Nursing textbooks: cleaning out after graduation

Is everyone stuck with a bunch of textbooks after graduation? I keep wondering if the folding legs on my table/desk are going to collapse. I've been looking forward to getting rid of a bunch of these and the day has finally come. So, here are my nursing texts divvied up by post-schooling usefulness...

Books I'm getting rid of immediately

Mosby's 2005 Drug Consult: I bought an old copy of a drug consult to save money. This one was a stinker. Very little info and difficult to read and look things up. The hospital where we did clinicals uses a different publisher's drug consult, and it was much better. Avoid Mosby's Drug Consult. Besides, in today's clinical environment, who needs one at all (Hint: go PDA)? Unless the computers go down, or you want to look something up at home... It's a good thing to have, I think.
Lab and Diagnostic Test Guide: I bought an old copy of this to get one that was co-authored by one of my professors. Not a bad choice, but in general the lab and diagnostic guide was not needed. Does anyone actually use this in school? All the information is available on the web, now, anyhow. Assigning it was not a good use of resources.
Nine Hills to Nambonkaha: ugh. Read my Amazon review.
Masting Project Management: double ugh. When I read books like this, I imagine people in lower and middle management jobs desperately looking for something, anything to escape. It depresses me. If you can't project manage intuitively, you're not going to be promoted much unless you kiss butt, period.
From Silence to Voice: I wanted to like this book, but in the end I thought it was mostly just a guide to common sense political wrangling and English composition. Better to get Strunk & White's and be done with it.
Nursing Diagnosis Handbook: I wrote a poor review for Amazon, although after I was forced to use this book more, I found it handy for school. However, I am still very skeptical about the entire nursing diagnosis project. Creating this entire system that's taught in school and then discarded in clinical practice just for the purpose of demonstrating "professional knowledge" seems like a waste. Plus, I'm not sure it does a good job of what it's supposed to do, which is describe nursing practice. In cardiac and critical care, there are plenty of assessments and interventions that nurses make that are essentially medical in nature.
Essential Drug Dosage Calculations: The math that nurses need to know is very elementary, however important it might be. Even more so now that so many products come pre-measured and pre-drawn. Buying this book was not useful for me, although, inexplicably, many of my classmates had difficulty with the simple math needed for nursing. In fact, there were even errors in the answer keys for some of our quizzes. I don't think this book was necessary, though, unless problem sets were going to be assigned from it.
Clinical Nursing Skills & Techniques: A fine textbook from which we did not have enough reading or test assessments. I am getting rid of it because it is out of date, but I may get another. The only thing is, all this information should be online for free!
Nutrition From Science to Life: The hokey title says it all. It was out of date when I bought it and would have been a waste of money anyhow. The science of nutrition is a lot more undecided and unknown than nutritionists would like to think, although there seem to have been great strides in the last 5-10 years. If I had to teach a nutrition course, I think I would make students more aware of the controversies rather than teaching "best diet" and "best weight."
Sociology in Our Times: Okay book, but I am outraged that this discipline is still teaching discredited crap like The Authoritarian Personality. This textbook has citations from the '50s and '60s. What a joke!
Understanding Psychology: Whatever. Didn't really need it for the Intro Psych class.
A Topical Approach to Life-Span Development: It aims low, but is a well-constructed text from which I was able to learn a lot. As with sociology, psychology has some sacred cows, like Piaget, that seem to me to be almost certainly wrong, although they are still taught without addressing issues like Piaget's out-of-date research techniques and lack of grounding in biopsych. All the background psychology a nurse needs is available online now.
Professional Nursing Practice: Read my Amazon review--this was a real, true waste of money.
Public Health Nursing: I think there was one reading assigned from this book in my community health course. Could have easily taught the course without this book. I think I may change my mind and keep it, though, as a reference. Public health nursing seems labyrinthine to me.
Wong's Nursing Care of Infants and Children: I hated this book. I hated everything about it. The prose, the design, the illustrations--it was all awful. It was almost unreadable, and I stopped trying when I discovered that it was still teaching Freud's developmental levels. These should be relegated to courses on history of psychology rather than being included in practical textbooks. The actual useful material in this book could have been condensed to a text maybe a quarter to a third the size.

Books I'm getting rid of soon

NCLEX review books: I'm tempted to keep Saunders' Comprehensive Review since it has a nice outline, but realistically, I'll never look at it again after the boards. These can all go to next year's students. Gone after the NCLEX.
Medical-Surgical Nursing: an okay text. It needs better design/layout. I couldn't really figure out how to use it efficiently until the course was almost through. Gone after the NCLEX.
Fundamentals of Nursing: why this text and the Med-Surg one? Too much duplication. If I ever want to refer to theory, I can find this in a library. Gone after the NCLEX.
Procedures and Techniques in Intensive Care Medicine: Well, this one wasn't assigned, but I'm getting rid of it after I read about a few of the procedures, like echocardiography. It's out of date, now, I think.
Psychiatric Nursing: Way too based in Freudianism and psychotherapy, but my impression is that without hanging on to these, psychiatric nurses wouldn't have anything to do except pass meds. The "decade of the brain" material seems like an add-on. Good layout, though, and easy to read. I came to enjoy this book.
Ethical Decisionmaking in Nursing and Healthcare: Arrrrrrrggghhhhhhhh!!! As soon as I find a way to make a formal and comprehensive critique of this book, it's going in the trash. What a boondoggle! Instructors can use it to justify any ethical/political opinion, and the book is so circular that they can get away with it.
The Complexities of Care: I read one of the chapters in the library and liked it a lot, so I purchased the book. Then after looking at a couple more, I am less enthusiastic, but I will read it before giving it to somebody else.

Books I'm keeping

Diagnostix: I got my blood pressure cuff out of the box once, when I first got it, to put it together and test it out. Why was this required for school? I will keep it for an emergency kit for the car, however.
Taber's: Whatever. All the terms are available on the web now, but I'll keep it. It was a waste of money to make it a required text, though. Books should be assigned thus: "Here are the web resources, but if Internet access goes down, you might need these."
Essentials of Nursing Research: Not much in here that couldn't be found in a library or online, but if you intend to pursue any research, it might be useful to keep in mind the standards that reviewers and editors will be looking to.
General, Organic and Biochemistry: I never learned this well enough before so will start reviewing after the NCLEX.
Critical Care Nursing A Holistic Approach: I thought this was a good book. I intend to read it cover to cover after the NCLEX. And if I'm going to start studying for the CCRN exam, it may come in handy.
Introduction to Microbiology: From our micro class, apparently a good intro textbook, although I have nothing to compare it to. I wish the micro class was aimed more at nursing and medicine, though if I were to pursue infection control, this will be a good review/reference work.
Pharmacology for Nursing Care: What can I say? I liked it. Others didn't. I want to keep it and compare it with other pharmacology textbooks in the future. I also want to review the material from time to time.
Physical Examination & Health Assessment: As with the pharmacology book, useful review material and I'd like to compare it to other assessment texts in the future.

Books for elective courses

Biopsychology: It was an okay course, but I was hoping for something sexier. I thought the Pinel textbook was weak and hard to read. Useful information is all on the web and changing very quickly anyhow. Getting rid of it.
Essentials of Strength Training and Conditioning: I think this book is outdated. Advice on workout design, nutrition, etc. seems old-fashioned. Getting rid of it.
Fundamentals of Molecular Virology: At first I liked this book, which is organized by viral family, but after getting into the course more, I wished I had a textbook that was organized differently--say, a chapter on known/common methods of cell entry, etc. This would have been better for long-term retention, I think. Keeping it.
Medical Microbiology: This was also the name of the course this textbook was for. It was a good course, and I squandered time and energy that semester being stressed out about Nursing Fundamentals, which turned out to be not much a challenge. Although much of the information in this text can be found online, it is not easy to access as it's in image databases, etc. This would be a good text to have on hand if you were working in a tropical area or even the south. Keeping it.
Emergency Care: I just discovered last week that my EMT license is still good. I thought it had expired, but apparently it's good for three years rather than two. The text is useful since it presents information in the way the EMS system utilizes it, which is different from nursing. Hopefully, I'll be accepted at a volunteer service after I get established in a nursing job. Keeping it.
Biochemistry: This text was for a course that I didn't actually get to take. When I was taking Biopsychology, I tried to get the professor for Biochemistry to let me into the course without the prerequisites. He said no, but I bought the book and started attending the classes anyhow, hoping he would let me in. He didn't. However, even without doing the reading, I was able to follow what was going on well enough, and I got to see a guest speaker who was a VP at a pharmaceutical company give a talk on the drug approval process. Very informative. Keeping it.

Books I bought for my own edification

Physiology: At the beginning of nursing school, I assumed that medical schools must use one, or a couple, standard physiology texts. I couldn't really determine whether this is true from looking on Amazon. However, Berne and Levy seem to be well-regarded authors. So, I got this text thinking that we would be studying physiology in more depth than we had in A&P (buahahaha) and that I would simply read from the Berne and Levy rather than from the nursing textbook. You can imagine how this worked out. Keeping it, though, and may start reading.
Renal Pathophysiology, Primer on Kidney Diseases, Clinical Physiology of Acid-Base and Electrolyte Disorders, Mosby's Fluid, Electrolyte, and Acid-Base Balance, Acid-Base, Fluids, and Electrolytes Made Ridiculously Simple: Somehow, I had the idea that these books were going to help me get way ahead on renal and acid-base info. Somehow, I had the idea we had to know a lot more about these topics than we actually did. Getting rid of them.
PDR Nurses Drug Handbook Cardiovascular Edition: This was a give-away from Bristol-Myers Squibb. Not much better than a standard drug guide. Getting rid of it.
Cardiovascular Physiology: This is the Berne and Levy, cardiovascular chapter only. A great little book that every cardiac, ICU and PCU nurse should read. Keeping it.
Principles of Physiology: A slightly less technical (dumbed down) version of Berne and Levy. Since I didn't have an A&P book, only an A book, this serves very well as a reference for physiology. Keeping it.
Core Curriculum for Critical Care Nursing: As soon as I get my "sea legs" in my first job, will start reviewing this to prepare for the CCRN exam, which I think can be taken after the equivalent bedside hours to about one year of full-time work. Keeping it.
Basic Arrhythmias: For when I thought I would get cross-trained as a telemetry technician a few years ago. Oh well. Keeping it, though.
Color Atlas of Anatomy: This is an amazing book that is actually photos of cadavers. This is about as close as I'll probably come to a gross anatomy clinic. Keeping it.
Atlas of Human Anatomy: Since I borrowed someone else's book for A&P, I don't have an A&P text. At first, when I still remembered all the anatomy from A&P, I didn't think that mattered. But I've forgotten a lot over time, so I needed a reference. I think this one is okay, although its low price and high volume at Border's made me wonder whether or not it might have some mistakes. I'm taking my chances.
Clinically Oriented Anatomy: I bought this after A&P thinking I would get a different perspective. This is a good text, but it's not an armchair book. It really needs to be used in a classroom setting. Still, keeping it.

Well, that's it. Really, there should be a single reference text that nurses could buy to support their practice. Classroom textbooks don't cut it as they present all information with equal emphasis, whereas some things will no doubt be easy to remember after starting practice, while others will not. Something to think about...

Post revised July 2009...

PSU 2009 commencement

In theory, I've now graduated from nursing school with a BSN. In fact, I've completed only the commencement ceremony today, and the actual graduation won't be finalized until after this semester's grades are turned in and all the i's are dotted and t's crossed. My name wasn't in the program for the commencement, but I assume this is because I turned in my graduation application to the registrar too late. Am I concerned? A little. The professor for the Community Health course is not trustworthy in my opinion, and we don't have tests in that course. Instead the final grade is based on her assessment of an overall portfolio of your work that is turned in at the end of the semester. The syllabus was a mess, and I'm not sure I turned in all the work for the course. Even so, I should be okay as long as she decides I'm sufficiently socialist for her liking. Anyhow...

Saturday started sunny but steadily descended into a drizzle with heavy rain later in the day. The commencement ceremony at PSU is split into a morning session--for the schools of education, health, and business--and an afternoon session--for the schools of art and sciences. We started gathering in the ice hockey arena at an overcast 9:30 for a 10:00am ceremony.

Commencement takes place in the gym of the college's field house--the only indoor venue large enough. It's pretty standard decorating fair, although they do well for a gym. A few years ago, a bagpipe band started leading the processional and recessional, which is a nice touch.

The student commencement address was given by a nursing student this year. The practice of choosing a commencement speaker based on grades is fairly dubious. My fellow nursing grad was smart enough but mostly just studied a lot, and her speech reflected that. It was schlock about going beyond your career path to become the type of person you want to be. Spoken like someone who has spent her entire life locked in an academic prison. Most of the grads there were, instead, in the position of having to face a career after spending the last four years exploring what type of person they were! We also had a speaker who's a star on some TV show and came back to college to finish his degree, but I don't watch enough to have any sense of his importance.

Then it was on to filing across the dais to shake the president's hand...

A family friend who is a professor was sitting in the front row as I came across the dais and gave me an embrace, which was really both unexpected and affecting as the rest of the ceremony was both anti-climactic and overshadowed by the aforementioned Community Health question as well as the upcoming NCLEX exam. For myself--and I sense this is the case for most nursing grads--passing the NCLEX is going to mean a lot more to me than graduating from nursing school.

Actually, if I'm honest, I'd have to say that nursing school, despite being in a BSN rather than ADN program, bears so little resemblance to the academic experience that I had in previous university study that I don't feel as though I've finished what I started and finally graduated from college per se. It was more like some sort of boot-camp-college-game-show amalgam for which you had to jump through successive hoops while attending classes and keeping the drill instructors happy. Although I have a full grab-bag of skills and disparate formal training, I don't feel that I've acquired a consistent body of knowledge or methodology. (The "nursing process" is too generalized and accessible to common sense to justify four years at university and tens of thousands of dollars.) At the outset, I was expecting to receive knowledge of "people as patients" and "patient care." Instead, it's a little petite medicine training, a little management, a little social science research... This makes me a little despondent. I came only for job training, but I got something else very different that's supposed to be academic and professional, but I can't define it well.

At end of the ceremony, the mace recesses down the aisle followed by the honored guests and faculty. Then the pipe band leaves followed by the newly graduated students. I had intended to get just a 30 second clip of the pipe band, but since I didn't know where they were in the line, I ended up taping the entire recessional. This has the advantage of showing almost everyone in the ceremony. The original .MOV file can be downloaded from the Vimeo site, and it should have better quality, I think.

The one part of the day I was really looking forward to was having my photo taken outside after the ceremony. Over the years, my father has brought home a stream of photos taken outside in the same place with his graduating students, so I thought it would have been nice for him to have one of me with him as the parent instead of the professor. Alas, it was not to be. By the time we got outside after the ceremony, the rain was coming down quite hard. As my mother pointed out, it was the exact same weather as the day I graduated from high school. I hope that's not an ill omen, as my post-high school plans didn't play out very well. Anyhow, family photos got relegated to the living room.

During lunch that day ("Tuscan tuna salad"--tuna, beans, onions, olive oil, wine vinegar, spring greens--it's nice to be back off the studying/library habits), I asked my father whether he had heard of artist Catherine Hartung, who I mentioned a couple posts back. He said, "Oh, you mean Kate?" It turns out she used to babysit me! The world is a small place, especially in upstate New York.

My brother had told one of the waitresses that he was going to McSweeney's that evening for dinner, so we decided to all go and then on to Harrigan's for dessert. It was a real north country eating out experience.

So now what?

...well, the first thing is to lie low until grades are finalized. Then, after I'm sure I've graduated for real, it's a marathon study session for the NCLEX. Of course, I have to figure out what I'm going to do with my life, too.

Post revised July 2009...

PSU 2009 pinning ceremony

Earlier this Friday evening was my university's nursing graduation pinning ceremony. I guess this is supposed to be a big traditional deal for nurses. I didn't go through the ceremony for a variety of reasons (e.g.: didn't want to do the whole flowers/parents/awards thing; not sure I'm actually graduating; perpetually feel excluded by, and thus resentful of, the class), but I did go to the ceremony and sit in the audience (high up in the back of the auditorium)...

Afterward, my parents and I went out to Arnie's for dinner.

Post revised July 2009...

Google Reader biased toward local news outlets?

I had this strange experience with Google's RSS Reader today. As you can see from the image, I got something from North Country Public Radio in my Google Reader inbox. What's strange is that NCPR is a fairly small-time local-ish public radio station. Their front page was pointing to an NPR report about Margaret Hamburg. Now, there must be NPR affiliates all over North America that use automatic news updates that were re-directing to the NPR report. So what are the chances that my local station's website would show up in my RSS Reader but not other ones? I wonder if this means Google pushes news to you in certain ways, such as preferring to show you websites with local affiliation over others. I think that's pretty problematic and should be transparent if it's happening.

ACLS certified

I passed the AHA's Advanced Cardiac Life-Saving course today, and am now re-certified in ACLS til May 2011. Shown above are George, who ran the course, Dr. Hartung, and Linda, who tested my mega-code. (Dr. Hartung's wife is a fairly good painter.)

I got a 100 on the written exam, and think I did pretty well on the mega-code relative to the PCU and ER nurses who were with me. I didn't make any mistakes (though I lost my 95 year old female patient after she was pronounced following a normal sinus PEA that wouldn't respond with a pulse), and I was able to correct some in the nurses while performing CPR, etc. (Note to providers: you don't convert nor defibrillate a sinus tachycardic rhythm. Sinus tach and SVT are not the same.) I was maybe a little more nervous and less in control of the situation at the beginning, but that's okay as I'm new (not even an RN yet).

Passing was a real confidence booster after my disasterous clinical immersion practicum and the Nur464 final yesterday. Linda is a former ICU manager, so I was pretty happy to get kudos from her.

Shoe captures tone of graduating

Shoe cartoon pretty much captures the way I feel about graduating after yesterday's Nur464 final fiasco.

HELP: Margaret Hamburg approved

The Senate HELP Committee voted to approve hottie Hamburg for FDA Commissioner. I thought this had already been done, but apparently during their previous session, they only "failed to voice opposition." Now it's official and goes to the full Senate, I suppose. From Reuters:

By Susan Heavey

WASHINGTON (Reuters) - A U.S. Senate committee approved President Barack Obama's pick to lead the U.S. Food and Drug Administration, sending Dr. Margaret Hamburg's nomination one step closer to final approval.

The Senate Health, Education, Labor and Pensions Committee approved Hamburg in a voice vote, said Melissa Wagoner, spokeswoman for panel chairman Senator Edward Kennedy.

The full Senate must still vote on Hamburg, a Harvard-trained doctor and former New York City health commissioner known for her work in bioterrorism preparations and other public health issues.

A Senate leadership aide said it was not clear when the floor vote would happen, although the staffer ruled out any further action on Wednesday.

The FDA is grappling with issues ranging from food contamination and drug safety concerns to the recent H1N1 swine flu outbreak.

Senator Mike Enzi, the committee's top Republican, urged party colleagues to support Hamburg, saying "she will face unprecedented challenges to public health, from medical product development and biopreparedness to import safety."

update: BTW, isn't this a stunning photo of her?

Nur464 Final: big time suck

Today (Wed, May 13) was the final in the Nur464 Care of the Adult III (critical care) course. This was my last final for the semester, and will hopefully be my last final of nursing school, assuming I pass everything, which I should (fingersXd!). The final sucked big time. It was a computerized final, so I received my grade immediately--72. That's a failure. Now, the final was non-cumulative, and, as far as I know, counted the same as the other tests in the course. So, I should pass the course anyhow, but I have done weakly in the last half of the semester. The topics for this exam were burns, chest and abdominal trauma, and organ donation/immune suppression. It shouldn't have been that hard. A couple questions I intuited correctly and then talked myself out of. One I missed because I purposefully didn't memorize a formula for calculating fluids in a burn victim (there being multiple formulas, with the assumption the formula would be given on the test, and fluids being an MD order anyhow). A couple I missed because of skipping subsections of reading I didn't think were relevant. A couple I missed due to simple lack of memory. But the ones that really bother me are the ones where I used bad judgment to arrive at the wrong answer. That was probably 1/3-1/2 of them. That sucks.

After the test, right to ACLS class, then back to the library to study for the mega-code for tomorrow.

Happy International Nurses' Day

It's today, May 12.

Australasiangate: Elsevier's publishing fiasco widens

The story about biomedical publisher Elsevier's unethical publishing practices, previously reported on here, is expanding. Instead of just one fake peer-reviewed journal, it turns out there were at least six. Pretty much any article you read in an Elsevier journal called The Australasian Jounral of... is suspect. It would be tempting to call this "Australasiangate," but that would imply (1) that this was a fake scandal, and (2) that Elsevier will suffer consequences appropriately for its ethical lapses. Probably, neither one is true.

Elsevier released a Press-Release, but to recover their credibility, they need to release specific names and remedies taken, rather than just saying that everything is better now.

"sane and rational": an approach to swine flu

Despite the deaths, the swine flu has not been without its humorous side. For example, in Afghanistan, Kabul Zoo quarantined that nation's only pig. The pig was a gift from China, which has taken the slightly less humorous action of quarantining a number of visitors from the Americas. Where does public health wisdom lie?

Writing in Virology Journal, William R. Gallagher of the Louisiana State University Health Sciences Center has reviewed the situation up to the current time and makes recommendations based on a skeptical view of the severity of the current outbreak but a healthy respect for the future of H1N1. The current form of the virus has more animal amino acid sequences than sequences from successfully pathogenic human strains. Nevertheless, the hemagglutinin sequence has shifted 27.2% from its 2008 cousin, and the neuraminidase has shifted 18.2%, leaving open the possibility that new rearrangements might incorporate more pathogenic human sequences along with these new H and N sequences to create a strain with greater pandemic potential.

Gallagher takes the sensible positions that shutting public services because of a suspected case, having elected officials override considered public health judgements, or bringing political agendas into the situation are all counterproductive. While I agree in large part, I'm not sure I can accept his argument that there's no sense in a quarantine focused on specific nations due to the fact that the specific H and N sequences arose elsewhere. It's true that some people have made uninformed calls for border closings, but I think the accusatory finger of political agenda should fall on Gallagher as well. The theoretical possibility of a future spontaneous re-arrangement is not an equivalent threat to an existing, spreading re-arrangement, especially when it's not clear, by Gallagher's admission, whether the pandemic nature of the outbreak might have been supressed due to natural seasonal variations, only to expose itself again next season. In any case, the current best course of action would seem to be to start working on a vaccine for this strain for next season.

Gallaher, W. (2009). Towards a sane and rational approach to management of Influenza H1N1 2009 Virology Journal, 6 (1) DOI: 10.1186/1743-422X-6-51

Pallimed blog: fake spit should be nursing measure

I want to draw your attention to a blog I just found. Pallimed is focused on palliative care and hospice. Yesterday's post focused on research on taste alteration in oncology patients, including nurses' aversion to administering fake spit:
I do not know why nurses and doctors can do so many other 'gross' things in medicine, but there is a severe and general aversion to writing for or administering saliva substitutes. It is more than just lack of knowledge, because even when informed, I have had nurses basically say, "I'm not giving that to them, That's disgusting!" Yet when I go in the room and have the patient try it, the patient exclaims (with a smile and a much louder voice) "My mouth feels alive again. Thank you so much."
That's pathetic, folks. He goes on to say that fake spit shouldn't even need a doctor's order. More nursing measures!

Hamburg nomination report, with video

Today, the NY Times weighs in with an article on Dr. Margaret Hamburg's nomination as FDA commissioner, and the Wall Street Journal blog points us to a video of the hearing, and a PDF of hottie's statement. Around 98:00-99:00, Senator Sanders essentially suggests that the FDA should regulate food and/or regulate food advertising not just for quality but for its health value. Dr. Hamburg replies that she thinks that's outside the job description, but she's too smart to say otherwise in a nomination hearing, so who knows. I would hope that she's not interested in getting the federal government involved in dictating diets.

update: video not working here, but that's okay, as Senate hearing is snooooooooore....

Hamburg nomination report, including new photos

Dr. Margaret Hamburg's nomination hearing for FDA commissioner took place earlier today, May 7. Reuters filed a report already, as did the AP several hours ago, along with photos:


WASHINGTON (AP) — President Barack Obama's pick to oversee food and drug safety pledged on Thursday to revamp protection of the nation's food supply to help prevent future disease outbreaks.

Dr. Margaret Hamburg, a bioterrorism expert who once served as New York City health commissioner, breezed through her confirmation hearing before the Senate Health, Education, Labor and Pensions committee, with no senators expressing opposition.

Hamburg, 53, said she wants to restore public confidence in the Food and Drug Administration by putting science first and running an open and accountable operation.

The full Senate is expected to vote on her nomination before Memorial Day. If confirmed, Hamburg's most immediate task will be to oversee development of a vaccine for the new swine flu. But she said food safety will be her major ongoing project.

"The agency is facing a range of new and daunting challenges," Hamburg told senators. "These include the globalization of food and drug production, the emergence of new and complex medical technologies, and the risk of adulteration or deliberate terror attacks on our food and drug supplies."

The FDA oversees products ranging from peanut butter to cancer drugs to medical imaging machines — a portfolio that represents about a quarter of consumer products. A few years ago, it was shaken by the withdrawal from the market of Vioxx, a painkiller that turned out to have serious heart risks. More recently, outbreaks of foodborne illness have exposed haphazard oversight of the nation's far-flung food supply chain. Within the agency, scientists in the medical devices center are in revolt over what they say is management interference. And a federal judge recently ruled that the FDA improperly politicized a decision on emergency birth control during the Bush administration.

On top of all that, the FDA must play a critical role in developing a vaccine for the new swine flu virus and ensuring that enough vaccine can be made to protect the public.

Hamburg, as an assistant health secretary under President Bill Clinton, helped lay the groundwork for the government's bioterrorism and flu pandemic preparations.

The swine flu vaccine will be her first task. "I look forward to being actively involved in discussion on such critical issues as how much vaccine to make, whether to alter seasonal vaccine manufacturing, and, ultimately, whether to recommend vaccination for the American people," Hamburg said.

Vaccinating the entire population for swine flu would be a huge undertaking, and might require more than one shot. It would also have to be coordinated with preparations for the regular flu season. But such a large scale effort may not be needed if the virus turns out to be mild.

Turning to food safety, Hamburg said it will require sustained effort, more money, and stronger laws to improve the situation. She wants to shift from chasing outbreaks after they have broken out to preventing them first. That would require all food companies to follow written safety plans, overseen by federal and state inspectors. Traceability and import safety — weak links in the system — would have to be strengthened.

Obama's budget, released Thursday, calls for a $260-million increase for the FDA's food safety program. Past budget cuts have hit the food inspection program hard, and part of the new funding would go to rebuild the ranks of inspectors.

Hamburg said she supports FDA regulation of tobacco and allowing Americans to import low-cost brand name prescription drugs from abroad, positions consistent with Obama's.

Hamburg in 1 hour 15 minutes

The US Senate HELP Committee's website has the following notice for today:
Full Committee Hearing - Hearing on the Nomination of Margaret A. Hamburg for Commissioner of the Food and Drug Administration; SD-430, 2:00 p.m.
I can't find an available TV or webcast. C-SPAN is supposed to have a webcast at, but I can't get the RealPlayer link to work. But if you're free in an hour, switch on the boob-tube.

Margaret Hamburg: Senate confirmation tomorrow

Dr. Margaret "Peggy" Hamburg (or "hottie Hamburg" as I like to call her), Obama's pick for FDA commissioner, has had her confirmation hearing moved up to tomorrow due to the swine flu. Actually, in this case the hype is accurate, and her credentials and background make her perfect for dealing with a food industry/epidemic mash-up like the swine flu. Good luck, hottie!

(If I can stay awake tomorrow after being up all night tongiht, and if I can find a TV to watch C-SPAN, I'll try my first live-blogging, but no promises.)

Medical schools shooting for the middle

KevinMD has a post up about some people wondering whether it wouldn't be better to admit to med school those who do not get top scores. This reminds of a legal case I saw on TV a number of years ago about a police department that rejected an applicant who had scored too high. They won the case based on the fact that research shows those who score too highly under-perform as police officers. Something to do with boredom, I think.

Anyhow, I think this is interesting because I've been wondering for a while whether doctors aren't overtrained or overselected. This topic comes up indirectly at Happy Hospitalist frequently in the form of arguments over the place of MLPs. The question in my mind isn't whether PAs are adequately trained but whether it isn't possible that our current educational structure doesn't include what's really needed--something in between a PA and MD. Wasn't med school designed for a circumstance where doctors had to rely much more on their innate knowledge and intelligence and participated in a lot more guesswork? Does it make sense to train MDs for a technological and knowledge context decades old? I don't really know, but as I've written before, the experienced nurses on my unit can predict what a doctor is going to order for patients 90% of the time. If a nurse can obtain this level understanding with so little educational background, do we need all the MDs to be trained at the same level or could we get by with a mix of some with less training?

Pandora is wow on little sleep

For those of you still in the academic world, you know it's finals time, and I've got all that crap going on. Right now, I'm going on just a little sleep and staying awake with Sudafed, caffeine pills, and polacrilex gum. This is an effective combination, and since my PA wouldn't prescribe me modafinil (I have diagnosed OSA, so don't get all self-righteous on me), it's about as good as I can do.

So, anyhow, I was starting to fall asleep a little while ago, so I switched on Pandora, starting with "Riders on the Storm", and it's taken me through stuff I've never heard before like Cream's Crossroads and Led Zeppelin's Nobody's Fault But Mine. Never having used "hard" drugs before, I don't know that feels like, but with the sleep deficit, nicotine, and whatnot, the music sounds pretty good.

Of course, give me a few days with sleep, treadmill, salmon, and water in place of coffee, and I'll probably be back to preferring Bach and Handel.

Plavix inhibited by Nexium?

Practicing my nursing response: "Well, I haven't heard about that, but it would be a good question for your doctor."

CE for bioterrorism

For Community Health course, I just took a CE course from the U of Albany called Terrorism, Preparedness, and Public Health: An Introduction. Two interesting illustrations:

BoingBoing hits health care home run

Today on BoingBoing, there are at least three, and I think five, health-care-related posts that need to be re-blogged...

Idiots in the state of Massachusetts think sex should end at age 60.

An exhibition at Harvard concentrates on family planning history.

Explanatory slings show people how you got your accident.

And, finally, there is an awesome new blog on photos of hospital food. I have to say that some of these meals (and especially the table settings) look fantastic compared to my hospital...

Huff & puff

The blog Science-Based Medicine has a long post on the nuts at Huffington Post. It doesn't surprise me that HuffPo would be a hotbed of anti-science thought, although I suspect if you asked many of the contributors (and even more, the readers) about the importance of "Obama's re-invigoration of science funding," they would say he is finally taking the US out of the Dark Ages into a new Renaissance.

Bad Elsevier, the story

Yesterday, I posted about Elsevier being on the take in a scheme by Merck to publish a fake peer-reviewed journal. Today, the blog Drug Injury Watch has more of the story:
Elsevier acknowledged that Merck had sponsored the publication, but did not disclose the amount the drug company paid. In a statement emailed to The Scientist, Elsevier said that the company "does not today consider a compilation of reprinted articles a 'Journal'."

"Elsevier acknowledges the concern that the journals in question didn't have the appropriate disclosures," the statement continued. "It is worth noting that project in question was produced 6 years ago and disclosure protocols have evolved since 2003. Elsevier's current disclosure policies meet the rigor and requirements of the current publishing environment."

Nur437 clinical immersion experience

My college has instituted a new program this year. For the last two weeks, our normal classes have been suspended while we participated in a "clinical immersion." This immersion involved working a minimum of 45 hours over two weeks one-on-one with a preceptor. It has been a useful but extremely frustrating experience. To be honest, if I had had this experience at the beginning of nursing school rather than now at the end, there's a good chance I wouldn't have continued in nursing. Or, if I had, I would have been a lot more motivated to memorize and also to practice skills in the skills lab, which I haven't done once during school (didn't seem necessary!).

I have included below the e-mails I sent to my faculty supervisor to update her on my experiences. I have changed some details in order to protect the privacy of the innocent victims of my care. If you read these, you will note my struggle with time management. I am convinced this is the result of BSN programs' failure to provide enough bedside clinical training. My max patient load previous to the immersion was two ambulatory patients for 6 hours. While I was doing the immersion, students in the final year of an associates degree program were working alongside me on the same hospital unit. They were all managing 4-5 patient assignments for an entire shift with ease.

As I have suggested before on this blog, the rationale behind the BSN program is not oriented toward producing work-ready floor nurses and this needs to change. I have no intention of going into management or research, and neither do any of the other students in my program. If professional leaders in nursing want the entry-level nursing degree to be a BSN, they need to face the fact that the BSN program needs to change in order to accommodate the different educational requirements of the floor nurse. University courses in research, management, and professional issues need to be bumped up to the MSN level. Research skills need to be changed from performing research to assessing its value and validity. The assessments course needs to be more focused on acute care unit skills rather than primary care skills. Focus on patient care planning needs to be changed from creating extensive documents to using them in the acute care setting. More clinical hours are needed.

Here's my schedule for the last two weeks:
Tue = met with preceptor
Wed = 7a-7p
Thu = off
Fri = 7a-7p
Sat = 7a-3p /3p-11p work
Sun = 7a-3p / 3p-11p work
Mon = off /3p-11p work
Tue = 3p-7p
Wed = 7a-12p
Thu = off
Fri = 3p-11p

Subject: Re: immersion experience
From: Chris xxxxxxxxxxxxxx
Date: Fri, April 24, 2009 10:40 pm
To: "Zoanne Schnell, PhD, RN"

It's very hard. I met with my preceptor Tuesday morning. My first day was Wednesday, a 7a-7p shift with 3 patients til 3p, then 5 patients 3p - 7p. Yesterday (Thursday) I read the book "Shadow Cities" by Robert Neuwirth for Nur425 Community Health. Today (Friday) I worked 7a-7p with 5 patients. Tomorrow I am back at 7a again and then again Sunday at 7a.

Since the most patients I've had in clinicals up to this point is 2 and the most hours I've been on the floor is 6, it's quite a change. I haven't been able to manage them all by myself, and my preceptor is pulling a lot of weight (doing the admissions today), but I improved a lot today from Wednesday, and I am confident that I will continue improving throughout the weekend.

I'm not sure what my schedule will be for next week. My preceptor is out of his regular shift Tuesday for the hospital's "practice council." I don't know if he works Wednesday or Thursday. Then Friday he is definitely on 3p-11p.

The biggest problem I'm having is keeping track of everything in my head. For example, when it comes time to report off for the next shift, I can't remember where every patient's Saline Lock is or what every patient's cardiac rhythm is without referring to the flowsheets. I'm trying to deal with this problem by creating a worksheet for myself to take notes on and will trial it tomorrow.

One problem I'm having is lack of exposure, although I guess this is to be expected as a student. For example, today I heard course rales for the first time and couldn't quite identify what it was since I've only heard relatively fine rales in previous clinicals. Also, I described a patient with liver failure as being extremely jaundiced, which caused some eye rolling since, apparently, the patient was only mildly jaundiced.

However, in another instance, I thought a patient was doing very poorly on Wednesday when no one else was concerned. That night, the patient declined and the priest was called for last rites, so my intuition in that case was correct.

Some critical thinking skills are lacking. For example, I could identify an ACE-I correctly today, but failed to figure out that it was for CHF. This was a case where, if I had known the patient's admission history as before a normal clinical, I would have pieced everything together. But forced to think on the fly under stress, the connections aren't quite there yet.

My charting was very weak Wednesday. Today was better, but my notes need a lot of work.

I have to keep reminding myself that I'm still a student. It's frustrating that I can work for 12 hours with only a 20 minute break for lunch and be behind when I can see that there are nurses who have time to sit at the nurses' station. Somehow, I'm losing a lot of time around the 3p shift change, but I don't know how.

Will keep trying...

Subject: Re: immersion experience
From: Chris xxxxxxxxxxxxxx
Date: Mon, April 27, 2009 10:31 pm
To: "Zoanne Schnell, PhD, RN"

Well, Saturday was a disaster, but Sunday went okay. On Saturday, I had a 5 patient assignment 7a-3p. My last 9a med pass didn't get completed until 11:45. My preceptor said it was a busy day, and we did have a scheduled paracentesis and unscheduled thoracentesis going on in the same room, but I still thought the day should have gone more smoothly. My overall charting was better but my event notes were not good (this is by my own assessment, not the preceptor). I worked that night 3p-11p and then went back Sunday for 7a. On Sunday, I had a 3 patient assignment and an admission. The day went textbook and even my notes were better, but of course it was a very light assignment.

I find that I spend my time trying to treat the computer and flowsheets rather than the patient, which is very frustrating.

My notes need a lot of work, and I think they indicate my thought processes aren't well developed. In one case where I thought a patient's mental status was deteriorating, I had taken into account a number of assessments but the event note was discombobulated, so my thinking processes weren't systematic. I think an assessment has to be systematic before severity can be assessed properly.

Anyhow, I'm hoping I can manage a 5 patient assignment 7a-7p on Wednesday, but the CCC students will be on R-3 as well, so I suspect I will only get 2-3. That will leave only 3p-11p shift left in my immersion.

Subject: Re: immersion experience
From: Chris xxxxxxxxxxxxxx
Date: Wed, April 29, 2009 10:11 pm
To: "Zoanne Schnell, PhD, RN"

I had a longer response, but when I hit the send button a few moments ago, I got logged out of webmail. It looks like it didn't go through...

Anyhow, 4 hour shift Tuesday, whole shift today, but my preceptor was charge nurse so I went home early, and 8 hour shift coming up Friday. Should have a total of about 56 hours not counting time as charge today.

Tuesday went well with 2 patients and 2 admissions.

Will update again after work Friday...

Subject: Re: immersion experience
From: Chris xxxxxxxxxxxxxx
Date: Sun, May 3, 2009 9:11 pm
To: "Zoanne Schnell, PhD, RN"

So, last Tuesday, my preceptor's shift was 7a-7p, but CVPH's "practice council" was 7a-3p. I considered attending practice council, but decided against it. I worked 3p-7p in the step-down part of R-3 with a 2 patient assignment, and I received two admissions during that period as well. My patients and admissions were stable, and this was a fairly easy shift. The thing that really stood out for me was that my preceptor had already completed and charted his shift assessments when I was starting on them. I don't even know how he did it. I was with him for all but a few moments at the beginning of shift, and I'm shocked he could do them so fast. So, I must be losing some time on my assessments. My preceptor said they are thorough, however.

On Wednesday, I was planning to do a 7a-7p shift, but when I went in to work, my preceptor was assigned to charge. I stayed until noon, but I wasn't really learning anything and felt I was in the way so I went home. As charge, I received charge report in the AM, attended a STEMI alert (similar to a code) in the emergency room, took a patient who developed an active GI bleed to the ICU, and participated in patient rounds in step-down. However, as a unit clerk on R-3, I have been working alongside the charge nurses for a number of years and already have a clear idea of their normal work day, so there wasn't much to get out of a charge experience.

On Friday, I worked 3p-11p. Unfortunately, this, my last shift, was the worst time I had during the immersion. I had a 6-patient assignment that I performed mediocre until my 9p med pass. Up to that point, I was struggling a little to keep up, but things were getting done. But I started the 9p med pass at 8:40 and didn't finish until about 10:50. During that time, I had one distraction, which was a temp spike in a patient that required a call to the MD. So, I was averaging about 18-20 minutes per patient. I can't figure out why it was taking me that long, although one thing is that it seemed like every time I went in a room, the patient and the roommate both had other things they needed me to do for them. Not sure how to manage that without essentially ignoring the patients.

However, the real problem was that when I noted how long it was taking me to get the med pass done, I started to get anxious and make mental errors that I might not have made otherwise. One was a med error. A patient with a QVAR inhaler had another patient's Symbicort inhaler in the med drawer along with an empty bag for the patient's QVAR inhaler. Not knowing what the inhalers look like, I assumed the one in the drawer was QVAR and since the barcode for the computer scanner is on the bag instead of the inhaler itself, the computer didn't catch the error, either. This was an easily preventable error since the name of the patient and the name of the med are printed on the inhaler, and since QVAR doesn't take a spacer, which was attached to the Symbicort inhaler. If I had been less anxious about finishing, I might have thought to check the inhaler or wondered about the spacer. The error was caught because the patient asked whether s/he was going to receive QVAR, too, AFTER s/he used the Symbicort inhaler!

The other mental errors I made had to do with (1) being rushed and forgetting, or (2) taking the word of others instead of verifying for myself. I had three post-cath patients, but one of them (post-procedure day 2) didn't get his groin site checked during the assessment because when I mentioned the groin site, s/he said s/he didn't have one. I assumed I must have been mistaken about it rather than looking for myself, then forgot to check my Kardexes to see who the third groin site was. In one of the other patients, the patient had several Q1hour groin checks left before the Q2hour groin checks started, but the aide doing vitals told me the Q1hour checks were done. I believed him instead of verifying for myself. Then, on that same patient, I completely forgot about performing the Q2hour checks when I got behind in my med pass. That patient also didn't receive regular turn-and-position care. In one patient, I forgot to perform a BID dressing change that I had planned to do after the med pass.

The med error was annoying, but I am really bothered at forgetting about the turns and groin checks on that one patient. Then I didn't complete the report off to the next shift until 11:25, although we kept getting interrupted. I stayed after the shift and went through all my patients med drawers to organize and order missing meds from the pharmacy. Also, although my paper charting (R-3 still uses paper flowsheets) was completed in time, my computer shift assessments didn't get done until after my shift was over. Very frustrating night, and I didn't go home until about 1am. Really, staying any more than a few minutes after end of shift is not acceptable.

It's unfortunate that this was my last shift since my self-confidence took a real blow. I have some trouble with focus and organization in general. I've always been afraid these would manifest in difficult patient assignments, and they did. In fact, right now, I feel like I'm not sure this a career I am capable of doing. I need to get back in and do a couple 4+ patient assignments adequately before I'll feel like doing anything but hanging my head. I am also extremely worried that I did something wrong on Friday that I am not even aware of, and I've been experiencing a lot of anxiety over going back to work as a unit clerk on Monday. What will I find?

Anyhow, it's over now. Will have to wait and see what my preceptor's assessment is.

Bad, Elsevier, bad

I had a lot of negative things to say about Elsevier last spring as I was forced to use their piece of crap Virtual Clinical Excursion software and workbook in maternity class. But even I am shocked to hear that Merck paid Elsevier to publish a fake peer-reviewed journal. Yes, bad Merck, too, but at least Merck is in the business of pharmaceuticals, not publishing. If Merck uses unethical advertising techniques, this doesn't necessarily compromise their pharmaceuticals. If Elsevier publishes a fake journal, this calls into question their entire existence as a business (not to mention the public service aspect of being a biomedical publisher).

While I love books more than computers, and I had a romantic view of the publishing industry through most of my young life, up through about 1998-99, it's time for these publishing houses to die. At least a little bit.

via BoingBoing

Local nurse went to Nepal

From a local newspaper...

Mount Everest, the tallest peak on earth and the anchor of the massive Himalayan range, rises majestically above the Kathmandu Valley in Nepal, an image that attracts countless tourists to the region annually.

But North Country resident Elizabeth Bailey has seen another side of Nepal, images not readily available for tourists but much more representative of what it really means to be a child growing up in this extremely impoverished region of the world.

Bailey, a registered nurse and professor of nursing at Clinton Community College, recently spent almost a month in Kathmandu Valley as a volunteer for the Global Volunteer Network, an international organization that brings community-related support and services to 21 nations.

"As a nurse, I was assigned to a children's home in the Kathmandu Valley," Bailey said of her visit, which stretched from shortly after Christmas 2008 to the day before classes at Clinton resumed in January.

"I had decided that I wanted to do some travel combined with volunteer work," she said. "I chose the Kathmandu region particularly because of the services they needed but also to experience the culture of the region."

Nepal recently emerged from a bloody civil war that began in 1995 with the Maoist uprising when Communist supporters initiated one of the most successful post-Cold War communist takeovers in the world.

An estimated 9,000 deaths were recorded during a seven-year stretch that saw the bloodiest action between Maoists and nationalists. In fact, nearly 70 percent of rural Nepal was under the control of Maoist guerrillas at the peak of the conflict.

In 2006, Maoist rebels began peace talks with the government, and within two years, the Maoists had gained political power. Sporadic violence has continued however, and the decade-long conflict has left its mark on the impoverished nation as a whole.

Bailey's work brought her into the teeth of the affected regions.

"The home I was assigned to had 31 children ranging in age from 4 to 19," she said. "Some were orphans but most were from very poor areas in the Humla District, a region that had been ravaged by Maoists.

"During the Maoist uprising, corrupt traders went into the poor districts and promised parents that they would take their children to places where there was no guerilla violence," she added. "They took money in exchange for taking the kids to Kathmandu."

Families sold whatever they had to raise the money to send their children away, she explained. The traders took the money and the children but then placed them in poorly kept dwellings where they were all but abandoned.

Even as the conflict ended, families had been ruined financially and had no means to take their children back — and so the Global Volunteer network has taken that situation under its belt.

"Their idea is to make these homes sustainable, to train managers to run the homes for the benefit of the children," Bailey said. "Volunteer Services now owns two homes in the Kathmandu Valley."

Bailey traveled daily from where she stayed with a host family in Kathmandu to the small village of Bistachhap some 30 minutes away. She rode the bus, which was little more than a family van with seating for around 15 people — typically, it carried 30 or more riders on most trips, she said.

The children — seven girls and 24 boys — were always happy to see her arrive each morning.

"They were very willing to form bonds," Bailey said. "They were used to having volunteers come and go. The youngsters came from all sorts of backgrounds. Many had been abused or neglected in homes they had been in previously.

"But despite all that, they were very loving children," she added. "They were dedicated to school. They didn't need discipline. They accepted their responsibility and did their chores to keep the house going. They were incredible kids."

The children slept in three separate rooms, one for the girls, one for the older boys and one for the younger boys. They'd eat their meals on the floor of a terrace on the building's roof.

The manager of the house, a 32-year-old man, had an older-model computer and would bring home movies that the kids could play on it. They would also play games like ping-pong, shuffleboard and marbles.

They also had two pet rabbits and, though it was the middle of the Nepal winter, worked regularly in a vegetable garden.

"The nights were very, very cold," Bailey said. "Although the temperature reached as high as 70 during the day, it dropped down into the 20s at night."

Most of the youngsters were bilingual and spoke fluent English, though few of the adults Bailey crossed paths with had the same ability.

The main house the nurse was working with was fairly well organized and managed, but a second home she spent time with offered a much sadder presentation.

"This home was being run by two college students, and they were doing the best they could, but they didn't really know what to do," she said.

"Volunteer Services will not just give money away. Spending the money has to be justifiable, and I just don't think this one home is going to make it."

With the political situation in rural communities less explosive, there is discussion of sending children back home to their families, but there is not a lot left at home for them to return to.

"A lot of these families are just not ready to care for their children," Bailey said.

"There's no infrastructure, no health care. Many of the fathers have had to go elsewhere to find work. There is just such a need for significant care in these rural communities."

Bailey, who is a clinical nurse specialist with a master's degree in nursing, spent much of her time healthwise caring for minor ailments and trying to alleviate lice problems that were quite significant in children.

She believes a lengthier visit would help strengthen the region's health-care needs.

She said she would return in a second to help educate both children and adults in the communities. She has hopes that she will be able to spend a more extended period in the region one day.

"What I did wasn't sustainable," she said. "What they really need is people to educate the public on health care."

Lithium for drinking water

Mindhacks points us to an interesting research article showing a significant negative relationship between levels of lithium in the drinking water and mortality. Here's the article from Scribd:

Used my other watch

As I reported recently, I lost the watch I had purchased for clinical rotations in nursing school. Instead of buying a new one, I took the less costly route of using a Timex Indiglo my brother had given me some years ago (like the one pictured below).

It turned out to be a good choice. While I prefer to have a watch loose on my wrist for comfort, the Timex Indiglo, which was too small not to fit snugly, actually fit much better for use in clinicals. Having a watch with a slimmer profile that fit close to the wrist made it much easier to get gloves and the sleeves of isolation gowns over my wrist. It also didn't require removal for every hand washing since the snugger fit kept the watch from falling down around the base of my thumb. The flatter, smoother design of the Indiglo with a smooth leather (as opposed to suede) is a fashion choice, but it also makes the watch easier to clean. Finally, the Indiglo is a much lighter watch, and I'm not even aware that it's on my wrist until I need it--just how a watch should be.

Overall, I'm happy with having lost my Expedition and switched to the Indiglo.