Pay no attention to that last post. IE still stinks (does the PNG below look blue to you?), but the JPEG looks okay.

Re-inoculation from the appendix and recurrent C. difficile infection (CDI) to find a topic to write a review article in Bio416 Virology, I came across a post on enzyme evolution in the Discount Thoughts blog that led me to a post on the possible functionality of the appendix. Bollinger et al., writing in Journal of Theoretical Biology, propose that the appendix is a tool for creating probiotic biofilms in the large intestine as well as re-inoculating the large intestine in the event of its defloration by, for example, diarrhea. Their argument rests mostly on recent evidence they cite suggesting that the immune system does not operate antagonistically with normal intestinal bacteria. They present an interesting idea. Although from a developmental view Clarkson points out the authors' limited conception of vestigiality, this view is less relevant to the proposed current functions of the appendix.

(One thing I didn't quite follow was the authors' statement that "receptors for secretory IgA that are important for biofilm formation are up-regulated by the presence of secretory IgA." I take this to mean that IgA is a positive feedback loop in the gut. This interpretation would make sense with regard to IBD and Crohn's. It would also help explain the connection between antibiotics and Clostridium difficile infection--if antibody production were partly dependent on the presence of antibodies, immunity would be partly dependent on the presence of bacteria. However, based on the abstracts for the relevant citations, the statement seems like a non-sequitur. Wold and Adlerberth (2000) conclude that mother's IgA results in less gut immune stimulation and lower salivary IgA, while Friman et al. (1996) refer to IgA's role in capturing probiotic E. coli but not IgA receptors. Peterson et al. (2007) agree with Wold and Adlerberth in finding that IgA attenuates the gut inflammatory response.)

Mongolian nomadic herders

The issue raised by Bollinger et al. of re-inoculating the intestines from the appendix put me in mind of a speaker who came to my nursing school last year. Sas Carey, RN, has traveled to Mongolia on several occasions to help build a health database of nomadic reindeer herders as well as to record their indigenous medical practices. Her travels resulted in the creation of a documentary film as well as a non-profit group called Nomadicare.

In her talk, I remember quite distinctly that she spoke about the herders treating chronic appendicitis by drinking liquified animal stool. My thinking at the time was that it makes sense if the intestinal bacteria from the stool compete with the inflammatory bacteria. In the context of Bollinger et al.'s theory, perhaps it is simply a re-balancing of similar gut flora that keeps appendicitis in check rather than allowing it to become acute.

Chronic appendicitis

You may be thinking that you haven't heard of chronic appendicitis, and it's true that in this country we as nurses are taught RLQ pain-appendicitis-surgery. And even as recently as 1998, Van Winter et al. was asking whether it really existed. However, a breif review of the literature shows that it's been accepted: Konstantinidis et al. (2008) found 6.1% of appendectomy cases from chronic symptoms; and Roumen et al. (2008) found that elective appendectomy relieved chronic RLQ pain.

Sgourakis et al. (2008) identified lack of bowel movement as a factor in chronic appendicitis but not blockage, which is interesting since blockage is the usual explanation for acute appendicitis. Do they have a different etiology? If Mongolian reindeer herders spend a lot of time in the saddle or going without food, could this lead to intestinal stasis and inflammation?

Also, if chronic appendicitis comes from stasis rather than blockage, could the infectious bacteria be different? The theory with acute appendicitis is that normal bacterial flora get trapped in the appendix by a blockage and start to infect the appendix wall. Perhaps in chronic appendicitis, it is the abnormal gut bacteria that get into the appendix. This would explain why the appendicitis is not acute (normal and abnormal bacteria are competing) as well as why the reindeer herders' techniques worked (adding more normal gut bacteria as a probiotic to compete with the infection).

And in fact acute appendicitis is not always caused by blockage, either. Brown et al. (2007) report the case of a man who developed appendicitis after Clostridium difficile infection. From a literature review, they conclude this etiology is rare but may be under-diagnosed since mild forms of appendicitis would be treated by antibiotics along with the C.diff while severe C.diff infections of the entire colon might obscure appendicitis.

The appendix and re-current C. difficile infection

If, as Bollinger et al. suggest, the appendix is involved in re-inoculating the intestine with normal intestinal bacterial, could it not also be a factor in re-current cases of C.diff infection? Maroo and Lamont (2006) state that the reasons some patients have recurrent C.diff infections while others do not is not known: stool samples of recovering patients indicate that spores are present in both patients who have re-current infection and those that do not. Reinfection through the fecal-oral route is a best guess. However, if C.diff infection can occur through die-off of normal bacteria, perhaps the appendix can also lose its normal flora, to be replaced by C. difficile and its spores, which subsequently re-infect the intestine.

As Maroo and Lamont show in their review, stool transplant, which they gingerly call fecal bacteriotherapy, is more effective than pure antibiotics for the treatment of C.diff infection. (The route of stool transplant does not seem to be a decisive factor.) As well, pulsed antibiotic treatment is more effective than daily dosing to prevent re-currence. Both these modalities would allow increased growth of competitive bacteria, which suggests that there is still a source of infection to be competed with.

Stool transplant off the steppe

Aas et al. (2003) performed one of the stool transplants reviewed by Maroo and Lamont. In their retrospective study, of 16 patients suffering from re-curring C.diff infections and multiple antiobiotic treatments, only 1 experienced a re-currence of infection following a nasogastric stool transplant.

The procedure used in this study was as follows:
Obtain stool sample less than 6 hrs before the transplantation procedure
Select a stool specimen (preferably a soft specimen) with a weight of 30 g or a volume of 2 cm3
Add 50–70 mL of sterile 0.9 N NaCl to the stool sample and homogenize with a household blender. Initially use the low setting until the sample breaks up; then, advance the speed gradually to the highest setting. Continue for 2–4 min until the sample is smooth.
Filter the suspension using a paper coffee filter. Allow adequate time for slow filtration to come to an end.
Refilter the suspension, again using a paper coffee filter. As before, allow adequate time for slow filtration.
Treat with omeprazole capsules (20 mg po) on the evening before and on the morning of the stool transplantation
Immediately before the stool transplantation, a nasogastric tube is placed. Radiography should be used to verify that the tube tip position is in the gastric antrum.
A total of 25 mL of the transplantation stool suspension is aspirated into a syringe and instilled into the recipient via the nasogastric tube
After the stool instillation, the nasogastric tube is flushed with 0.9 N NaCl. The nasogastric tube is then withdrawn.
The patient is permitted to resume a normal diet and all customary physical activities immediately after discharge from the gastroenterology clinic.
This is a lot more expensive than I imagine the Mongolian herders' method is, but I suspect it is also a lot more pleasant for the patient.

Anyhow, to sum up: one theory of the appendix is that its purpose is to re-inoculate the intestines after a pathologic (or possibly pathogenic) event like diarrhea; appendicitis (including or especially chronic appendicitis) may be caused by inoculation of the appendix with pathogens; re-current C.diff infection is not explained, but the effectiveness of probiotic treatment suggests a source of re-infection; and, finally, Mongolian herders' traditional treatment of chronic appendicitis with methods proven to be effective in treating re-current C.diff infection suggests a possible connection between the appendix and C.diff.

  1. R RANDALBOLLINGER, A BARBAS, E BUSH, S LIN, W PARKER (2007). Biofilms in the large bowel suggest an apparent function of the human vermiform appendix Journal of Theoretical Biology, 249 (4), 826-831 DOI: 10.1016/j.jtbi.2007.08.032
  2. Wold AE & Adlerberth I. (2000) Breast feeding and the intestinal microflora of the infant—implications for protection against infectious diseases, Adv. Exp. Med. Biol. 478 (2000), pp. 77–93. Abstract from Scopus.
  3. Friman et al. (1996) V. Friman, I. Adlerberth, H. Connell, C. Svanborg, L.A. Hanson and A.E. Wold, Decreased expression of mannose-specific adhesins by Escherichia coli in the colonic microflora of immunoglobulin A-deficient individuals, Infect. Immun. 64 (1996), pp. 2794–2798. Abstract from Scopus.
  4. Peterson DA; McNulty NP; Guruge JL; Gordon JI (2007). IgA response to symbiotic bacteria as a mediator of gut homeostasis. Cell Host & Microbe [Cell Host Microbe] 2007 Nov 15; Vol. 2 (5), pp. 328-39. Abstract from Medline.
  5. Van Winter, Wilkinson, Goerss, & Davis (1998). Chronic appendicitis: does it exist? J Fam Pract, 46, 507-509. From
  6. Konstantinidis KM; Anastasakou KA; Vorias MN; Sambalis GH; Georgiou MK; Xiarchos AG (2008). Journal Of Laparoendoscopic & Advanced Surgical Techniques, 18 (2), 248-258. Abstract from Medline.
  7. Roumen RM; Groenendijk RP; Sloots CE; Duthoi KE; Scheltinga MR; Bruijninckx CM. (2008). Randomized clinical trial evaluating elective laparoscopic appendicectomy for chronic right lower-quadrant pain. The British Journal Of Surgery, 95 (2), 169-174. Abstract from Medline.
  8. Sgourakis G; Sotiropoulos GC; Molmenti EP; Eibl C; Bonticous S; Moege J; Berchtold C. (2008). Are acute exacerbations of chronic inflammatory appendicitis triggered by coprostasis and/or coproliths? World Journal Of Gastroenterology: WJG, 14 (20), 3179-3182. Abstract from Medline.
  9. Brown TA; Rajappannair L; Dalton AB; Bandi R; Myers JP; Kefalas CH. (2007). Acute appendicitis in the setting of Clostridium difficile colitis: case report and review of the literature. Clinical Gastroenterology And Hepatology, 5 (8), 969-671. Abstract from Medline.
  10. S MAROO, J LAMONT (2006). Recurrent Clostridium Difficile Gastroenterology, 130 (4), 1311-1316 DOI: 10.1053/j.gastro.2006.02.044
  11. Johannes Aas, Charles E. Gessert, Johan S. Bakken (2003). Recurrent Colitis: Case Series Involving 18 Patients Treated with Donor Stool Administered via a Nasogastric Tube Clinical Infectious Diseases, 36 (5), 580-585 DOI: 10.1086/367657

NCLEX and neuroscience... testing what?

I suppose many nursing students complain about the NCLEX-style questions they are forced to answer in nursing school. Today, purely by chance, I witnessed an interesting little correlation that I suspect sheds light on the nature of nursing exams.

In my Nursing Management/Leadership course this afternoon, we did an exercise where we were asked to come up with as many words as possible using the letters from "teamwork." For example, the words "team" and "work" are in "teamwork" as well as the words "tea" and "am." We had a time limit, and the most number of words one person came up with was 19. We then went around and added the words everyone else had come up with to make a total of 50-something words.

At the end of adding everyone else's words, the dry-erase board was a series of columns of mostly two- and three-letter words, with the exception of two columns that contained mostly words of four letters or more. These columns belonged to myself and one other student. She and I thought up mostly four-letter words, and almost all the four-letter words in the class were from the two of us. Interestingly enough, we two are the only older students in the class and the only ones with previous educations--I with an aborted almost-degree in humanities and she with an MA.

We two were very much in the middle of the group as far as the total number of words we thought up, but the type of words we were trying to produce involved a different level of anagrammatization (or whatever you call it).

Now, what's really interesting is that earlier in the day we had a post-test review in Psych Nursing, and on one particular question, this other student and I chose the "wrong" answer because we interpreted the question in a similar way that was different from the professor and the other students. When I tried to explain what I thought the question was asking, she looked at me confusedly like she thought I was crazy, and I guarantee I was thinking "you know, I'm not crazy."

I think--and I have always thought--that nursing exams really don't test knowledge (very well) or critical thinking skills (as they supposedly do) but, rather, whether or not you think the same way as the instructor.

Of course, you would guess that thinking like the instructor was "getting at the right answer," but I often don't feel that way. In fact, on more than one occasion, the "correct" answer on a test has also been the foolish or illogical interpretation in my view. (In this case, illogical means poorly thought out, not intuitive.)

Now, if I had just asserted my opinion, I suspect you wouldn't give it a second thought before dismissing it. However, given the difference in style demonstrated in the word test, you should consider whether the NCLEX questions don't just test the ability to sink up with the nursing instructors.

"Sink up" isn't a very rigorous concept, but I know that women who live together do sink up in other ways, such as their endocrine processes. I don't think it's out of the realm of possibility that women sink up in their neuro processes as well. Does this constitute "education"? I don't think so, but what does that matter since the whole field is dominated by women?

Participate in research

One thing I think is that nursing, and health care in general, does not make enough connections with the fitness industry and sports medicine.

Think of all those older people lying in bed who you, as a nurse, are encouraging to use the Incentive Spirometer in order to prevent pneumonia. How often do you witness people with feeble breathing capacity who are unable to move the IS even close to the goal?

Now think of all those fitness commercials advertising "core" fitness. Do you think there is any connection between youthful core fitness and elderly ability at IS? Of course, you would have to study this to find out, but I would be willing to bet on it.

If you're interesting in making the nursing-fitness connection, you can start now by participating in research on the effect of stretching on exercise. Although stretching before exercise to prevent injury is a gospel on many sports teams and among personal trainers, the evidence is actually not very good, and there is some thought that stretching before exercise actually increases the possibility of injury. (I only warm up now.) For better flexibility, stretching after exercise is definitely preferable.

Depression and heart attack

Right now on RN radio's The Health Report, listen to a podcast [download mp3 here] about depression and heart attack.

Researchblogging, part deux

In February, I blogged about the Researchblogging blog (I know, I know...). I tried to actually sign up for an account today, but they have to "review" my blog. Well, reviewers, here it is. Why don't you activate my account?

Echo, AAA, and Eastern Promises

This morning, I got up bright and early and rode my bicycle up to the Day's Inn to get an echo with M-mode and AAA done. This was courtesy of the folks at

The tech who performed the scan was an older gentleman who had an Eastern European accent (Hungarian?) and reminded me of the actor Armin Mueller-Stahl in the movie Eastern Promises.

(Eastern Promises, by the way, is not only a good movie in its own right, it is a great movie for portraying a nurse as something other than a sex object, a matron, helpless or simply just an extra. I guess Naomi Watts as Anna is technically supporting cast, but she is a nurse-practitioner, and appears in no scenes being subservient to doctors. Plus, Viggo Mortensen is from a town nearby where I live in upstate NY. So, Eastern Promises is, I guess, as near as possible to an officially-sanctioned CXLXMXRX film.)

Anyhow, after it was all over this tech looked at me shrugged, nodded his head, and said in his Hungarian accent, "you're a good guy, Chris." What is that supposed to mean? Does it mean you are in good health or it's not your fault? I have to wait two weeks for results. Hopefully, this company, which looks a little shady to me, won't steal my credit card number or sell my echo to insurance companies...

Brain rules

There is a great new website out called, which accompanies a book of the same name. It attempts to put brain science into a format usable by professionals. This is not nearly the first such book/website to this, and it won't be the last. However, from what I can tell looking it over, it's very well done, and its focus on topics like exercise, stress, and gender makes it applicable to nursing, both to nursing school and to the hospital work environment. Here's a slide show from the site:
Brain Rules for Presenters
View SlideShare presentation or Upload your own. (tags: reynolds garr)

New information about C.diff management

Earlier today the CDC had a conference call on updates to managing Clostridium difficile. The PowerPoint used in the call can be found at the COCA website, and I have made an abbreviated copy, which is below. For nursing, the main points are as follows:
  1. C.diff is being referred to as CDI (Clostridium Difficile Infection)
  2. new cases of more severe, antibiotic-resistant CDI are being seen in lower-risk populations
  3. animals may transmit CDI
  4. CDI's incubation period is not known and CDI can be contracted w/o prior abx
  5. nurses should advocate for decreased use of quinolones and abx in general
  6. PPIs and H2 blockers increase risk of CDI
  7. restricting Fluoroquinolones is the primary method of controlling CDI outbreaks
  8. asymptomatic carriers are a major transmission point for CDI outbreaks
  9. continue to wash hands thoroughly with warm water and soap
  10. bleach is the primary effective cleaning agent
  11. patients remain contaminated after symptoms end and should not be removed from isolation

Nursing management/leadership course: can I make it?

I'm starting to experience intense anxiety over my Nur428 Management and Leadership course. Early in the course, we went over management styles including the "good" laissez-faire management style. I understood immediately at that point that what the instructor was getting at was that we were on our own.

Unfortunately, this management style does not work for a required course that no student has been prepped for or wants to be in. Moveover, it doesn't work for a situation in which the actual goal of the group is to produce things for the manager that are based on nothing but the managers ideas. Our instructor quoted General Patton as saying something like "Don't tell people how to do things, tell them what to do and let them surprise you." But the things Patton is referring to are "take that city" or "defeat that battalion," not "complete 'the project'." What the hell is "the project?" you ask. That's a damn good question.

Anyhow, I hope I can make it through the course. I started pushing ahead and have violated some of the nebulous rules the instructor made up for our project. I got verbal okays from her, but in the last analysis, she could turn against me and point to her rules. Not a good position to be in. I hope I can make it through the course. If I don't, I will be quite upset, as I started asking what I could do to get ahead in this course last spring...

Open heart observation

Last semester, after my perioperative rotation, I asked if I could go back and observe an open heart procedure. The request was granted, then I was bumped in favor of a nurse I work with on R-3. But I kept at it, and I was finally allowed in yesterday, Sept 11. It was a fantastic experience.

For preparation, I wanted to find some material that would explain whether there were anatomical structures I should know not covered in A&P and some material that would explain the procedures (beyond patient education). I found a great resource in Cohn's Cardiac Surgery in the Adult, 3rd ed., which is provided full-text online for free by (Unfortunately, I didn't find it until the night before the surgery, so I didn't have time to prepare. The only major thing was that I don't remember discussing the annulus of the heart valve in A&P, and that was a major knowledge component for following the surgery. A little embarrassing, but I'll live.)

I arrived at about 0530, grabbed breakfast in the cafeteria, and then headed up to meet the patient around 0630 and follow down to the pre-op setting where the patient was interviewed by the nurses and anesthesiologist.

The actual surgery started sometime around 0730, and at the point at which the patient went on bypass, I had a view from the anethesiologist's spot at the head of the bed that was essentially the same as what is shown above. (The surgeon operated on my right and his PA stood to the left.) We brought the patient to the ICU directly from the OR around 1500. In the meantime, I guess I was expected to take several breaks, although the whole procedure was so interesting that I stood through the whole thing and didn't really notice the cold. The only break was a quicky around 1230 that they strongly suggested I take. The standing and cold were much easier to take due to the quite good mix tape/CD that was playing throughout the procedure--some oldies like the Stones mixed with some modern bands. The transitions wre well done and good at keeping one in "the zone" throughout the surgery.

Although I was only interested in having a clearer understanding of what the cardiac surgeon does (because of some less than smooth interactions between him and the staff on my floor in the hospital), people kept asking me whether I thought I would enjoy working in the OR. I had definitely ruled it out following my previous perioperative rotation, but this surgery was something quite different. And if there were a possibility of acting as an RNFA, that would be a career worth pursuing...

Anyhow, wish I could say more, but it would probably be a HIPAA violation. Also, I remain a little overwhelmed by the whole thing. I keep thinking about the procedure, but when people talk to me about it, I don't have anything to say. In some ways, the procedure was very domestic and routine, while in others it was full of machismo, with a Damocles sword hanging above everyone. It's the best thing I've experienced since I entered nursing school.

Is a medical record a form of surveillance?

Freedom, Not Fear is a day to raise awareness about surveillance issues. It is exactly one month from today on Oct 11. Is this something for nurses to concern themselves with? Well, I think a "surveillance society" really is an anti-humanistic situation that all people should oppose. But on International Freedom from Surveillance Day what should nurses draw attention to? Well, there are issues of security/privacy surrounding medical records and such.

The formation of medical records aren't strictly surveillance activities, but I do think that in the context of a government and society where surveillance is almost ubiquitous and data can be easily stolen or otherwise unprotected, any collection of information about a person is tantamount to surveillance via data fusion. Although the typical nursing response to this situation would be to educate and reassure the patient while trying to avoid non-compliance, and the typical nursing management response would be to "improve the system," I think nurses need to re-consider whether their basic premises are correct about data collection. I don't have a lot of experience yet in a clinical setting, but while I have seen nurses speculate about patients based on their nursing datasets, I have never seen a case where the admission data set is the key to a patient's care.

Anyhow, add International Freedom from Surveillance Day to your GoogleCalendar or whatever, and think about data fusion, privacy, and nursing assessments between now and then...

Inspirational films for leadership/management

For Nur428 Management/Leadership, in teams, we are supposed to choose an inspirational movie for the class to view and then write a review of it. Here are some of my picks:

"The movie should illustrate the content of the topics in this course, for example, teamwork, leadership, change, and motivation."

Something the Lord Made (2004) - A true-story HBO film about a the '30s-era collaboration between pioneers of cardiac surgery from different races.
Not One Less (1999) - A 13-year-old girl is put in charge of a school in rural China when the teacher leaves. She must retain all her students.
Red Beard (1965) - A medical student receives an unorthodox education at an unconventional medical clinic.
Evelyn (2002) - Based on a true story, an Irish father sues to have his children returned when the government puts them in orphanages after their mother leaves them.
Seven Samurai (1954) - Out of work mercenaries are hired by a dysfunctional farming village to help it defend itself against bandits.
Walkabout (1971) - Two lost Australian children are returned to their home with the help of an aboriginal child.
Rabbit-Proof Fence (2002) - Three aboriginal Australian children return to their home on their won.
The Snow Walker (2003) - A caucasian Canadian pilot crashes his plane while transporting an indigenous woman with TB. They must cross the tundra together.
The Shawshank Redemption (1994) - A jailed innocent man brings hope to a prison and then successfully escapes.
The Lives of Others (2007) - A true story about an East German secret police who is changed by spying on artists.
Secretary (2002) - A secretary and boss, both with abnormal personalities, learn how to develop a relationship based on their unique situation.
Bridge on the River Kwai (1957) - British POWs pull together in their own way to build a bridge in Thailand.
Japanese Story (2003) - Two people thrown together by business must tour the Australian outback and find personal development.
12 Angry Men (1957) - 12 jurors debate the outcome of a trial.
Band of Brothers (2001) - A true-story HBO miniseries based on the WWII experiences of a paratrooper unit that is held together by excellent leadership. Especially relevant to leadership are Episode 1 Currahee and Episode 5 Crossroads.
Working Girl (1988) - A secretary learns how to impersonate an executive.
The Hidden Fortress (1958) - A (non-military) group of misfits finds its way through enemy territory during a war.
Life and Death of Colonel Blimp (1943) - How a set-in-his-ways Englishman is outmaneuvered by history.
Shackleton (2002) - A true story of an antarctic expedition gone wrong and how the crew survived.
Hotel Rwanda (2004) - A true story of a Rwandan hotelier who saves refugees during the Hutu-Tutsi conflict.

Y alu polymorphism as a quilt

I suppose this is a good follow-up to the post on Gray's Anatomy. (The study of genetics is the new study of anatomy, right?) The image above is a quilt that is designed to show a YAP genomic sequence: "the Y alu polymorphism sequence of an Italian male is encoded in this quilt. The quilt is made of shot silk, which reflects light differently depending on the orientation of the weave and the viewer." The quilt is by Beverly St. Clair, a psychiatrist who is also a quilter, and more explanation of her method and how to read the quilt can be found on her website.

I chose this YAP quilt because the Y alu polymorphism is a unique marker that can be used to trace male ancestry via the Y-chromosome. You may have seen this in the news with regard to the Lemba tribe in Africa. Here is a link to one of the first primary source document for YAP. And here is an example of how it can be used in genetic population studies.

via BoingBoing

Gray's Anatomy turned 150 years old

I came across this WIRED blog entry yesterday. It's from a while back, but it struck me that possibly there are people--especially nurses and doctors--who might not know where the TV show Grey's Anatomy got its name.

The 1858 Gray's Anatomy: Descriptive and Surgical by Henry Gray was, to my knowledge, the first modern, comprehensive anatomical guide and the most famous until very recently. Nurses might be interested to realize that it was conceived around the Crimean War, which makes it contemporary with Florence Nightingale [.pdf]:
The shortcomings of existing anatomical textbooks probably impressed themselves upon Henry Gray when he was still a student at St George’s Hospital Medical School, near London’s Hyde Park Corner, in the mid-1840s. He began thinking about creating a new anatomy textbook a decade later, while war was being fought in the Crimea. New legislation was being planned which would establish the General Medical Council (1858) to regulate professional education and standards.
Gray and Carter belonged to a generation of anatomists ready to infuse the study of human anatomy with a new, and respectable, scientificity. Disreputable aspects of the profession’s history, acquired during the days of bodysnatching, were assiduously being forgotten. The Anatomy Act of 1832 had legalised the requisition of unclaimed bodies from workhouse and hospital mortuaries, and the study of anatomy (now with its own Inspectorate) was rising in respectability in Britain. The private anatomy schools which had flourished in the Regency period had finally closed their doors, and the major teaching hospitals were erecting new purpose-built dissection rooms.
In its 150th year this year, it is now in its 40th edition, authored by English anatomist Susan Sandring.

I think for years, Gray's illustrations served as the standard against which other anatomical pictures were judged. And although there are much better (i.e., more accurate and occasionally more pleasing) illustrations out there now, the ones from Gray's still represent for many people, in some symbolic way, the discipline of anatomy. Luckily for us, they are out of copyright now (so use 'em for decoration, as above...).

As for Henry Gray himself and his partner Henry Carter, little seems to be known (or at least been uploaded to the inter-webs). I couldn't even find a date for his birth or death and had to use May 6, Gray's date of medical school matriculation, for my Medicine, Nursing, and Health Care Days GoogleCalendar. To help remedy the situation, a history of Gray's was commissioned for the 150th anniversary. Author Bill Hayes "combed through nineteenth-century letters and medical-school records" to write The Anatomist. (I haven't read it yet, but as it seems to be the only work available on Gray and Gray's, I can't help but recommend it.)

Getting constrained by nursing jargon

In my Nur428 Management course today, we reviewed our objectives for our management project. One of my objectives is to achieve a certain level of empathy with an administrative perspective on direct care (as opposed to a floor nurse perspective on administration). But when I mentioned this in roughly similar language today I was told that I should reword it with reference to "quality", "evidence-based practice" and cognitive terminology (since the instructor groups empathy in the "effective" portion of a 3-domains-of-knowing system).

There is so much that is wrong with this situation. Start with the assumptions. For example, the 3 domains of cognitive, effective, and psychomotor are wrong. In the first place, these domains were meant as a way of thinking about learning not as definitive statement about real domains of knowledge. Second, we know now that a cognitive-effective distinction isn't even accurate psychologically.

Domains aside, I did actually have as an objective empathy. To cram empathy into an effective domain and say it isn't appropriate terminology for learning about management represents conceptually wrong ideas about management-labor relations as well as a truncated understanding of empathy as a human experience.

And whose objectives are these anyway? Is my objective in this course quality improvement?

What all this points to is the way in which nursing jargon and weak professional bases such as the 3 domains of knowledge constrain actual humanistic learning in nursing school. There is a lot of talk about critical thinking in nursing school, but there isn't actually much (i.e., any) encouragement to thinking that is independent, introspective, skeptical, or speculative. The English language is pretty much sufficient, and much more flexible in description than jargon. Jargon is only helpful when it summarizes concepts more efficiently or identifies very specific knowledge. Calling something a decubitus is far better communication tool than describing the appearance and probable origin of some breakdown. However, being forced to use the phrases "quality improvement" or "evidence-based" does not do a better job of communicating, it constrains the available range of thoughts--it is a tool of conformity, not learning.

In my experience of nursing school, I would say the most conforming students tend to be more successful in their school work, but they are also the most unhappy, unpleasant students in school and I'm not sure they are better in practice.

Some interesting considerations about the Electronic Medical Record

ERMurse brings up some good points about Electronic Medical Records and how they interfere with patient care, although not all his criticisms are justified.

Most importantly, he highlights how EMRs often restrict access based on roles. My hospital is transitioning (slowly) to EMRs, and in my role as a ward clerk, I have access to very little beyond order entry. However, this is a recent change. Previously, ward clerks, doctors, and nurses in my hospital all had essentially the same access.

I am constantly being asked to do things now that I used to do without problem. Most commonly, I am asked to enter a patient's height and weight in the computer while the nurse is in the process of getting the patient settled in bed. (This is necessary because the way our systems are arranged, the pharmacy can't get started on a patient's meds until they have a height and weight entered by the floor.) I used to it all the time. Now, I have to remind nurses that I can't, which means they have to do the nursing admission immediately if they need a med. Crazy? Yes.

Frankly, restricting my access has done nothing to improve patient care or confidentiality (the nurses tell me anything I ask--maybe not right, but reality...) and added heretofore unknown difficulties.

However, ERMurse is not right on all counts:
(1) We also have charting by exception, and this works just fine. I can't imagine how any nurse could advocate excessive charting in the face of the trade-off between care and charting.

(2) Care planning is essentially a waste of time, and a care-planning module is as well. On my PCU unit we use primarily clinical pathways and some generic care plans, and these are completely adequate. I thought care plans were a waste when they were introduced in my Nursing Fundamentals course, and I have seen nothing since then to change my mind. This and the so-called "nursing process" (which Virginia Henderson correctly criticized as having no unique professional qualities) are historical anachronisms. Time to go! Sorry, ERMurse.

Videos games improve surgeons

Check out impactEDnurse on APA research showing surgeons perform faster and more precisely if they play video games...

Semen extraction from corpses: ethical considerations

More on the morality of semen extraction from the Androlog. I thought this was interesting for two reasons: first, in nursing, you don't often hear doctors talking about patient advocacy; second, this brings up a real patient/family services and education issue, not to mention palliative care...
Androlog Mail

{Regarding Grace Centola's question about cadaveric sperm retrieval,}

In 1978, as a clinical instructor at UCLA, I was asked to retrieve sperm from a prominent politician's son who was on life support awaiting organ donation. In 1980, I published 'Method of Obtaining Viable Sperm in the Postmortem State' in Fertility and Sterility and over the past 30 years, at the request of grieving families, I've performed or facilitated in the retrieval of approximately 50 postmortem procedures.

When I receive a phone call from a grieving family in tremendous pain due to the untimely loss of a husband and/or son and who can be comforted and given hope by sperm retrieval, in the spirit of the Hippocratic Oath to decrease pain and suffering, I facilitate their request. Conditions of refusal are based on a family member's opposition or if the deceased had previously had a vasectomy.

To date, out of the approximate 50 postmortem requests I've been involved with, only 2 wives wanted to retrieve their husband's sperm and both had normal children with IVF/ICSI. I would recommend to proceed immediately with postmortem retrieval but inform the families there may be some objections to its use. Very rarely will the sperm be used but giving families hope and decreasing pain is always a kind and healing opportunity for a physician.

Lawyers, judges and ethicists do not have patients. It is our duty as physicians to be an advocate for our patients in need.

Cappy, M.D.

Open-free logos: add 'em

When I am working on papers, PowerPoints, and other documents for nursing school, I tend to use either GoogleDocs or OpenOffice. I make a point to use these programs even though Microsoft products are ubiquitous and easy to use on campus. So, I want people to know. I don't just want them to know I use GoogleDocs and OpenOffice, I want them to know that these programs even exist! So, you too, use and add logos. I always put acknowledgements and copyright info on the last slide of a PowerPoint. APA paper format does not yet integrate copyright possibilities, but I put it at the very end and nobody has complained yet...

Revised: I added more to my Flickr account...

Say No to injecting saline before suctioning trache

The latest issue of American Journal of Critical Care has a clinical evidence review that finds that injecting saline into a trache before suctioning provides no positive benefits and is possibly harmful.1 The recommendation is to stop this practice and thin mucous by keeping the patient hydrated and using mucolytic agents.

I was especially anxious to see this article published because I came to the same conclusion last year while doing a research review for med-surg. In fact, I thought the evidence was so clear that I was going to try to publish a paper about it as soon as I graduated. Now I've been beat to it!! So I am pleased to see my perspective validated by seasoned professionals, but annoyed that a publishing opportunity was taken away.
  1. Halm & Krisko-Hagel. (2008). Instilling normal saline with suctioning: Beneficial technique or potentially harmful sacred cow? American Journal of Critical Care, 17(5), 469-472.