A few minutes in the life of a nurse.

I can't believe how many things my brain has to deal with at work. For instance, in my way to work I walked past my own patient being emergently transported with the paramedics from an outside hospital - not that I knew it was my patient yet. They were arriving at the change of shift, so within five minutes I was getting report from the day nurse while simultaneously helping the paramedics slide the patient into bed, assessing the patient (are they breathing right? vitals stable? pupils working? talking? oriented? following commands? moving all extremities equally?) and holding a pan and towels while they vomited all over the place. Meanwhile I'm trying to make a list of things in my head that I needed immediately: oxygen, blood draws, drugs, do I have IV access?, doctors to be paged, etc. I trusted, by faith alone, that the neurosurgeon had already seen the scan by computer and that the intensivist had got some kind of report from the other hospital. But I was the only one (besides the day nurse, who was trying to go home) who was actually seeing the patient. Getting the patient semi-settled for two seconds, the day nurse and I go to the desk to give a decent report, but in the middle of that the doc calls, so I have to grab the phone while I can and get all the orders I'll need (otherwise I'll have to page in the middle of the night) - IV fluids, labs, electrolyte replacement, insulin, DVT prophylaxis, pain meds, antinausea meds, are we doing another CT scan?, consults, and by the way we're not going to surgery emergently, right?, give a quick run-down of my assessment in twenty words or less, try to rifle through the paperwork from the outside hospital to see if this patient had gotten fresh frozen plasma to reverse their bleeding (they hadn't, so that meant I had to stat draw a type and crossmatch and send for the blood products ASAP), all while the day nurse still talking in my other ear with suggestions for what else I might need from the doctor (which I actually appreciated a lot). Getting off the phone, I had to still get a report on my other patient, including a rundown of the issues I'd have to take care of related to them being an agitated, neurologically compromised patient on a ventilator and titrating cardiac drips.

This was the first five minutes of my shift. The day nurse said "Wow, you're a good multitasker." I'm like...um, not really. This is just me panicking.

But I felt kinda good about myself and my pace....until the family came in while I was trying to figure out my next step, and asked what the plan is, and my brain froze for several milliseconds while I tried to formulate and distill everything that was currently happening and would happen in the next several hours - without using medical jargon. NOT EASY.

Why Veganism Doesn't Work (mostly)

A few days ago Tasha, the blogger at Voracious Vegan, wrote an epically long post about why she abandoned veganism - "Vegan No More". It basically comes down to her health: after going to the doctor and finding out she had a severe vitamin B12 deficiency, with the typical anemia that results, and realizing that her tiredness, lack of stamina during exercise, and depression were all symptoms of B12-deficient anemia, she realized (after many rounds of denial) she had to start moderately eating meat products, or she'd harm herself. Logically, she says, a harmful diet cannot be a natural diet. Therefore humans are not naturally meant to be vegan.

She dramatically writes about the energy she started to feel from eating a normal diet:

At 5 weeks I noticed a steady, permanent buzz of energy that carried me throughout the day. I started being able to run errands, work out, and do my writing ...  Joy and the most indescribable sense of relief and tranquility were now just a given when I woke up in the morning. And now, after 2 full months of non-veganism, I can honestly say that I feel reborn.

To put it in clinical terms, she reversed her anemia and probably bolstered her B-vitamin-deprived neurological health immensely.

Vitamin B12 deficiency is very common with a vegan diet. (Don't believe me? Google it; countless vegan nutrition websites acknowledge it.) This is because the only things capable of making B12 are certain microorganisms, and these microorganisms (for our purposes) only live in animals. Plants and animals cannot make B12. Animals, however, depend on it to make blood and DNA and other seemingly necessary things. Therefore, if you are an animal, you must either perform cool feats of digestion like hindgut fermentation (moving food through the colon to generate B12, then regurgitating it back for digestion)...

Bovine digestion is way vegan.

...or you have to eat animals. I can't do hindgut fermentation. Therefore I have to eat animals, or their eggs, or their milk. It's not my fault; it's my ecosystem. 

If you're a vegan, you have to take B12 supplements made in factories; since that's a luxury our ancestors didn't have, I'm assuming it's not 'natural'.

Vegans try to manipulate their diet into something resembling a complete human diet, but it doesn't really work. As Tasha said:

I was baffled by the suggestions to eat imported goji berries, use maca powder in my smoothies, or eat more spirulina. All these exotic recommendations were supposedly needed to make me healthy on a diet that is heralded as natural and ideal; it absolutely did not make sense.

But even in simple nutritional terms, veganism fails. All you can eat is beans, veggies, and grains, right? Carbohydrates, indigestible fiber, and incomplete proteins. From what I've seen of oh, probably ten years of hanging around vegans and seeing them eat, it's mostly carbs. Tons and tons of carbs.

Vegan reuben sandwich? Don't shudder, I've eaten one. It's all carbs. Their only protein source is beans and grains. That still maxes you out on carbs, and the protein is incomplete anyway. You need all the amino acids to survive. Plants don't give them. You can, enlisting the help of the last 100 years of food scientists, try to compile a diet of vegetarian sources of most the amino acids and essential nutrients you can normally only get in animal products, but this doesn't seem very 'natural' either.

I only chose to write about this because I've seen more than a few people deteriorate through veganism, becoming unhealthily skinny, almost cachetic, like cancer victims.

Incidentally, it's meat loaf night.

Not this guy.

A Summary of the Illinois Home Birth Safety Act

Here's a summary of the Home Birth Safety Act (Illinois SB 3712). I meant to write this ages ago; I hope it's not too late for people who want to be informed about this bill!  You can read the full text of SB 3712 here.

It legalizes CPMs but establishes the title of Licensed Midwife (LM). You can also call yourself "LM, CPM" if you hold CPM certification. However, see below; it sounds like CPM certification is a requirement for licensure.

Licensure requirements (pp.27-28):

1. An Associate's degree, either a general degree or nursing or midwifery, including life sciences, biology, and pharmacology.
2. Complete a 3-5 year midwifery education program approved by the North American Registry of Midwives including "clinical internship"
3. Pass a written and practical exam
4. Hold a valid CPM credential

It sounds like existing CPMs could be "grandfathered in" before August 2010, but since the bill didn't pass before then, would that date be moved? Interestingly, no evidence of practice submitted for licensure can be used against midwives if it occurred before the Act legalized such practice (p. 28 lines 9-13) though don't trust me on that, I'd figure it out for yourself before endangering yourself!

Midwives would be enabled / required to (pp.6-7):

1. give prenatal care and testing according to ACOG guidelines
2. provide 24 hour on-call availability
3. provide labor support and supervise delivery
4. provide postpartum observations until mother and baby are stable, for no less than 2 hours
5. complete birth certificates
6. offer metabolic blood screening of the newborn
7. offer vitamin K injections
8. offer administration of antibiotic eye ointments (gonorrhea prophylaxis

Medications midwives would be enabled to use, with strict dosing limits written into the bill (pp.8-12):

1. Oxygen for fetal distress
2. The aforementioned eye antibiotics (tetracycline and erythromycin)
3. Oxytocin or Pitocin for postpartum hemorrhage prevention or treatment
4. Methergine for postpartum hemorrhage
5. Cytotec for postpartum hemorrhage
6. Vitamin K
7. Rhogam
8. Intravenous fluids (lactated Ringer's solution, which is water with electrolytes) for "maternal stabilization"
9. Lidocaine injection for local anesthesia for repairing perineal tears
10. Sterile water injections to the lower back for nonpharmacological pain relief (?? I don't know anything about this!)

Midwives must have a formal relationship with an obstetrician or certified nurse midwife (p.21), including quarterly reviews of client records, but not requiring their presence for clinical care, and must consult with them when needed, such as (pp.13-20): 

1. Pregnancy-induced high blood pressure or persistent severe headaches
2. Persistent urinary tract infections
3. Significant vaginal bleeding, not associated with labor or uncomplicated spontaneous abortion
4. Rupture of membranes before 37 weeks
5. Notable decrease in fetal movement, or no fetal movement
6. Anemia (low hemoglobin) that doesn't respond to supplements (i.e. iron, B vitamins?)
7. Fever > 102 degrees for more than 24 hours, or > 100.6 at delivery
8. Nonvertex presentation (i.e. not head down) after 38 weeks
9. Persistent vomiting or dehydration (hyperemesis)
10. Rh negative sensitization
11. Elevated blood sugar levels resistant to dietary changes
12. Positive HIV or genital herpes
13. Malnutrition
14. Suspected blood clots (deep vein thrombosis)
15. Low-lying placenta after 28 weeks
16. Labor before 37 weeks
17. Gestation longer than 42 weeks "by reliable confirmed dates" (remember the Day 14 myth!)
18. Multiple gestation
19. Prior uterine incisions. Home midwives may attend not attend first-time VBACs but may attend subsequent VBACs. In other words no initial HBAC, home birth after cesarean.
20. Abnormal ultrasound findings (low fluid, restricted growth, etc)
21. Failure to void the bladder 6 hours postpartum
22. Signs of significant maternal depression
23. Dozens of findings related to the infant, including Apgar < 6 at five minutes, respiratory distress, low birth weight, failure to pass meconium by 48 hours, jaundice, etc.

Consultation does not precluding the possibility of out-of-hospital birth.

Guidelines for emergency transfer to hospital include the emergencies you'd expect, but explicitly delineated (pp. 19-20).

Midwives may NOT (pp. 22-23):

1. Give prescription medications to induce or augment labor
2. Use vacuum extractors or forceps
3. Perform "major surgical procedures" including "abortions, cesarean sections, and circumcision"
4. Accept primary care for a woman with significant organ system disease, cancer, insulin dependent diabetes, confirmed Rh disease, alcoholism, drug abuse, current serious psychiatric illness, and several other conditions 

The seven-member Illinois Midwifery Board will consist of (pp.23-24):

1. Four CPMs with three years out-of-hospital birth practice
2. One obstetrician or family practice physician with at least two years out-of-hospital birth practice
3. One certified nurse midwife with at least two years out-of-hospital practice
4. One "knowledgeable public member" who has given birth with the assistance of a CPM at home (interesting)

After three years of the passage of this Act, no one may act as or give themselves out to be a home birth midwife without being licensed under this Act. Midwives who are unlicensed but still practice are subject to a civil penalty up to $5,000 in addition to any other penalties under law.

The rest of the bill has to do with administrative issues, how Board membership is managed, and disciplinary actions and license suspection/revokation (nothing seemed out of the ordinary here, basically revolving around people who violate the Act).

The Illinois Home Birth Safety Act - vote tomorrow?

Thanks to the Unnecessarean for pointing out that the Illinois Home Birth Safety Act (SB 3712) is most likely being called to the floor Wednesday - tomorrow! This bill establishes the recognition of certified professional midwives. 27 US states have CPMs.

Midwives are illegal in states in red.
Image credit: Surachit.

We've had four home births here in Illinois, and we may (believe it or not) have more children someday, so this bill directly affects us. Here's what I think.

I generally support this bill because I think it makes sense. The home is a safe place to have a normal, non-high-risk birth. Normal women can give birth without a physician's manipulation; so it makes sense to allow an educated, informed woman to choose to do so. Hospitals have been repeatedly shown to be not very safe or accomodating places to give birth. On the other hand, these midwives already practice and do good for the community. They've been through extensive training and are often already registered, but they cannot legally perform these services in Illinois (though they can in neighboring states!). By legalizing the practice of home midwives, you're helping women make the legitimate choice to birth at home (which is already their right!) and enabling them to hire a compassionate, knowledgeable birth expert to assist them.

On the other hand, these same midwives are now going to be subject to possibly unnecessary restrictions. For instance, this decade's obstetric community (and the insurance companies who write their paychecks) have swung back to a more paranoid view of breech births and vaginal births after cesareans, with little evidence to do so and while other countries are progressively moving forward on allowing these births to proceed nonsurgically. This law would not allow midwives to attend first-time VBACs, though they can attend subsequent VBACs - so women must try to find a VBAC-friendly obstetrician (good luck with that). Midwives would also have to refer breech presentations to an obstetrician for "consultation" - and what obstetrician is going to approve a home breech birth, when he or she knows that no insurance company would allow them to attend one in the hospital?  Home midwives already attend HBACs (home birth after cesarean) and breech births successfully; but they would be disallowed under this new law.

There are other issues, like the fact that your very good (albiet illegal) midwife might not be registered how the state wants them to be; they might not have a general Associate's degree (a relatively arbitrary requirement in addition to all their midwifery training); they might be subject to more stringent reprimands and actions by the midwifery board than an obstetrician would be by the medical board (i.e. women complain all the time about obstetricians and nothing happens to them, but the first complaint by a woman against a CPM would probably be handled severely.)

But generally, I think that the bill is a good one, or at least a step in the right direction.

See also my summary of the Illinois Home Birth Safety Act.

Why You Should Lift Weights (no, really)

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I've posted previously about how my cholesterol was super high - in the 300's - back in January of 2010. Since I worked in a cardiovascular ICU at the time, I was, shall we say, greatly inspired to get that cholesterol down. I didn't want to be one of our thirty-year-old open heart cases. The main way I could see to do it was to lose some weight and get fit. So my wife and I joined a gym, something the highly unathletic pair of us had never done before (though she at least was an Irish dancer, which certainly burns calories!).

By cardio and diet change alone, I managed to get the weight of my 5'9" frame down from 185 lbs to 174-176 lbs, and my BMI (if you believe in that) from overweight to borderline okay. That was probably over about three or four months of hitting a treadmill 4-5 times a week. I ran a 5k run without even requiring chest compressions on the pavement. I also decreased my caloric intake, sorta counting calories but mostly just eyeballing it. Remember, your weight is directly increased or decreased by calories eaten minus calories burned. That's why the Twinkie diet worked for that nutrition professor; it was a simple trick of restricting ingested calories.

But I feel the real gains (or losses) came with strength training. I felt I had lost a fair amount of fat around my neck, arms, etc, but had plateaued around 175 with a fair chunk of abdominal fat. Adding some basic strength training using only free weights and body weight exercises, I managed (to my surprise) to pretty rapidly drop my weight to 161 lbs. Probably in less than two months. I guided myself using the UC Berkeley Wellness Letter's guide to Building Muscle and Bone - At Home, On Your Own. It's one of the rare internet guides not intended for gullible guys who don't care about health but just want big biceps to pick up chicks. You can "follow" it at home or at the gym. It's not really a program, but a simple guide to some exercises you could do in 20-30 minute intervals 2-3 times a week.

So why does it work? Muscle tissue uses more calories than (inert) fat tissue. So you not only burn some calories during the workout, but you burn more calories on a daily basis. There's less of a need to burn 300-400 calories in 30 hard minutes on a treadmill (which you can then ingest in a burger - or a couple Twinkies!). In fact, I generally find weight training much easier than cardio. Cardio requires significant amounts of stamina and endurance over what is for most people (like me) a long period of time - 20 or 30 minutes at a time or more if you really want to see a change. Weight training is so easy compared to that because it's in short intervals. You can rest whenever you want. There's no time limit - you could do it for 15 minutes and not be wasting your time. There's no strict rules or exercise requirements - you could do a single-exercise program like One Hundred Pushups and start seeing results.

What did you expect? Some dude with ripped abs?

Keep in mind - this isn't bodybuilding, which is (as I understand it) all about aesthetics. Guys who want big arms are essentially bodybuilders, focusing on single areas of the body and worrying about appearances. Men and women of any age who want to increase their overall body strength, or lose weight, or gain healthy weight, or increase bone density, or have less back pain, do strength training and are not bodybuilders. Granted this puts me in the same class as grandmothers doing pool exercises, rather than the dudes doing infinite bicep curls...but at least what the grandmas are doing makes sense!

In a later post I'll talk about the whole-body strength training program I'm using now - stronglifts 5x5. I feel like it's the best one out there. It's really simple, it's logical, I've been able to reduce my cardio time, and best of all it's free.

The Day 14 Myth

Natural family planning seems to be one of those things many people have heard of, but practically nobody understands except the people who use it. My wife and I have used it, and it hasn't failed us. It's a pretty simple system of fertility awareness. You use simple observations to tell where you are in the menstrual cycle. In fact, once you get the hang of it, it becomes easier to think of the menstrual cycle as what it really is: the ovulation cycle. At least that term makes more sense to me, since it describes the process that's really happening in women's bodies, rather than just the most obvious outward sign of it.

Because it's fertility awareness, it can be used both to avoid and to achieve pregnancy. Or it can be used simply to know what's going on. In fact, both the simplicity and the many practical uses of it make one wonder why nobody uses it in modern healthcare.

Consider the woman who has an "abnormally" long cycle, longer than the textbook 28 days. If she's concerned about this and mentions it to her doctor, she'll likely get put on birth control pills. But birth control pills just produce a fake cycle; it stops everything your body is doing, and once a month you take fake pills which let you bleed something like a menstruation. Why is the doctor so concerned with a 28 day rigidity? There's nothing wrong with the woman. The only benefit I can see is the assurance you won't "randomly" get pregnant or have your period, which you can tell without pharmaceuticals by using fertility awareness. That's because, "irregularity" aside, nobody has a random cycle.

Or say she wants to get pregnant. She'll be referred to a fertility specialist who will also, bizarrely, presume a 28 day cycle. Her hormone levels and other factors will be checked around when she's supposed to be ovulating, to see if everything is working correctly. Unfortunately, to most doctors, she's supposed to be ovulating on Day 14 after her last period. Since this might be nowhere near when she's really ovulating, her results be inaccurate, and further medical decisions will be made based on wrong information.

Or say she does get pregnant. She'll go to an obstetrician and be asked about her last menstrual period. Then her due date will be calculated using a simple wheel device, tacking on an extra two weeks to account for the two weeks between textbook period and ovulation. Except what if she ovulated three or four weeks after her period? Her due date could be set weeks early, leading to unnecessary tests, or induced labor for being "late," and a premature underweight baby. In fact, if you use fertility awareness and know when you conceived, some people advise "fooling" your standard-issue obstetrician by making up your own LMP date two weeks before you conceived just so you have an accurate due date!

All of these misguided medical judgments (can I say medical errors?) are based on a bizarre myth: that the standard woman ovulates on Day 14 of her cycle. There's no scientific basis for this. Even if it is common, it's not nearly common enough to be applied to all women.

Even though these physicians all studied and can presumably remember how the whole female reproductive cycle works, how follicle-stimulating hormone and luteinizing hormone are produced by a woman's pituitary gland, how estrogen and progestin shift, how the uterine lining depends on these hormones to grow and shed, how cellular miosis occurs and how a woman's haploid gametes form, how an egg is produced and travels and is fertilized, how the corpus luteum and early placenta produce hormones to sustain a pregnancy; even though they know all this, they presume a Day 14 ovulation and take a chance at throwing all their real-world clinical judgments off. Little of that textbook knowledge matters if you base your real clinical decision-making on a myth.

Guess the unscientific portion of this menstrual cycle diagram.

I suspect that part of the problem with using fertility awareness in modern medicine is that it requires significant time devoted to teaching and answering questions (prescribing the Pill is much quicker, and I doubt physicians are reimbursed for teaching fertility awareness), and that it depends on the woman observing and tracking herself, and not the physician or the labs.

If you've experienced this, please comment and share your story. And if you've seen the opposite, doctors and other clinicians who don't presume a Day 14 ovulation or who know anything at all about fertility awareness, please share their stories as well. It would certainly be heartening.