find dozens of real-parent reviews of Hyland's Teething Tablets, or look over the Facebook fan page for more accolades. No reports of adverse effects are easily found online; let me know if you come across any.

It's just dumb. Dumb, dumb, dumb. This product is so benign it's not even funny.  I'm sure this is chiefly based on the fact that belladonna, used as a plant-based ingredient, contains recognized drugs, but is not a purified or easily measurable form of the molecular drug compounds. The FDA would probably happily recognize and study Hyland's Teething Tablets if they were purified prescription drugs manufactured by Big Pharma. But they're not, nor do they need to be, and Hyland's probably doesn't have the resources to begin processing like a big pharmaceutical company. So the FDA will just wear them away.

Ironically the FDA action and recall led to the product selling out on Amazon.com. My wife knows someone who just ran around town and purchased 25 bottles.

"The Fading Art of The Physical Exam"

NPR just ran a piece on how physicians aren't examining patients anymore. It's true, even in an environment like the intensive care unit where small details can make or break you. When a physician follows a patient in the ICU, or even on the general floors, they typically don't do daily evaluations. It's even rare to see them use their stethoscope. Rather, they depend on the nursing assessments. They assume that the nurses would tell them if anything is amiss.

Of course, the piece centers on how diagnostic testing is replacing physical examination. Diagnostic testing is a little more glamorous and newsworthy - it's expensive, technological, and sexy.

"We're now often doing expensive tests, where in the past a physical exam would have given you the same information," says Jason Wasfy, a cardiologist-in-training at Massachusetts General Hospital in Boston.

As a result, many doctors are abbreviating the time-honored physical exam — or even skipping it altogether.

The missing piece is that patients aren't being taken care of by expensive testing. The radiology department does not follow your patient for you on a daily or hourly basis. The time-honored physical exam is skipped partly because you can just run tests instead, but mostly because nurses are during frequent assessments.
Doctors can't auscultate chests as well as they used to because they can just look at a chest x-ray instead, but also because the nurse is going to report on any problems with their oxygenation status, with their breathing efforts, with how their lungs sound, and with what treatments are working or not working.

In fact, the situation is a little ironic: because nurses can be sued for not telling the doctor pertinent information, and because doctors can (and do) defend against lawsuits by claiming nurses did not tell them what they needed to know, doctors can safely assume that nurses are evaluating their patients for them.
I know, that's just more physician-bashing. Well, not really. I actually don't mind that they trust our assessment skills and our judgment. We're with the patient all day long, and they have forty patients to see that day, so they need to listen to us.

What about when the doctors sees you directly in the office? The article goes on to claim that "Even when doctors go through the motions of doing a physical, their diagnostic skills aren't what they used to be" and refers to a test where doctors missed a large number of defective heart sounds. I think this is because physicians receive their training in the hospital, where they can, as I said, rely with the nurse's assessments and diagnostic tests to do their evaluations for them. It still goes back to the hospital nurses.

Like I said, I like the autonomy and authority this gives to the RN. And if the news isn't aware of it, that's fine. But I have to admit it's a little worrisome. If you don't have a thorough nurse, and your physician just glances in at you and reviews the chart, then something could be missed until it causes such a big problem nobody can overlook it.

The fact that your healthcare system can't "waste" the expensive time of physicians on general physical exams for everybody means that it needs really, really good nurses.

An Ode to Certified Nurse's Aides

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When I worked at a nursing home as a nurse's aide, I realized something that seemed so obvious yet I've never heard anyone talk about it. I realized that the basic functional unit of a nursing home is the nurse's aide, the certified nursing assistant. CNAs are why they build nursing homes. Sure, there are nurses, but their main job is med passing--being in charge of, say, thirty patients at once. That makes them more like ancillary staff, like the occupational therapists. The reason people go to (or, er, are put into) nursing homes to help with their activities of daily living, when they can't bathe, eat, or toilet themselves. It's not a glamorous job, but people in the United States typically don't want to do this themselves. Whatever. The point is, the basic unit of the nursing home is the certified nursing assistant. And your CNAs will, for better or worse (and trust me, there are worse!), have the most impact on your nursing home experience. I don't think people realize that, or care. That's probably a function of the throw-away nature of the nursing home: in general, people get disposed of there until they die.

I always wanted to write a book about my nursing home experiences. First of all, it's sort of like a prison. Some people go to stay as permanent inmates, and others (the post-hospital rehabilitation patients, if your nursing home has them) will get discharged. People are there for all sorts of reasons: permanent debilitation, temporary rehab, even simple reasons like IV medications. On the same day, in the same hallway, there would be some people sitting in wheelchairs, screaming and talking gibberish, and a young guy getting treatment for AIDS walking among them. The same room (two beds to a room, of course) would have a old long-term resident in Bed 1 who can't walk and needs two people to get him into the wheelchair or onto the commode, and a young construction worker with broken legs in Bed 2 who needs the same exact assistance.

I remember an older woman who loved seeing pictures of my baby (wow, I just said "baby" singular - I only had one at the time!). She was so friendly and perpetually sat in her wheelchair by the front door to greet people. Never saw her family...until she died, when they came out and filled the room and spilled out into the hallway. She was completely comatose and breathing agonally and some young kid was playing guitar for her. I'm like...she probably would've liked this back when, you know, she was conscious.

There are so many other stories. Someday I'll dig around in my brain and come up with all of them.

Also, Dirty Jobs with Mike Rowe should visit a nursing home. But somehow I don't think even that show could go that far.

Gimme your assessment in five words or less!

I do a thorough neurological assessment on this very sick but awake and responsive patient who just suddenly stopped answering my questions, stopped following commands, stopped showing any cognition of their environment at all. No response to shouting, shaking, or sternal rub. No eye focusing or tracking. Still had their reflexes intact (pupils, cough, gag, corneals), still responded to painful stimuli (i.e. withdrew hands and feet to light nailbed pressure) but kind of an absent stare and a shaky hand - absent seizures maybe? They were pooping out on the ventilator, too - is it respiratory? A metabolic condition? What's going on?

I think this is a pretty decent assessment. I tell all this to the night shift resident. They walk in, gently prod the patient and try to converse with them and fail, and call the intensivist at home, and all my assessment work gets distilled down to: "Yeah, um, the nurse thinks this patient is kinda more out of it than they usually are...what do you think?" 

Thanks, I coulda done that!! "More out of it than they usually are." I had to laugh. I know the intensivist is an intelligent person who knows this patient well, so they can put the pieces together even with scant info, but I did want to pull the phone away and talk to the doctor for real. I hope when the docs get these calls from residents they don't think we're the ones not using our brains.

Not that I'm mad at this resident! I'll take a resident who listens and isn't afraid to ask their higher-ups over the ones who just shrug everything off when they don't know what to do!

Anyway, we drew a blood gas analysis and adjusted the vent settings, and the patient eventually perked up and started responding again.