Wednesday, June 10, 2009


Hello everyone.

It has been a while since my last entry.

I have been struggling with some of issues about my Diabetes. I have discovered that I may know the science and theory behind managing Diabetes but, I have difficulty balancing the emotional aspects and belief systems to successfully manage my Diabetes. I have suffered setbacks and failures in consistently doing the necessary things at the best time. I will explain this cryptic statement in the follow paragraphs.

I agreed to work night shift for my hospital because of their staffing shortage. I failed to consider how the schedule change would affect my health. I did not just agree to changing my schedule from days to nights but, also agreed to a series of constant schedule changes as I reverted back to days to care for my family when off work and revert to nights when working.

I was controlling my Diabetes with Glucophage, Actos, Byetta and diet before the shift change and was considered "well controlled" by my Doctor. After the schedule change my blood sugars became erratic. I began to "forget" to take my medications at least once a week in the morning and 3-4 times a week in the evening. I could not remember if it was "My Morning" or evening. What a mess.

My Byetta was even worse. I needed to take it 30-60 minutes before eating but could not establish a "Routine" that worked. When I got up to go to work, I would eat in less than 15 minutes after waking. When coming home from work, I would eat as soon as I got home so I could go to bed. When not working, I could not regulate sleep or eating. What a mess. I would miss 60% - 75% of my Byetta doses. I could not understand why I could not maintain a consistent compliance with my medications.

I was very disappointed with myself because I should be able to take my medications "on time." I began to discuss some of the behaviors other Diabetic nurses used to regulate their disease and learned some very important things.

The first thing I learned is that we cannot rely on memory to remain consistent. Most people form behavior patterns because it helps their life become "stable." We wake up at about the same time. We eat about the same time. We go to bed at about the same time every day. These routines are what we organize our daily routines around.

We eat the "foods that we like" and these foods are usually a small part of all the choices available to us on a daily basis. While we may "try" new foods, we do not often adopt the new foods into our daily routines. Our lives feel unsettled when our routine is too far out of balance. We tire easily and become forgetful.

The nurses who were controlled Diabetics have leaned to follow the same eating and medication routines whether working or sleeping at night. They eat breakfast in the morning, Supper in the evening and a snack at noon or midnight. They take their medication at the same time every day and do not change it for their work schedule. They still experience a broader range of blood sugar results than they would like.

The poorly controlled Diabetics are just as inconsistent as I was when they try to alternate their daily schedule with their work.

So rule one to compliance for me is a consistent schedule. I am back on Day Shift now and this should be easier to accomplish. I hope so!!

Rule two is a consistent medication schedule. Habits can be formed that will overcome a bad or confusing day. These habits of when and how to take my medication will help me to remain consistent.

Rule three is consistent eating habits. I can control my simple carbohydrate intake best when I eat at the same times and similar foods. Consistent habits can be altered in small ways for consistent improvement. This will be one of the most difficult for me to maintain.

Rule four is consistent activity levels. (This is the hated "Exercise") I need to do the same activities about the same time each day. I need to get some organized activity several times a week. (Walking, Biking, Running, Swimming.)

Wednesday, April 22, 2009

The Relationship Nurse

Hello, I am Richard, RN. a nurse who works with Michelle and who coined the phrase, The Relationship Nurse for Michelle.

I noticed the other nurses speaking quietly with her on a frequent basis and the sudden silence when I approached. OK, I'm the charge nurse and this happens, but I also knew about Michelle's joining an origination called Slumber Time Parties about a year ago.

I did not connect the sudden silences with her out of the hospital activities until last week when one of our coworkers complained about the loss of excitement in her 4 year old marriage and Michelle responded, "I have an idea that could help. Let's chat." When I allowed the two of them to withdraw into a quiet area without shadowing or teasing I became "an OK" guy to talk with about something that had been for "women only" until that moment.

We don't share the nitty gritty details, but Michelle began to share some of her journey with me. She had discovered a way to help others in a compassionate, caring manner that was supportive, non judgmental This perfectly describes the Art of Nursing.

Some nurses find a way to help others when away from work. Extra income, something they enjoy or just because they feel better when then give emotionally to others are some of the reasons they find secondary occupations. (Occupation means jobs to me, but the long word sounds better in the sentence. Ha!! Take that 4th grade English teacher)

The stories they share should be sold to TV. I laugh until I cry or cry until I laugh at some of their stories. One of our Nurses, Michelle, has started working with Slumber Parties. She likes to solve "Relationship Issues" for her clients and she enjoys working with other women to improve the quality of their relationships. (yes, sometimes the men, but the men usually just follow the woman's lead. Yep, that's true for me.)

Michelle was sharing with us the other night and I laughed until I cried. As I listened I believed others would enjoy her stories as well. I am going to help her start a blog about her stories. The names and enough details will be changed to protect privacy, but the stories will all be based on real life stories. I hope you find them worthwhile.

I hope you all laugh, enjoy and learn from her as I have. She is a fabulous lady and a natural nurse. Michelle is an excellent bedside nurse. Intelligent, compassionate, skilled and hard working.

She is a tiny little bundle of energy. She says she's five feet, but I think she's closer to 4 ft 10. She is small enough to still fit in her high school jeans even after 2 boys who are now in high school. Her high schools jeans just went to Good Will last summer because they were "out of style, not because they had grown too small. (I just want to scream with envy over that, don't you?...)

She is still married to the father of her boys. He is over 6 feet tall and they look like an "odd couple" indeed. She started to work with Slumber Parties while trying to bring new life into her own relationship and has enjoyed the results and working with others so much she now spends as much time with her fun job (Slumber Time Parties) as she does on her "real job." I have watched her personality change and improve over the last year while she worked on her relationship and helped others.

I recall what I thought when I first heard her describe Slumber Time Parties. I thought "OOOOKK, a bunch of women sitting around laughing about sex toys while they bashed their men and got bashed on margaritas."

I did not want any part of that scene and felt that it was an example of dysfunctional relationships.

I was wrong.

OK I'll repeat that: I WAS WRONG.

Michelle has used the information and tactics to repair her damaged marriage and is now teaching others to do the same. I would not have expected this behavior from her and I have been astounded.

Michelle has expanded her nursing. She now provides excellent nursing for those who need a medical nurse and for those who need a relationship nurse.

Check out her blog Michelle, The Relationship Nurse. E-mail her and ask for her advice. She is better than Ann Landers ever was because she can be realistic and funny.

Thursday, April 16, 2009

Long Term Acute Care

What is Long Term Acute Care? There is a lot of confusion about what an LTAC is and what they do for patients. I hope this helps some people understand the function of LTACs better.

First let me explain what an LTAC is not.

LTACs are not nursing homes.

LTACs are not rehab centers.

LTACs are not assisted living centers.

LTACs ARE acute care hospitals (similar to a regular hospital). They are designed to provide care for the patients who are too fragile or ill to recover in the time allotted by Medicare at a regular hospital. A simple version is that they are the sickest of the chronically ill patients found in any normal hospital.

We provide care for the patients with multiple illnesses that play against each other such as the patient with heart failure who needs to have excess fluid removed from their bodies and is also a kidney patient who is difficult to remove fluid from. The diabetic patient with multiple complications such as heart disease combined with poor circulation in their legs along with open wounds that do not heal. The patient who has been paralyzed for many years and now has multiple wounds, bladder difficulty, infection issues and problems associated with a lifestyle that prohibits physical activity. The patient with lung disease that the regular hospitals cannot get off of a ventilator. The patients with infection in their bones who need complex and long term antibiotic therapy along with complex wound care. These are just some of the typical patients seen in an LTAC on a daily basis.

Our patients are always fragile and it becomes a challenge to provide the best care. Each patient and their care is different, challenging and requires daily review and revision. Nursing becomes critical for these patients in order to provide them with the best chance of healing and returning to their home. (or nursing home).

Our patients are with us for an average of almost 4 weeks. Our staff, our patients and the patients family get to know each other much better than in the typical hospital where the patient only stays an average of 3-5 days. We become attached to most, tolerant of a few and we get to understand almost all of our patients and their families. The emotional rewards of practicing the ART of nursing with our patients are enormous. The feelings of accomplishment when one of our ventilator patients speaks for the first time in weeks cannot be explained. The "warm and fuzzy" feelings when we finally stop wound care on patient whose wounds have been open for over a year are incredible. The wounds are finally closed. Seeing a patient go home that none of us believed would survive is an indescribable sensation. This is why we have chosen to work in an LTAC.

The hardest part of our jobs are the patients who do not respond to treatment. Those who continue to get worse until physicians and nurses can no longer help. We see many more of these patients than the normal nurse. We become closer to them and their families. We cry when they pass.

And yet, I find rewards even when a patient does not survive. I know that we have done everything we could. I feel we have provided some dignity for the patient and the family. I know we often provide comfort, acceptance and closure for the families. Acceptance and closure are frequently impossible to provide in a fast paced Short Term Acute Care hospital. (a normal hospital).

I hope this helps others to understand what an LTAC is and why I find the work so very rewarding after 20 years of working in World Renowned ICUs and ERs.

Monday, March 30, 2009


I have a friend who is diabetic. I love the way she states "Diabetes doesn't define me, but it helps explain me." She has reached a point of acceptance with her diabetes that I have not reached yet. I hope that I eventually arrive at the same spiritual point with my diabetes.

I am a nurse who has taught diabetes for more than 20 years, but I was only diagnosed with diabetes a year ago. I have found out that the things I have always taught are true, but incomplete. I have always mentally accepted the vagaries of diabetes and now I have to emotionally accept the consequences and effects of diabetes in my life. I believe this will be a journey that I will continue to learn about for the rest of my life.

Diabetes is different for every diabetic. Our bodies respond differently to stress, exercise, food and medication. Our physician and our dietitian become some of the most important people in our lives as we learn about OUR DIABETES.

So I would like to go through my teaching that I use with patients and personalize the lessons. This will take several posts over the next few weeks. I hope others find reading these as rewarding as I hope to find writing them.

I will begin with the simple statement that "every diabetic is different and their treatment plan is as individual as their face. Their treatment plan must be worked out over time between them and their doctor." We must all find a doctor that we can speak comfortably with and trust their care. This allows for a better working relationship between them and their doctor. I have even stated that working with a doctor they could communicate with and trust was one of the most important factors in successful treatment for diabetes.

The new diabetic will be started on a diet and medication regimen by their doctor. Most diabetics will be asked to check their blood sugars at home. The good news is that these machines can be obtained for very little money or even for free. The companies who make the monitors provide a certain number of free monitors because only their strips will work and you then have to buy strips. Most insurance companies and Medicare will help with machines and strips. I prefer a monitor that allows me to check my blood sugar on my hand or forearm.

Monitoring blood sugars allows the diabetic and their physician to see the effects of medication, diet and exercise. I have found it amazing how blood sugars can be elevated from some foods that I thought were OK and see very little elevation from foods that I thought would create a problem. One on my patients has a very large increase in blood sugar from 1/2 of a slice of bread, but very little from a serving of regular Vanilla pudding. The pudding contains sugar and I thought he would see an elevation of 100 points when he actually had and elevation of only 25 points.

Speaking of blood sugar brings me to the final subject of this blog. What is Diabetes? Most people believe that diabetes is a problem of high blood sugars. It is not having an elevated blood sugar!!!!!

Diabetes is a shortage of insulin in our bodies. Our blood sugar builds up in our blood stream when there is not enough insulin to carry the blood sugar into the cells where it can be used for as fuel for the cells. When our cells do not receive enough blood sugar they become damaged over time. This is what can cause the wide spectrum and devastating complications associated with diabetes. Treatment is usually designed to balance a reduced need for insulin with supplementing the bodies production of insulin. Both result in a lower blood sugar as less foods are converted to blood sugar and more blood sugar is carried into the cells of the body.

Wednesday, March 25, 2009

Little Miracles are Precious

Oh Happy Day. Saw a former patient last night. I can't tell you her name without breaching confidentiality, but I can share some of the info that makes her special to me.

She had entered another hospital for a simple procedure and been through every complication that could happen. Her overnight stay had lasted six weeks and she was sent to us when there was no longer any hope for survival. We started caring for this woman (I'll call her Nancy) when she was not expected to live more than a few days to weeks. She needed additional surgery, but the surgeons believed she would die on the table if ANY surgery was attempted. They refused to operate.

I have seen this before and we spent more time with the family. Their need for emotional support almost overwhelming. We tried to be honest with them since the outcome was unknown. Nancy did not have a terminal illness. There was not a terminal disease causing the end of her life. There WERE many serious problems that made each other worse. The doctors could not treat one without making another worse. We believed that no human had the physical reserves to survive and she was very close to death.

We prepared her daughter and her husband for her impending death. We allowed them to cry on our shoulders as we cried with them. We listened to her daughter speak of how she learned to be a mother by remembering the way Nancy raised her. We encouraged the family to spend time with Nancy and we ignored the visitation hours. We all accepted that Nancy was going to pass away.

Medical care and nursing care continued even though we did not expect more than life to be prolonged for a few weeks. Nancy had "the look" of deathly illness that so many Nurses and Doctors have come to recognize. "The Look" makes healthcare professionals feel helpless. We know our patient is critically ill and there is so little we can do to help. We also know that we are not Gods and do not really know the outcomes. We do the best we can as we fumble in the dark trying to help others.

For seven weeks we continued to follow the treatment with very slow and very slight improvement in Nancy's condition. Her husband spent less and less time with her as we watched his grief increase. Her daughter tried to remain hopeful but, I knew she was struggling as she brough Nancy's grandchildren in and pretended there would always be time to see "Nanna" when she was better.

The family and the staff became rundown from the stress. Yes, the staff becomes attached and the stress builds for them. They will not feel the same loss as the family, but the stress of a dozen episodes a year takes a large toll for the caring staff involved.

Monday morning of Nancy's eighth week with us and her fourteenth week in the hospital I noticed an difference in her attitude and appearance. Her skin was not as grey and lifeless as on Friday. She smiled at me and stated she felt better for the first time. She could stand with help for the first time and her voice was soft but not a whisper. I worried that this was the "Rally before the End."

Tuesday she walked to the bathroom alone.

Wednesday a stomach X-ray showed that she was getting better rapidly.

Friday she went to Rehab to get her strength back.

That was three Months ago.

Now this strange woman walks up to me and gives me a big hug and says thank you!! This woman recognized me but, I was unable to remember her. Then I saw Nancy's daughter. I was soooo embarrassed!! I know she looked different but it was still embarrassing.

How could I forget Nancy!!

I cried again. With joy and with Nancy. This is why we do all that we do.

Tuesday, March 24, 2009

Who Is Richard, RN?

Wow!! What a question to start a blog with. Who is Richard,RN? Who I am, what I believe in, and what makes me different are important questions when people are deciding to read a blog.

I am a Registered Nurse. I have been an RN for over 20 years. How I became an RN and some of my history before nursing are stories for the future. All I will say for now is that I have had "an interesting life."

I have worked in ERs, and ICUs for most of my career. I posses an insatiable curiosity about how things work and why they work that way and I love to share any knowledge I acquire. My curiosity is quite eclectic (I had to look up this word but it works so well some times.) This means I learn about healthcare, alternatives to modern healthcare, computers, blogging, marketing, dieting, TV, Movies, Books etc. etc. I spent years with my youngest daughter watching science based TV like CSI with a laptop between us as we researched the actual science as they were presenting something on TV. Found out lots of stuff that was fun to know. And some of it was pretty useless, but my daughter now loves science. My eclectic curiosity may pay big dividends for my daughter.

I love teaching my patients and their families. A great deal of information is available to the public on heathcare issues such as diseases, medications, treatments and a thousand other questions that I have been asked to answer. But how do my patients and their loved ones find this information? How do they translate Medical Speak to something they can understand. An article written by some pharmicutical geek with 2-3 PHDs is difficult to understand when you are a 65 year old immigrant from Thailand who works hard but can barely read and write 3rd grade English. The Medical Speak his doctor uses isn't much better and the nurses frequently give information so incomplete that it is worse than useless. "This is your heart pill" doesn't help when they take 4 medications for their heart. I enjoy the challenge of translating Medical Speak to something that can be used by the patient and their family.

I believe people are more likely to make wise decisions when they UNDERSTAND what is being said to them by healthcare professionals and how their choices effect them as a patient.I would like to help others and hope this blog allow me to perform this service. Write comments. Ask questions. I don't promise to have the answers, but I will share what I can and what I learn. We can learn together.

So, ask me what you want to know. Tell me what you already know. Let's talk, chat, laugh and just help each other.