The hillsides of Southern California are notoriously prone to landslides. On January 10, 2005 the steep cliffs behind the unincorporated town of La Conchita, in Northern Ventura County crumbled into the community killing 10, injuring 15, and destroying 31 homes http://www.latimes.com/local/california/la-me-la-conchita-20150104-story.html#page=1. The same hillside had failed, in the same area ten years before in 1995 destroying 9 homes, but the community had gotten lucky the first time being spared any loss of life. Now 10 years later, the community of La Conchita is looking back at what has changed since 2005, and members of the emergency response system would be well advised to do the same.

Though the two previous events occurred after significant rainfall, the US Geological Survey has authored a study of the La Conchita area, siting geological evidence of frequent landsliding in the past several milenia that suggests this area is at significant risk for landslide activity even in the absence of rainfall (http://pubs.usgs.gov/of/2005/1067/508of05-1067.html#conchita07). And yet the community of La Conchita continues to grow, with approximately 300 residents including about 30 children. And though the community has made efforts toward increasing preparedness for future events with emergency supplies and a tractor stored in a safer location within the community, a proposed modification of the hillside itself that would significantly reduce the risk of failure, remains stymied at the state government level.

The types of disaster most likely to affect Ventura County are fire, landslide and earthquake and as we have seen time and again, and though landslides are fairly predictable they still manage to incur incredible cost to both property and human life. The website http://readyventuracounty.org/ is a great resource for learning how to be prepared for a variety of disasters. Nurses would do well to keep themselves up to date with resources such as this, and with the disaster response plans in place at the facility with which they are affiliated… Because it seems that the people most at risk of harm due to landslides are not planning on getting out of the way any time soon.

My mom was first diagnosed with cancer when she was 40. Her fight back to health was brutal, and so five years ago, when it came back, she wasn’t willing to go through treatment again. Now… I’ve never been the type of person to prolong a person’s life beyond their ability to enjoy it, but her decline was so fast and hard that I found myself struggling to accept the limitations that she wanted imposed on her care. My dad and I helped her pass peacefully at home, and have been doing well, so I was a little surprised the other day when I was reminded of that fierce independence that my parents shared.

In a conversation with my dad a couple weeks ago I mentioned something odd that we had learned in class; that one’s choice of a healthcare proxy is critical because advanced directives can be unnoticed or even ignored. A week later, the subject of a friend needing to completely remove his bladder due to cancer came up, and my dad very pointedly stared me in the eye and stated “I would not do that.” I am his healthcare proxy.

To be honest, I was similarly convinced that tubes of any kind keeping me alive was a non-starter before I learned so much about them, and frankly, it would have been easier to abide by his wishes not knowing what I do now. On the other hand, I am so grateful that I am now in a position to understand the mysterious language that doctors mumble over patients when they come for help, frightened and completely overwhelmed. I know that when the time comes, I’ll translate the jargon faithfully, and help my dad pass with the same pride with which he lived, but I also know now how hard that is going to be, and think of this often when working with patients and their families. So, at least from my perspective, the Seven End-of-Life Care Domains article (Clark et al, 2003) assigned for discussion this week is a powerful guideline for interventions and behaviors that would help to ease this process, for everyone involved.

Reference:

Clarke EB, Curtis JR, Luce JM, Levy M, Nelson J, Solomon MZ, (2003). Seven
End-of-Life Care Domains Associated Quality Indicators and Related Clinician and Organizational Interventions/Behaviors. Robert Wood Johnson Foundation|Critical Care Medicine 2003, 1-15.

As people live longer with chronic disease and depend more often on complex medication regimens at home, the burden of managing home therapy continues to fall, unassisted, on the patient and family. As I sat listening to my overwhelmed and tearful friend tell me about how her father ended up in the hospital for CHF exacerbation, I couldn’t get this out of my head. He had not been taking the increased dosage of one of his heart medications that the doctor had prescribed because the information had simply gotten lost in the mix. Though my friend typically helped her parents keep track of these things, issues with her own family came up, her brother tried to help but is not well versed in medical lingo… They had each done their best but before they knew it her father’s condition had deteriorated, and here we sat.

Unfortunately, programs and services designed to support patients in the management of their chronic conditions at home have not grown at the same rate as the complexity of the home regimens themselves. Case management in the hospital focuses on medical equipment, and home health nursing services catch those patients without adequate support at home, but where is the support for everyone else? My friend is the most medically literate family member involved in the care of her father and her understanding of the medications that he takes is limited to a general understanding of what it is for (e.g. heart, blood pressure, blood thinner), where to look on the bottle to find how much he should take.

What our healthcare system needs is more robust case management that works in association with the primary care provider and regularly checks in with patients living with chronic disease, to confirm that the patient is taking the right medications, at the right dosages. This service could be staffed by nurses trained in over the phone triage that can discuss with the patient, or primary caretaker, any questions regarding their current condition, and changes to home therapy regimen made at the previous doctor’s appointment. This service would compensate for the ever decreasing amount of time that doctors can spend with their patients, would decrease the number of turn-around admissions to hospitals, and provide support to the patient’s support network… which in the end would improve everyone’s quality of life.

What fortuitous timing that we should be covering cardiac intensive care during February, our National Heart Health Month! There was a smorgasbord of articles to choose from, but I was drawn to one on hemodynamics since just spent a good week or so completely immersed in that wild and wooly world…

Since 1996, pulmonary artery catheters, once considered the gold standard in hemodynamic monitoring, have been falling out of favor due to mounting, yet inconclusive, research finding that they are associated with increased likelihood of patient death. Central venous pressure monitoring has similarly been found to have minimal effect on patient outcomes when treating shock, compared to the use of conventional fluid replacement protocols (Johnson & Ahrens, 2015). Rather, Johnson & Ahrens (2015) propose that effective hemodynamic management of critically ill patients is best achieved by focusing on stroke volume optimization.

Stroke volume is the earliest and most reliable sign of hypovolemia because it is least affected by compensatory mechanisms, and the most effective means by which to measure stroke volume while maintaining the context of preload, contractility and afterload, is esophageal Doppler imaging (Johnson & Ahrens, 2015). This article proposes that correction of hypovolemia is best achieved through stroke volume optimization (SVO), a type of cyclic fluid replacement algorithm that recommends administration of fluid boluses for improvement of stroke volume by increments of 10% or more. When stroke volumes no longer increase by the full 10%, no more fluid is needed (Johnson & Ahrens, 2015). Hemodynamic monitoring of SVO protocol utilizes esophageal Doppler imaging, (or other indirect methods measuring cardiac output when contraindicated) (Johnson & Ahrens, 2015).

Implementation of SVO is supported by 11 large-scale, randomized controlled trials conducted by agencies such as the National Health Service, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services and Aetna. And though esophageal Doppler imaging, bioimpedance, and pulmonary artery catheters are all reimbursed by Centers for Medicare and Medicaid Services, esophageal Doppler monitoring is the only one of these endorsed by the Agency for Healthcare Research and Quality (Johnson & Ahrens, 2015).

I just can’t wait until next week when I have my very first day in ICU…

Reference

Johnson, A., & Ahrens, T., (2015). Stroke volume optimization: The new hemodynamic algorithm. Critical Care Nurse (35)1: 11-27.

“I am only one; but still I am one.
I cannot do everything; but still I can do something.
And because I cannot do everything,
I will not refuse to do the something that I can do.”
- E.E. Hale, American writer

One of the things I really love about nursing is that every so often patients have a way of reminding me why I do it…

This week had been dragging by, bringing one technical difficulty after another along with it. By the time I slunk into work yesterday, behind my extra large cup of coffee, I just wanted to get through the shift without anything else going wrong. And then the inevitable… a patient suddenly dissolves into frustration and tears, and more than anything just needed to be heard…

Behind my calm exterior I struggled to re-prioritize while she talked… So many tasks to do, so many other patients, and what answers do I have to really solve her problems anyway?… So I took a deep breath to still my thoughts and looked deep into her eyes (my way of stripping away clinical roles to reestablish a human connection with someone). This technique tends to work pretty well to keep a situation in the present, but then she really looked back at me. It felt a little like watching an icicle melt in a ray of sunshine… calm, gentle, refreshing. I stayed with her for a total of about 15 minutes, but the moment touched both of us profoundly.

As I dive into the wild and wooly world of Care of the Complex Client, it is moments like these that remind me what it is all for. To do what I can, to make the difference that I can, day by day, hour by hour, minute by minute.