Monthly Archives: February 2011

Matters of the heart

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Amy was 28 and pregnant when she had a heart attack. Despite crushing chest pain, sweating and nausea, “I was told it was the baby kicking my diaphragm,” she relates.

Her symptoms continued on and off for two years. First they were attributed to exercise-induced asthma, then to pleurisy. It took a severe episode and a stress test to finally diagnose what was happening. Amy was promptly hospitalized, only to have a massive heart attack while undergoing an angiogram. Since then, she has had 11 stents implanted and gone through two bypass surgeries.

Her story, and those of more than 20 other women, appears on the Heart Sisters blog as a compelling illustration of what it’s like to experience a heart attack – and a reminder that we often know less than we think about recognizing a heart attack and taking appropriate action.

This is especially true for women’s heart attacks. The personal stories at Heart Sisters have some common threads – most of these women had chest pain, and many of them also had heartburn, nausea and sweating. Additionally, several of them reported fatigue, flu-like symptoms, and back or arm pain. Although pain, heartburn and sweating among men generally raise the index of suspicion for a heart attack, many of these women were initially told they had a virus or a panic attack, or that their symptoms were pregnancy-related.

It has only been in recent years that heart attacks in women have been studied more closely. One of the things that has been learned is that women’s heart attacks often don’t follow the standard pattern we’ve come to associate with what Heart Sisters blogger Carolyn Thomas calls the “Hollywood heart attack,” in which the victim clutches his chest (usually it’s a he) and perhaps falls to the ground.

Here’s an even bigger revelation, though: Overall, Americans aren’t very good at recognizing a heart attack, period. Nor are they very good about taking correct action if they suspect they or someone they know is having a heart attack.

In an article that appeared a few months ago in Future Cardiology, author Jing Fang cites some rather disturbing statistics:

… National surveillance data show that the awareness of heart attack symptoms is still low among US adults – only 31% of US adults knew all five symptoms of a heart attack in 2005, and this percentage did not improve when compared with 2001. Further, a study demonstrated that the delay in seeking treatment for a heart attack has changed little in recent decades, despite increased public awareness of the benefits of reperfusion therapy.

There’s more. Although awareness of women’s risk of having a heart attack has grown substantially among both white women and women of color, their knowledge of the warning signs of a heart attack hasn’t improved.  A survey conducted in 2009 among 3,000 women found that while more than half knew cardiovascular disease was the leading cause of death for women, only a minority knew that shortness of breath, chest tightness, nausea and fatigue were heart attack symptoms. And only about half said they would call 911 if they thought they were having a heart attack.

If you talk to local paramedics, many of them will tell you there’s a denial factor among men as well as women. Sometimes they delay calling 911 because they’re stoic or embarrassed. Sometimes they decide to drive to the emergency room themselves.

Indeed, despite all the public awareness campaigns about what to do if you think you’re having a heart attack, there still seems to be a fair amount of confusion. From the Future Cardiology article:

The symptoms of a heart attack may vary and may be similar to symptoms of other diseases, consequently a person may think that they have diseases other than heart attack and, therefore, wait too long before calling 911 or going to the hospital. Moreover, even individuals who are aware they are experiencing a heart attack may delay seeking care owing to a number of factors including fear, concerns about cost, self-treatment with medication, distrust of the healthcare system, consulting with family members, and embarrassment about calling emergency medical services if the condition turned out not to be a heart attack.

It appears there’s still work to be done on the education front.

How well do you think you could recognize the signs of a heart attack? Take the American Heart Association quiz here. You can also take the American Heart Association’s online heart attack risk assessment here.

The weeknight dinner dilemma

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On the Chowhound discussion boards, there’s a lengthy, ongoing conversation about what’s for dinner. One person this past week was having Vietnamese beef salad over noodles. Someone else was making quesadillas. And quite a few people were serving leftover chili, beef stew or braised pork.

Of all the challenges involved in eating more healthfully, the dilemma of what to have for dinner on a weeknight surely ranks near the top. When the Reser’s Fine Foods blog asked readers last fall to name some of the biggest obstacles, the responses sounded familiar: Picky children. Picky spouses. Lack of time. Competing priorities. The struggle to keep the menu from becoming monotonous.

One woman wrote, “My biggest challenge is getting something healthy on the table in a reasonable amount of time – and also having the ability to multi-task while making dinner! So much to do in the evenings, with so little precious time!” For someone else, it was the difficulty of coming up with and sticking to a meal plan. “I mean, days you don’t have what you need, or want what you have, or are just too tired to try,” she wrote.

Far easier to resort to fast food or a restaurant meal that’s on the table in minutes, with a minimum of effort.

So what’s wrong with having a takeout dinner or restaurant meal every so often? Nothing, really. The real issue is when it becomes the default strategy night after night.

A few years ago a study was published that tracked 3,000 healthy young adults for 15 years. The findings were interesting and probably not all that surprising: After 15 years, those who frequented fast-food restaurants more than twice a week had gained 10 extra pounds and had a two-fold greater increase in insulin resistance, putting them at risk of type 2 diabetes.

To get an idea of what’s in those fast-food meals, here are some statistics, courtesy of the FDA: A biscuit, egg and sausage breakfast sandwich contains around 37 grams of fat. A regular-sized double hamburger contains 32 grams of fat. The recommended daily allowance: 67 grams, which means consuming even one of these menu items can use up half of your dietary fat allowance for the whole day.

Sodium is another culprit. For most people, the major source of salt intake isn’t the salt shaker; it’s processed foods that are high in sodium. But consider how hard it might be to cut back when a meat combo submarine sandwich can contain more than 1,600 milligrams of sodium, or a single large cheeseburger with bacon has 1,300 milligrams. The recommended daily allowance? For healthy people, it’s 2,300 mg per day. For those who are 51 and older, African-American or who have high blood pressure, diabetes or kidney disease, the recommendation is 1,500 mg a day or less.

Wanna get really, really specific? A couple of weeks ago, Men’s Health magazine published a list of the “20 worst foods in America.” Here’s the list, which names names, provides calorie counts and suggests dining alternatives that are more palatable.

According to multiple studies, there’s really no substitute for meals prepared in your own kitchen. When you make it yourself, you can exercise far more say over how much fat, cholesterol, salt and sugar ends up on the dinner plate. Put another way, one of the eating-related behaviors that has been shown to make a difference is how often – or how seldom – we eat out.

A study that appeared in the Preventing Chronic Disease journal a few years ago surveyed 4,300 American adults about weight loss, weight loss maintenance and eating patterns. The results indicated that those who didn’t eat at fast-food restaurants were more likely to be successful at losing weight than those who reported eating fast food twice or more a week. Because this study looked only at weight loss and weight-loss maintenance, the findings are limited. But the authors point out, “Data on consumption of foods away from home suggest that when dining out, people eat more food, higher-calorie food, or both. Therefore, dining behavior is a potentially modifiable contributor to caloric intake and weight control.”

In other words, it’s something we can change. Other studies have found similar benefits for people who need to control how much sodium and/or sugar they consume.

How to make weeknight dining less of a dilemma? Kathleen Zelman of the WebMD Weight Loss Clinic offers some of her own solutions:

My strategy for quick and easy dinners starts in the grocery store. The produce bins in my refrigerator are always full. In addition to fresh fruits and veggies, I load the refrigerator with low-fat yogurt, fat-free half-and-half (a cooking trick I learned from our “Recipe Doctor” Elaine Magee), a variety of cheeses, hummus, eggs and skim milk.

Depending on what is on sale, I stock my freezer with items such as pork and beef tenderloin, salmon, tilapia, boneless chicken breasts, and lean ground round. When I get home from the market, I divide these foods into portions for two so I can easily defrost them a few hours before dinner. Also in my freezer is a supply of whole-wheat rolls, ciabatta rolls, Lean Cuisine dinners, chicken pot stickers (I toss them into chicken broth with mushrooms and scallions to make soup), and bags of frozen veggies.

Staples in my pantry include cereals (Kashi Go Lean Crunch and Special K are our favorites), brown rice (Uncle Ben’s ready rice), whole-wheat blend pasta, canned petite diced tomatoes, Mandarin orange segments, sweet potatoes, nuts, a variety of canned beans, soup, coffee and assorted teas (my afternoon pick-me-up).

I’m one of those people who cooks on weekends for the week ahead. The down side of this is that it takes planning. The up side? Well, in the freezer right now are single-serving containers of lentil stew with turkey sausage and carrots, and a pan of pasta shells stuffed with spinach and low-fat ricotta. Another strategy that seems to work well in our household: having a repertoire of weeknight meals to fall back on that are fast, taste good and require minimal energy to make.

LiveStrong.com has several specific ideas on its website for simple weeknight dinner options, low-carb menu suggestions, diet-friendly dinners, and even several useful tips for how to plan a dinner menu (take one week at a time; vary the menu to keep it interesting; get input from the rest of the household on their likes and dislikes).

Two of the most often-cited resources: Cooking Light and Everyday Food. And when I Googled “healthy weeknight meals,” I came up with more than 400,000 websites ranging from the Food Network to Eatingwell.com.

Yes, it takes time, energy and organizational skills to come up with weeknight meals that can easily be prepared at home. But with all the resources available to help, it doesn’t have to be a continual dilemma.

Image credits: Photo, Wikimedia Commons; logo, Troy Murphy, West Central Tribune

The weekly rundown, Feb. 9

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Blog highlights from the past week:

Most-read posts: Wedding ring = better health?; Small indignities.

Most-read from the archive: Of ethics, identity and patient choice, from Sept. 1, 2010.

Link with the most clicks: an online risk assessment of burnout, from Burned out and used up.

Most blog traffic: Thursday, Feb. 3.

Search term of the week: “scream painting.”

Paging Dr. Google

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Three years have gone by since Time magazine published a now-infamous essay about patients who Google. According to the author, Dr. Scott Haig, Googlers were among the worst possible patients, armed with “a barrage of excruciatingly well-informed questions” and spewing sentences “burst with misused, mispronounced words and half-baked ideas.” His disdain couldn’t have been more clear.

Unfortunately Dr. Haig committed the classic logical error of assuming “this patient is a Googler, this patient is obnoxious, therefore all patients who Google are obnoxious.”

But the genie was already out of the bottle. Although many information-empowered patients were quick to denounce him, more than a few physicians must have privately applauded Dr. Haig for giving voice to some of their own misgivings about patients’ use of the Internet.

The medical world has always been rather ambivalent about symptom-Googling and online research by patients. Will patients overreact or draw the wrong conclusions from what they read online? Will they show up in the exam room with a stack of printouts? Most of all, will it alter the doctor-patient relationship when patients have better access to information?

The tide, it seems, might be slowly beginning to turn on this issue. Not too long ago, Time magazine printed another essay about patients who Google – only this time, it was titled “Googling symptoms helps patients and doctors.”

Oh, sure, the cast of characters included a supercilious, condescending, eye-rolling intern and nurse. But guess what? It wasn’t the patient who was the problem, writes Dr. Zachary Meisel: “The real problem was with my team: we weren’t well equipped to deal with her online homework – and it became a distraction.”

Dr. Meisel writes:

… To debate whether patients should or should not Google their symptoms (which a surprising number of doctors seem to enjoy engaging in) is an absurd exercise. Patients already are doing it, it is now a fact of normal patient behavior, and it will only increase as Internet technology becomes ever more ubiquitous. The average Joe has more health information at his fingertips – both credible and charlatan – than all the medical libraries ever built put together. So the real question is, What can professionals do to translate this phenomenon into better health for their patients and the public?

Hallelujah.

Although health care professionals will probably continue to struggle with this for many more years, there at least is a growing recognition that the Internet, when used appropriately and effectively, can be a powerful tool for patient care.

But what this entire debate seems to be missing is the significant number of Americans who don’t even have access to online health information, let alone the wherewithal to become Googlers.

The Pew Research Center recently released a report examining Americans’ information-seeking behavior online, and the results are concerning. Among the findings: People of color, people with disabilities, older adults and adults with limited income and education are among the least likely to obtain health information online. Among adults with a college degree, for instance, 93 percent of those surveyed said they went online for health information; for those who had less than a high school education, it was 38 percent.

Those who had broadband were more likely to go online than those who had dial-up access. Rural respondents also used the Internet at lower rates than either urban or suburban residents.

There’s already a health literacy gap between those who are well educated and those who are less so. Health disparities among Americans who are minority and poor have been well documented. Now we also have a growing health information gap between the Internet haves and have-nots.

Which should we worry about more: the fact that patients have access to Google and might misuse it, or the fact that hundreds of thousands of people are disadvantaged by not having online access at all?

Photo: Wikimedia Commons

Small indignities

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No one ever said being a patient was easy. But what they don’t warn you about is the small stuff.

Crystal Phend, a reporter for MedPage Today, recently blogged about a trip to the knee specialist. No, an unusual flare-up of pain in her knee wasn’t a new injury, she was told. The doctor “gave me an educational sheet, answered all of my questions, and walked out,” she writes.

Wait… did this mean the visit was over? Was the assistant coming back? Was it OK to change back into her street clothes? Should she stop at the front desk to see if she needed to make a co-payment?

Phend wonders: “Could it be a matter of courtesy to finish with some signal of what comes next?”

Her post prompted a couple of readers to voice their own frustration with some of the little slights and oversights that patients often encounter at the doctor’s office. Wrote one person:

First thing the nurse does after she calls you in is to weigh you. Most people are carrying a bag or wearing heavy clothes that need to be placed aside. The only place to put it is on the floor!!! No hooks, no desk or chairs around the scale. Ridiculous.

Why can’t clinics have a shoe horn available in the exam room to help make it easier for patients to put their shoes back on, someone else wondered. This same person concluded, “It may cause me to think a bit more consciously of maintaining my health so as to avoid the indignities, large or small, one encounters in going to the doctor’s for routine care.”

In some of the online cancer forums, I’ve seen patients, usually women, voice their frustration with radiation treatment facilities that don’t have changing areas, forcing patients to undress next to the linear accelerator – often while technologists are in the room, setting up for the treatment session. Judging from many of these anecdotes, some facilities don’t even have hangers or hooks for patients to hang up their clothing.

The list of little rudenesses could go on and on. Need I mention clinicians who barge into the room without knocking, or don’t bother to close the door? Or the frequent failure to explain to patients what is being done to them and why?

Then there are The Rules, the unspoken set of expectations for how patients are supposed to navigate the system. Jessie Gruman, president of the Center for Advancing Health, is undergoing treatment for stomach cancer and recently blogged about the challenges of trying to follow the rules:

As far as my chemo nurse Olga is concerned, I can do nothing right.

She scolded me for sending an e-mail when she thought I should have called and vice versa. She scolded me for going home before my next appointment was scheduled. She scolded me for asking to speak to her personally instead of whichever nurse is available. She scolded me for calling my oncologist directly. She scolded me for asking whether my clinical information and questions are shared between my oncologist and the staff of the chemo suite. I could go on…

“Funny,” I think to myself. “If she had told me the basic ground rules of interacting with her and her colleagues, I would have been happy to follow them. Otherwise, how am I supposed to know – guess?”

Gruman cites interviews conducted by the Center for Advancing Health on the many frustrations people face in communicating with health care providers: “People can’t figure out how to get their test results. They are puzzled about whom to call after hours or on weekends. They are baffled about whom they should talk to regarding billing and insurance problems. They are flummoxed by the new and unfamiliar demands placed on them by different sources of continuing care: rehabilitation hospitals, cardiac rehab, oncology suites, neurologists and other specialists and, for some, unfamiliar primary care medical homes.”

It’s not that health care providers don’t care. Most of them do. But they’re often busy and overworked, and many have forgotten – or maybe never stopped to think – that what’s familiar to them is vastly unfamiliar to patients. What providers might perceive as insignificant, such as expecting patients to place their coat or handbag on a perhaps not-too-clean floor while they’re weighed on the scale, can easily be perceived by patients as inconsiderate or even disrespectful.

Is there a difference in being cared for as a patient and being cared about? Several years ago Elaine Feder-Alford, a faculty member at Towson University in Maryland, spent eight days in the hospital with streptococcal pneumonia. In “Only a Piece of Meat,” she describes how her dignity and her sense of personhood and control were stripped away by hospital staff intent only on the clinical aspects of her care. Here’s just one example of how it affected the patient: At one point, a nurse comes into her room to add potassium to her IV drip, then quickly leaves. Moments later, Feder-Alford starts to experience a burning, stinging sensation in her arm. Her family calls for the nurse, who comes back in and adjusts the pace of the drip. Feder-Alford writes:

I wonder why the nurse couldn’t have stayed with me for just a few moments after she administered the potassium so that she could monitor my reaction to the drug and regulate it accordingly. That would have been for me a moment of caring.

So much of the discussion about health care is focused on the big things - cost, utilization, hospital readmission rates, infection prevention, evidence-based care. To be sure, these are important, but whatever happened to the small things? It would cost next to nothing for radiation therapy facilities to bring in a portable folding screen so patients could have a little privacy while they’re changing. An extra minute in Feder-Alford’s hospital room would have saved the nurse a second trip and avoided discomfort for the patient. More than that, it would have been a kindness – one of those small thoughtfulnesses that matter to patients but often get overlooked because they’re, well, small.

When it comes to the patient experience, small is anything but small.

Wedding ring = better health?

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What next – prescriptions for a trip to the altar? Dr. Randall Bock, a Boston-area physician, wonders if it’s appropriate to advise patients to get married for the sake of their health.

After all, doctors urge patients to stop smoking, lose weight, get vaccinated, have a colonoscopy and so on, Dr. Bock points out. Why not tell them to get married – especially since multiple studies have found that marriage is generally associated with better health?

Here’s an excerpt from his post, via Kevin MD:

Not only do people live longer married, but they live wealthier and happier, and this conclusion remains even after you factor out preselection towards marriage people. You could argue that maybe those destined for poorer life expectancies never marry in the first place but probably the opposite is true, people who need care and caring tend to marry at a higher frequency.

Dr. Bock then shares a story about one of his patients, a 22-year-old unmarried woman with a 1-year-old child. The child’s father has asked her to marry him but she wants to go back to school and isn’t ready yet for marriage. Dr. Bock suggests that she “consider the beneficial social and general health aspects of solidifying her ongoing relationship with the child’s father.”

The patient listens politely. Dr. Bock thinks the conversation was productive. But two days later she calls to let him know she will not be coming back as his patient, ever.

According to the science, Dr. Bock actually has a point. Whether marriage affects health and longevity has been well studied. One of the earliest of these studies was undertaken in the 1850s by British epidemiologist William Farr, who analyzed French birth, death and marriage records and concluded that those who were married generally lived longer and were in better health than those who were unmarried or widowed. Subsequent studies over a century and a half have confirmed Farr’s observations, associating matrimony with a lower risk of pneumonia, cancer, dementia and even likelihood to undergo surgery.

Although it would be easy to conclude that everyone should get married so they can be healthier, the picture is more complicated than this. Later and more detailed studies have found that the type of relationship matters; marriages that are stressful or abusive are worse for people’s health than a happy, supportive marriage. Other studies have noted that people who have married and then divorced are less healthy than people who remained unmarried. The marriage benefit also seems to be strongest for men but less so for women.

The philosophical questions raised by this are intriguing. A recommendation from the physician can have power, especially when it comes in the context of a solid, ongoing relationship between doctor and patient. Patients often will discuss things with their doctor that they might not bring up with someone else. If the goal is to help the patient be healthy, why not suggest lifestyle and social choices that are backed up by evidence?

On the other hand, physicians need to beware imposing their own values on their patients. And anyway, where would you draw the line? Church-going and moderate alcohol consumption also have been linked to better health. Does this mean physicians should start urging their patients to go to church every Sunday and knock back a beer or two each night? Does the promise of better health trump every other consideration or preference the patient might have?

For what it’s worth, virtually everyone who responded to Dr. Bock’s post thought he crossed the line. “Completely and utterly inappropriate,” one person wrote. “You do not know the child’s father, and the patient was not there for social advice.”

A female reader took Dr. Bock to task for imposing his views about marriage on a patient whom he barely knew. “I would no more take personal marital or religious advice from a physician than I would from a mailman – except my mailman probably knows me and my family far better!” she wrote.

What do readers think? Should doctors be talking to their patients about the health benefits of marriage? Or is this a topic that should remain off limits unless the patient specifically asks for advice?

Photo: Wikimedia Commons

Burned out and used up

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burnout n. 1. the point at which a rocket’s fuel or oxidizer is completely burned up and the rocket enters its free-flight phase or is jettisoned; 2. damage caused by overheating; 3. a state of emotional exhaustion caused by the stresses of one’s work or responsibilities.

How do you know when you’ve arrived at personal or professional burnout? In a post from four years ago that has since become a classic, emergency-room nurse/blogger Kim McAllister describes the signs:

You feel you are “on stage” for eight solid hours playing the part of a nurse.

You smile so hard for so long your face hurts.

You resent everyone. The doctors. Your colleagues. Your manager. Your patients.

The point comes when you snap. You can’t play the role any longer.

(You don’t have a choice.)

Depression follows.

You have to take medication just to get to the point that you can put on those damn scrubs and put one foot in front of the other.

(A commercial for “ER” makes you physically sick.)

You spend the majority of your time off sleeping. Your family suffers as apathy and anhedonia infuse every aspect of your life.

You can’t quit. You’re trapped. You need the money. You have to have the benefits. You desperately look for something outside of nursing to cling to, something else you can do for a living.

But… you aren’t educated to do anything else and besides, every other job you consider just pays minimum wage and you can’t support your family.

Although she’s writing about nurses, McAllister’s words surely resonate with anyone who’s ever experienced what it’s like to be worn down, depleted, used up, fried, physically and emotionally burned out.

Burnout has always been one of the hazards of the human condition. Lately, though, it seems the pressures of contemporary life, coupled with the recession, have increased our vulnerability. Workplaces have been pared down by layoffs. People are working harder with fewer resources. Stress levels are high. The struggle to keep up with all the demands often leaves everyone feeling mentally depleted and emotionally frayed.

Psychologists first began using the term “burnout” in the 1970s, and it’s an apt one. One by one, the flames of enthusiasm, vitality and motivation are quenched, to be replaced with cynicism, withdrawal, depersonalization, emptiness and depression.

Anyone can experience burnout, but some factors seem to place people at higher risk.

Experts who study burnout have identified a number of these factors. Some are external, such as work or home environments that are disorganized, unsupportive or excessively rigid. Others are internal, such as overly high expectations of oneself. An interesting article that appeared some years ago in Psychology Today explores another perspective: that job burnout is primarily the fault of organizational dysfunction rather than people’s individual mental makeup. The author, Christina Maslach, is perhaps one of the best-known researchers in the U.S. who focuses on burnout.

Other researchers have raised additional intriguing questions, such as how e-mail, cell phones and other electronic gadgets might be contributing to burnout, and the role of cultural attitudes towards work, multi-tasking and efficiency. They’re summed up in this article that appeared in New York Magazine in 2006; it’s rather a long read but worth it.

Although burnout is often associated with stress, these two states of mind are not synonymous with each other. HelpGuide, a mental health education website, explains it this way:

Burnout may be the result of unrelenting stress, but it isn’t the same as too much stress. Stress, by and large, involves too much: too many pressures that demand too much of you physically and psychologically. Stressed people can still imagine, though, that if they can just get everything under control, they’ll feel better.

Burnout, on the other hand, is about not enough. Being burned out means feeling empty, devoid of motivation, and beyond caring. People experiencing burnout often don’t see any hope of positive change in their situations. If excessive stress is like drowning in responsibilities, burnout is being all dried up. One other difference between stress and burnout: While you’re usually aware of being under a lot of stress, you don’t always notice burnout when it happens.

If this sounds like you or someone you know, an online quiz here can help you assess whether you’re headed for burnout and perhaps are in need of some intervention. Burnout that’s ignored can lead to depression, anxiety, substance abuse and increasingly difficult relationships with family and friends.

What to do about burnout? Many organizations in the fields of mental health and human resources have information and suggestions that are available online. Here’s a sample: MayoClinic.com, LiveStrong.com, and Workplaceissues.com. What they have in common is a focus on becoming more resilient, recognizing what you can change (and what you can’t), and re-engaging with the things that matter to you in life.

Emergiblog’s Kim McAllister describes her experience with burnout as a descent into a black hole. It took some counseling and antidepressants, plus learning how to avoid overwork and take care of herself, to help her regain her passion for nursing.

For each individual, the answer to preventing burnout, or finding one’s way back from burnout, is going to be different. For McAllister, it was reconnecting with the reason she went into nursing – to take care of patients.

In a post titled, appropriately enough, “Sweeping Away the Ashes,” she writes: “Lose sight of the person and you lose sight of the profession. Lose sight of their humanity and you lose sight of your own. Lose sight of your own and you become a burnt shell. You would think that after three decades of this, I’d have figured this out by now. I guess you never stop learning.”

Image credits: Photo, Wikimedia Commons; logo, Troy Murphy, West Central Tribune.

Reflections on hand washing

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We’ve all heard it a million times: Wash your hands.

Time for dinner? Wash your hands before you sit down at the table. Been playing with the dog? Wash those hands. Is someone in the household ill? Wash your hands, and do it often.

Despite the many technological advances in health care, we have yet to improve on the simple, low-tech effectiveness of soap, water and vigorous scrubbing of the hands – or, as it’s known in the health care world, “hand hygiene.”

The importance of clean hands has been reinforced in recent weeks as influenza, norovirus and the common cold make the rounds. One of the ways each of these viruses can be transmitted is, you guessed it, via hand-to-hand or hand-to-surface contact.

Germs might be too small to see but hands often are teeming with them. It’s estimated that the average human hand harbors 150 different species of microorganisms. Most are harmless but some are not. A few years ago I participated in a classroom experiment involving a swab and culture of each person’s hands, and the culture results for one individual contained staphylococcus.

Most of us know these basics, so why do we often skip the hand washing routine? A few years ago the Minnesota Department of Health conducted an observational study of people who used the public restrooms on the Minnesota State Fairgrounds. The findings were interesting: Adults were more likely than youths to wash their hands after using the restroom, and females had a better rate of hand washing than males. Overall, however, the rate of hand washing with soap and water hovered between 30 percent and 75 percent. The worst group? Teenaged boys, of whom only 18 percent were seen washing their hands.

Nor should we assume health care professionals are better than the general public when it comes to hand washing. When an online survey was conducted among facial plastic surgeons to assess how well they knew and practiced hand hygiene, only about half of the respondents were able to correctly identify which products were the best at killing germs. Nearly 60 percent couldn’t correctly identify when hand washing should optimally take place.

The authors, whose work appeared in 2009 in the Archives of Facial Plastic Surgery, concluded: “Adherence to hand hygiene practices is suboptimal among facial plastic surgeons.”

Overall, it’s believed that fewer than half of health care professionals consistently wash their hands according to best practices for preventing the spread of infection. The reasons are probably the same as for the general public: forgetfulness, not enough time, inconvenient location of sinks, lack of soap and paper towels, and perceived low risk.

The advice from the Minnesota Department of Health: Since there’s no way to know what kinds of germs we might be picking up on our hands, the best defense is frequent and thorough hand washing with soap and water.

Here’s how to do it: Wet your hands with clean water. Apply soap. Rub your hands together vigorously and scrub all surfaces, including between your fingers and under your nails. Scrub for 20 seconds (here’s a rule of thumb: 20 seconds is the equivalent of singing the “Happy Birthday” song twice). Rinse with clean water. Dry your hands briskly.

Waterless, alcohol-based hand sanitizers have become increasingly popular. People like them for several reasons: They’re portable, quick and easy to use and are less apt to dry the skin. There are conflicting opinions, though, on whether they’re as effective as old-fashioned soap and water at killing germs. Some of the research has found that hand sanitizers containing less than 60 percent alcohol don’t work as well. They also seem to be less effective in real-world conditions than the 99.9 percent success rate that many manufacturers claim.

Whether you prefer hand sanitizer or rely on soap and water makes little difference, however, if you’re lax about hand washing in the first place.

Wash your hands!

Photo: Wikimedia Com