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Don't be lazy

Baby trapped in car 
August 2, 2010 -- Recent news items illustrate the important contributions family nurse practitioners make in preventing and diagnosing deadly health problems. On June 13, the Houston Chronicle ran a "Sunday Q&A" feature by Cindy George in which University of Texas nursing professor Elda Ramirez gives advice on how to cope with the very hot days that region experiences. Ramirez clearly has knowledge, but she also displays an ability to convey practical health information to lay people in a direct, engaging way that is one of the hallmarks of NP practice. And today, the University of Central Florida's Today site posted an article by KJ Lewis about Arden Monroe-Obermeit, who appeared as a morgue technician on the Discovery Channel reality show Dr. G: Medical Examiner. Monroe-Obermeit was about to graduate from the university with a nursing degree, and to enter its Doctor of Nursing Practice program so she could help people avoid ending up in the morgue because of preventable conditions. The article reports that Monroe-Obermeit's new career path was inspired partly by an NP who diagnosed her Cushings disease when many physicians could not. We thank those responsible for these helpful pieces, which look past stereotypes and recognize nursing expertise.

How to avoid getting stuck like chuck

Dr. M-O
How to avoid getting stuck like chuck

The Houston Chronicle "Q&A" is headlined "Heat gets to you? Here's how to survive." The short introduction explains that Elda Ramirez is an "associate professor at the University of Texas School of Nursing who treats patients at several Memorial Hermann [Health System] locations." Ramirez "teaches students to assess heat-related injuries," so she now "explains ways to safely survive sultry summer temperatures."

Reporter Cindy George asks for Ramirez's "general rule of thumb" in "beating the heat," and Ramirez advises carrying liquids and an umbrella, watching for heat-related changes, and if necessary, walking into a store to cool off. George asks for a "not-so-obvious" tip, and Ramirez suggests carrying a gallon of water in your vehicle, because "you never know when your car is going to break down," and also "mak[ing] sure you have your cell phone charger because if your phone dies, you're stuck like chuck." Ramirez also offers advice on skin protection (clothing such as "light cottons that cover to your wrists and ankles," sunscreen that is "at least 50 SPF").

In response to a question about children left in vehicles, Ramirez is blunt:

In the summertime, a lot of grandparents or other people have the children who don't normally have that responsibility. Have a backup system. Have the parent of the child always call and ask: Did you drop off the baby? Maybe have the day care call if the kid doesn't show up. Have a picture of the baby right by the speedometer or on the rearview mirror. Always have something that reminds you: I have the baby. And if you're going in the store, always take the kid out. Don't be lazy.

This is great advice. With regard to Ramirez's point of having something in the car to remind you of the baby, she might have also noted that one of the most effective tactics is to put your purse, backpack, or briefcase next to the baby in the back seat, so that upon exiting the car you'll be forced to retrieve it from right next to the baby.

Perhaps the strongest theme running through Ramirez's advice in the Q&A is hydration. George asks how to know you've got enough water. Ramirez says "pre-hydrate," and explains:

In the summer, people think they've been drinking plenty of water, but they don't realize how much they're losing from the heat. Soda and juice can make you actually lose more fluid. Drink straight up water and even sports drinks that have electrolytes, which I water down. The minimum requirement is eight glasses of water a day. In this kind of heat, you've got to add another four to six -- especially if you're working outdoors. Look at how often you're urinating and if the urine is dark, that's not a good sign. It should be clear to a little yellow. Dark urine means it's concentrated and there's not enough fluid in your body to dilute it.

George invites Ramirez to expand on the advice for those who work outside, and she urges them to cover up, hydrate, and know the warning signs of heat exhaustion, which she explains a little later. She also stresses looking for shade, taking breaks, and cooling the outside of the body with water. Ramirez recommends that athletes work out in the early morning and later afternoon. She says babies should not be out, but if they are, they must be hydrated, and must get "absolutely no soda and nothing with sugar." Toddlers need "water, Popsicles and Jell-O." The elderly, who may be especially vulnerable because of other health issues, "shouldn't be outdoors." She recommends keeping pets out of direct heat unless there is shelter, and spraying them with water, or wetting an area for them to lie in "because the only place they sweat is from their mouths."

Ramirez explains how heat can make us sick, and warning signs to look for.

Heat exhaustion is when the body is beginning to compensate for overheating. People start heavily sweating, feeling tired, dizzy and nauseated. They need to immediately tell someone or call a friend if they're alone. The person should seek hydration, shade and shower with cool water. Heat stroke happens if you don't heed the initial warnings. By that time, you have probably fainted or vomited. You start having muscle cramps, the pulse starts going up and their temperature is super high. They're not sweating and they're acting weird. That's when it's an emergency. And some people who have heat exhaustion need to be seen by their doctor or the nearest urgent care center.

Ramirez knows what she's talking about, and the report makes clear up front that she is a professor at a major university. But note how simple and direct her advice is--no jargon, just plain, clear explanations and pragmatic, specific advice, such as stepping into a store, taking water and a cell phone in a car, covering certain parts of the body, sun block of a certain quality, and photos as a backup system to remind care givers that they have the baby in a potentially dangerous situation when they really might forget. She does not just issue vague, general formulations (e.g., "hydrate," "seek shelter") and stop. She tells people specifically what to look for ("It should be clear to a little yellow") and what to do (adding four to six glasses of water to the usual minimum of eight). She uses colorful language that will stick in people's heads ("stuck like chuck"; "acting weird"). And she is blunt when necessary: babies and the vulnerable elderly should not be out at all.

These teaching skills are one reason nurse practitioners are so good at preventative care, and primary care generally. Their communications are tailored to convey vital health information that patients can use, rather than to display advanced knowledge. This may not be as glamorous as what Hollywood shows, and fewer people may be impressed with adverse events prevented, as opposed to some dramatic surgical intervention. But just as many lives can be saved this way, if not far more. And the cost is relatively tiny. Our only issue is with Ramirez's suggestion that people with heat exhaustion may need to see their "doctor or the nearest urgent care center"; hasn't this NP forgotten something? Anyway, we thank Cindy George and the Chronicle for allowing Ramirez to demonstrate not only how to "beat the heat," but also how to provide health care.

Dr. M-O

The Today article about Arden Monroe-Obermeit offers another illustration of NP skill. "Former ‘Dr. G’ Cast Member Becomes Nurse," explains that Monroe-Obermeit spent eight years as a morgue technician, "performing more than 3,000 autopsies and 500 death scene investigations," and that she appeared for four years on Dr. G: Medical Examiner. Now she will graduate from the University of Central Florida's College of Nursing with a "nursing degree," presumably a bachelor's. The piece reports that she will soon enter the Orlando university's "new post-baccalaureate Doctor of Nursing Practice program in the fall to prepare for certification as a family nurse practitioner" (and that she already has a bachelor's in Biological Anthropology from the University of Florida).

The piece emphasizes what motivated Monroe-Obermeit to take this path. She explains:

I saw too many deaths caused by people ignoring their diabetes or their heart conditions. In nursing, I absolutely love teaching patients how to avoid becoming a case at the morgue.

Here again is the focus on prevention and teaching that allows NPs to be such effective primary care practitioners. But there is more. For years, Monroe-Obermeit "battled her own health issues, which she said many doctors were not able to diagnose."

She long suspected Cushing's syndrome, a rare disorder that causes high levels of the hormone cortisol and results in a myriad of symptoms, including fatigue and weight gain. It was a nurse practitioner who finally ordered radiological studies that helped her obtain the Cushing's diagnosis and get treatment. Medical specialists then surgically removed a tumor from her pituitary gland. After treatment, she quickly lost 80 pounds. Her TV fans noticed and applauded her in fan mail and blogs.

"A nurse practitioner made a huge impact on my life by helping me obtain a very difficult and rare diagnosis," she said. "The impact she had on me was inspiring. My dream is to be able to do that for just one of my patients in the future."

The piece is not long or detailed, but it delivers a critical message that is often overlooked: nurse practitioners are expert at diagnosing disease, and one reason is that they listen to patients and think broadly. It's not enough to have a lot of technical knowledge. Of course, some physician groups have questioned whether NPs are qualified to diagnose, and because all the research suggests otherwise, the physicians often fall back on anecdotes and assertions about years of formal education. However, as this piece shows, there are plenty of anecdotes going the other way, in which NPs (or RNs) have diagnosed a serious condition that physicians failed to see.

Shall we conclude that primary care physicians should not be permitted to practice without NP supervision?

See the article "Heat gets to you? Here's how to survive," by Cindy George, posted June 13, 2010, on the Houston Chronicle site. And see KJ Lewis's "Former ‘Dr. G’ Cast Member Becomes Nurse," posted August 2, 2010, on UCF's Today site.




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