Fashion, uniforms, and sexy nurses

Fashion label Louis Vuitton had a show not too long in the past that showcased a new line of leather handbags. The image of the white-clad nurse was used to set off the cases. Since there hasn't been a revival of anything fashionwise related to the nursing uniform, I can only imagine that the point was to draw attention to the bags' similarity to old-fashioned medical bags and, in drawing attention itself, to dispell any criticism of the bags as boringly derivative of the old medical bags. No doubt fashion insiders would have different explanations.As I mentioned on a previous post of The Sexy Nurse Report series, the white-clad nursing uniform that is ubiquitous in Sexy Nurse imagery remains so because it has social and aesthetic cache. While it's true that presenting nurse imagery of this uniform promotes misguided thinking about the nursing profession, it has remained for reasons other than a desire on the part of the public to think of nurses as "handmaidens" to doctors, etc. It is a powerful visual image in its own right.

Why it should be a powerful image, I am not entirely certain. How did any fashion arise in any time? Fashion is in conversation with its own history at all times but must also give a nod to the aesthetics of the human body as well as functionality and other considerations. As can be seen from the following fashion photo, the white nursing uniform in broad outline is a modern white dress that is still favored today.
history of the (white) nursing uniform

I don't want to write a lot about the history of the nursing uniform. This is information that is pretty much available to anyone with access to an academic library or the Internet. If you are looking for a good starting point for research, try the dyk2 site and its mirror. These both have lots of photos.

For my purpose, we only need to recognize that in the history of nursing, the white nursing uniform is not a standard. Herewith, a few historical images to make my point. First some period medieval and rennaisance imagery of nurses.

In the WWI era, uniforms tended to be long, cover a lot, and trend toward greys and subdued colors.
Common in this era was the very unsexy and unfashionable apron.
And with this apron, I think we have the origin of the modern image of the white nurse uniform. It is not, as you might imagine, that the white apron turned into a white uniform. Quite the opposite. It is the unfashionableness and lack of visual power in this apron that led to the downfall of this style of uniform. The connection is that WWI saw the nurse used in a national mobilization campaign to support the war effort. Take a look at advertisements from this period.

As you can see, advertising images from this period had very little to do with the reality of nursing uniforms like the ones shown in the photos above. The idealized, all-white uniform is simply a powerful visual image created, or at least enlarged and perfected, by advertisements and propaganda of this era.

However, as life imitates art, the images created by artists and advertisements for WWI became the reality of nursing uniforms by WWII.
Perhaps it was the widespread use of black-and-white photography and an increased consumption of magazines and media during the post-war era. Whatever the case, from this famous kiss to today, the white dress, stockings, and white cap have been considered the quintessential nursing uniform. The white uniform became "what a nurse wears" in the public imagination. This despite the fact that, as the following photo from the 1960s shows, real nurses continued to dress in a variety of ways.
white uniforms in the sexual revolution

As I mentioned in a previous post, the sexual revolution that started in the 1960s resulted in part in a breakdown of the censorship of sex in literature and, eventually, in pop culture, resulting in the free Internet pr0n available to all today. I documented some of the changes brought about by these new standards in my post Sinners in White.

But the changes in censorship did not apply to only books and the printed page. There was a rash of low quality films from this period that highlighted previously forbidden violence and sex. The term "grindhouse films" describes some of this phenomenon, as do the terms "sexploitation" and "blaxploitation," referencing films made on a low budget and meant to attract viewers purely by exploiting prurient interests or the desire of African-American viewers to see their own race and racial themes presented on screen.As any man will tell you, the male sexual psyche is an abundance of creative energy. Women in all sorts of roles became sexual characters as well as nurses. (This is in complete conformity with Rule 34, which is a truism of modern media and the male mind.)

As we have seen, the white nursing uniform we identify as a Sexy Nurse Uniform was thought of by the public at this time simply as "how nurses dress." So, it should come as no surprise if sexploitation and the public's perception of nursing resulted in the presentation on film of nurses in sexual situations wearing the stereotyped white uniform. And this is just what we got. For example, the 1970s film The Sensuous Nurse.
Midnight Blue was a sexploitation TV show that started in the 1970s and ran til 2002.

There was even a series of films with Charlie's Angels style Sexy Nurses that ran in the 1970s, starting with Night Call Nurses.



To be fair, films did recognize in a limited degree that nures wore other uniforms. As you can see from this foreign pr0n film, Sexy Nurses can dress in blue as well:Of course, sexploitation is only one step away from pornography. And we did start to get that as well. Note that in these ealier pornography films, as in Nurses Report above, the plots stay closer to a hospital-based script. This indicates to me that the Sexy Nurse, at this early point in time, was still essentially a fantasy that existed only in men's heads and in the seamy outlets like the occasional adult theatre where these fantasies could be played out. The Sexy Nurse as a nationally recognizable trope or image had not yet entered the general culture.


Later in the development of pr0n, the Sexy Nurse became less a fantasy tied to the real world and more a stock character. The plots, likewise, began to stray more from a recognizable hospital script:
In the present day, the Sexy Nurse is a full stock character, but at the same time, real nurses uniforms have less connection to the Sexy Nurse image. As a result, current pr0n films have taken to modifying the uniform with large medical crosses and red trim indicating the Red Cross color scheme so many identify with health care. These new Sexy Nurse portrayals can be downloaded all over the Internet.
And as others have pointed out or document regularly, pornography is now a part of our general culture. So, as you would expect, the current image of the Sexy Nurse in white (with red trim) uniform has become ubiquitous. As with the WWI artists creating the image of the nurse uniform that became a reality in following decades, life again imitates art, and imagery like that above can be seen in public. Celebrities are into it.
And if you want to dress up for Halloween, the Sexy Nurse is one of your best options, even at the last minute. In fact, if you do a Google search for nurse Halloween costumes, just see what you get.
conclusion

So here's a summary of my story about the white nurses uniform and the imagery of the Sexy Nurse.
  1. Before WWI, nurses wore aprons and other unsexy wear.
  2. During WWI, artists and advertisers got the war campaign bandwagon and started promoting images of the nurse all in white, a powerful visual image that worked well on posters and in advertisements.
  3. During WWII, the white nurses uniform previously promoted on posters became more of a widespread reality.
  4. With famous images like the V-J Day photograph of the sailor and nurse kissing, the white nurses uniform entered the public mind as the reality of "what a nurse looked like."
  5. The sexual revolution ended most censorship in the US and Europe. The result was the portrayal of nurses as sexual characters.
  6. Based on #4 and #5 above, it was only natural that sexualized images of nurses would portray them in the white uniform.
  7. As time has progressed, the Sexy Nurse in the white nursing uniform has become a stock character of pornography, while the real world of health care has moved away from the white nursing uniform, resulting in a severing of Sexy Nurse imagery from hospital- and health-care-based scripts.
  8. Pornography is now an accepted part of our culture and available generally. As a result, the image of the Sexy Nurse portrayed in pr0n has become the standard in the public mind, most visible in lame Halloween costumes.

So, to bring it back around to Louis Vuitton now, I think it is most likely that, although Vuitton's mankiller bags were modeled in nursing uniforms more similar to the real uniforms of the 1940s-1970s than to the fantasy uniforms of current pr0n, it is pornography that is responsible for the continuation of the public association of nursing with the white uniform.

Japan, 'kongo', and the earthquake

Author Robert Twigger has an article in The Independant about why Japan will recover:
In all areas of life the Japanese extol, in a light-hearted but determined way, konjo, or "guts". To possess it is seen as the norm rather than the exception. When I was earning my living in Tokyo as a teacher, I once phoned in to say that I had a temperature of 40C. I was told to go in anyway. (The Japanese sound like nurses! - ed.)
. . .
The tragedy now unfolding in Japan must dwarf any trite evaluation of that country's ability to recover, yet, as anyone who has experience of Japan and its history will opine: the Japanese are different.

The missing, then present, then missing pulse

From the "mistakes were made" file:

Post-op patient comes with multiple bypass procedures on one leg. The surgical leg had no pulses before surgery, even by doppler. The non-surgical leg had pulses that could be detected by doppler. Coming to me after surgery, the pedal and post-tibial pulses on the surgical leg are easily dopplered, though. The surgeon came with the patient and dopplered a popliteal pulse, pointed it out, and said that was the one he was concerned with.

Later in the evening, the patient's non-surgical leg pedal pulse disappears. The foot is warm, and the post-tibial is present. Probably not a good time to call. Then the non-surgical pedal pulse returns and the surgical pedal pulse disappears... erh?!

After some mucking around, it appears that turning the patient side-to-side causes the pedal pulse on one side to disappear and on the other side to re-appear. What gives? I don't know. Nobody else knows.

Judging either foot, the situation does not warrant a call to MD. However, the patient also has a swelling that appears to be a supremely enlarged mons pubis. It feels hard underneath. I'm thinking, hematoma?

Looking at the whole context, does the positional nature of the pedal pulses tell us anything about a possible hematoma in the pelvis?

Apparently, the answer is no. If you want to feel like an idiot, explain this theory to the surgeon at about, say... 4:00 AM.

Open letter to ANA on genetic testing

In reporting on the recent March 8-9 meeting of the MCG Panel of the FDA's advisory committee, I find it problematic that I have no recording or minutes of the meeting. Of the five W's of reporting, I am missing the vital Who and hoW components. So, I was taken by surprise yesterday as I was working on my call to nursing organizations to submit comments to federal docket FDA-2011-N-006 in support of patients' rights to view their own genetic information. It turns out the American Nurses' Association has already weighed in on this matter by sending Ann Maradiegue of George Mason University to testify before the panel on March 8th. The ANA has endorsed her testimony, which is available in PDF format from NursingWorld.org.

In reading Dr. Maradiegue's testimony, I was struck by how much she seems to stay "on message." It leads one to speculate that, as Dan Vorhaus and Daniel MacArthur have suggested, the outcome of the MCGP meeting was pretty much a forgone conclusion. For a fact-finding meeting, Dr. Maradiegue presents little transparency of the assumptions and reasoning underlying her testimony, while the research she presents tells us only that the industry is currently unregulated, which everyone knows. She presents no evidence in support of her implied preference for a "routed through a clinician" standard of regulation. The meeting, indeed, appears to have been an exercise in consensus-building rather than fact-finding.

Speaking as a nurse, I cannot endorse or agree with Dr. Maradiegue's testimony. She and the ANA claim to speak for all nurses on this matter. She told the MCGP that, in her testimony, she would inform them "what the nursing profession’s perspective is on the regulation of genetic tests, including Direct to Consumer genetic testing." However, she did not. If she had, her talk would have included statistics on professional opinion research conducted by the ANA. Instead, she has simply reiterated the opinions of select members of the ANA leadership. As the ANA does not license nurses or count them all as members, this is not the "nursing profession's perspective".

Therefore, I feel obliged to send Dr. Maradiegue and the ANA the following open letter critiqueing their statements and asking them to revise their position.


Ann Maradiegue, PhD
School of Nursing
George Mason University
Fairfax, Virginia
amaradie@gmu.edu


Dear Dr. Maradiegue:

As a nurse, I would like you to know how strongly I disagree with your March 8 testimony for the FDA on direct-to-consumer genetic testing and encourage you and the ANA to submit new comments on federal docket FDA-2011-N-0066.

In the coming era of cheap gene sequencing, access to and control of personal genomic data will--and should be--seen as a human right. Your testimony implied that health care professionals should be a protected category of Americans with an exclusive right to order and receive the results of genetic tests. As you must be aware, when whole genome sequencing becomes affordable in the near future, this standard of regulation must result in a denial of access to fundamental information about Americans' personal histories and relationships to our species and its development.

Moreover, your implicit suggestion that health care providers' interpretive abilities keep patients safe is disingenuous in multiple ways. First, as Bloss, Schork, and Topol (2011) demonstrated, the available evidence shows no harm to consumers in DTC genetic testing. Second, as you well know, neither APNs nor MDs receive education that specially qualifies them to interpret genetic data. Third, your comments presuppose genetic testing in the context of acutely or chronically ill patients when the FDA is considering regulation of all genetic testing. Fourth, your comments present a false dichotomy between an unregulated industry and clinician control of access to genetic data when a range of regulatory rules are possible that would not restrict Americans' access to their own personal genomes.

That genetic testing interpretation is complex and uncertain is due to the fact that genomewide profiling of the type offered in DTC testing is not diagnostic but reflective of risk, risk that is also found in lifestyle choices about exercise, substance use, and nutrition. In these other areas, knowledge of risk (and even advice about risk reduction) is openly available to patients without clinician intervention. Nurses should support a regulatory scheme that would promote testing accuracy but make information about genetic risks as available to Americans as information about lifestyle risks.

Your testimony puts you and the ANA, in the words of former President Clinton, "on the wrong side of history." Rather than leading change and advancing health, your testimony promotes social and technological stagnation that will send innovative industries overseas. Rather than promoting patient rights, your testimony acts as a handmaiden to the American Medical Association's docket comments and their misguided guild mentality toward the future of medicine. This guild mentality is reflected in your call for federal funds to educate nurses about genetics when you could have easily called for federal funds to improve science education and increase public knowledge of genetics.

I call on you to revise your position on DTC genetic testing. Your testimony's implicit support for the AMA's recommendation of a "routed through a clinician" regulatory standard can be undone by an explicit statement that this standard should be rejected. The FDA has re-opened its comment period for federal docket FDA-2011-N-0066. I encourage you and the ANA to submit comments in support of DTC regulation that would ensure the accuracy of consumer genetic tests while maintaining free and open access to their own genomes for all Americans.

Thank you for your attention.

[Updated March 15, 2011: Dr. Maradiegue responded to my e-mail by asking for my full name and "background information." While this is reasonable in polite society, it is also what someone would do if they intended to silence you by exerting professional pressure. No accusations here, but we must say "c'est la vie" and leave it at that...]

ResearchBlogging.org
Bloss, C., Schork, N., & Topol, E. (2011). Effect of Direct-to-Consumer Genomewide Profiling to Assess Disease Risk New England Journal of Medicine, 364 (6), 524-534 DOI: 10.1056/NEJMoa1011893

Sinners in white: romance and sleaze of the sexy nurse

This summary is not available. Please click here to view the post.

Nursing organizations should comment on DTC genetic testing

On the issue of Direct-to-Consumer genetic testing, nursing organizations like NYSNA and the American Nurses Association can make official statements. Since the FDA re-opened its docket comments on the recent March 8-9 meeting of the Molecular and Clinical Genetics Panel, there is a forum for the FDA to hear official statements from nursing organizations.

Since DTC genetic testing is a patient- and consumer-advocacy issue, I hope that nursing organizations will take the opportunity to let the FDA know that they oppose a "routed through a clinician" level of regulation that would take away Americans' rights to have access to information about their own genes.

The American Medical Association has already let the FDA know its position. The AMA believes all genetic testing should require a doctor's prescription and the results of genetic tests should only be available under a doctor's supervision, for patient safety. However, as various bloggers have pointed out, direct-to-consumer genetic testing has been a reality for several years, and the only studies of the issue have shown no harm to patients. An evidence-based approach to regulation contradicts the AMA's position.

As I have argued in another post, the health risk information provided by genetic testing is non-diagnostic and similar to the health risk information provided by nutritional information. Therefore, a standard of regulation similar to nutrition facts and health claims on food labeling is more appropriate to genetic testing companies than requiring doctor supervision for genetic testing. I hope nursing organizations would take a similar view.

about FDA docket comments

The Food and Drug Administration maintains an independent committee of expert science advisors. This committee's Molecular and Clinical Genetics Panel (MCGP) recently met over a 2-day period to hear presentations about and to discuss DTC genetic testing before making its recommendation to the FDA on regulating DTC testing.

Government agencies solicit official statements, called comments, from interested parties as part of fact-finding missions before making regulatory decisions. These comments are solicited through the federal government's official journal, the Federal Register. The Federal Register publishes an indentification number, called a docket number, and organizations wishing to submit comments use this docket number to tell federal agencies which regulatory decisions they are commenting on. Comments are submitted online and can be read by the public at www.regulations.gov. This website is searchable by docket number.

Comments for the MCGP meeting were solicited under federal docket number "FDA-2011-N-0066," which can be seen at the following web address:
http://www.regulations.gov/#!docketDetail;D=FDA-2011-N-0066
The Federal Register call for comments on the MCGP meeting can be read here (click on the PDF there for a scan of the Federal Register page).

Comments are meant to be made by organizations and institutions with a vested interest in the outcome of the federal regulatory decisions, not by individual citizens. Nursing organizations, which have a vested interest in any regulations affecting patient rights, should submit official comments soon. Individual nurses and health care professionals can send letters to the FDA and to Congress.

read more about DTC genetic testing

Here are some resources for reading more about Direct-to-Consumer genetic testing:
  • This 23andMe webpage, explains what direct-to-consumer genetic testing is, and how it works.
  • The International Society of Nurses in Genetics has released a statement on DTC genetic testing: as noted above, their main concern over DTC testing, the safety of patients, has been shown through evidence not to be a problem!
  • Ann Maradiegue testified on behalf of the ANA at the MCGP meeting March 8-9. Although she implied that she supports a "routed through a clinician" standard of regulation as against a lower standard of regulation, she did not state this explicitly. The ANA and other nursing organizations should take this opportunity to undo the damage done by Dr. Maradiegue's testimony and state explicitly their support for regulation without a "routed through a clinician" standard.
  • You can read all my posts about DTC testing, in which I lay out the position that consumers need assurances about genetic testing that would parallel the FDA's system of food regulation, not regulations appropriate for potentially dangerous drugs and equipment.
  • Genetics lawyer Jennifer Wagner has written an open letter to Congress about FDA over-reach in this area.
  • Lawyer Dan Vorhaus provides excellent, if very detailed, coverage of the MCGP meeting and the whole issue of DTC genetic testing
  • Geneticist Dan Macarthur comments on the AMA's position
Thanks for your attention.

The author of this blog is a registered nurse who works in an ICU in the northeastern United States. You can connect on LinkedIn.

[revised March 13 @5PM]

DTC genetic testing: the issue isn't dead!

According to legal expert Dan Vorhaus, the FDA is going to re-open its site for public comments on Direct-to-Consumer genetic testing as well as hold town hall-style meetings around the country.

This means the issue of DTC testing isn't dead, yet. So get in those e-mails, faxes, letters, and phone calls to the FDA... and to your representatives in Congress!

Find mailing addresses and more information in all my posts on DTC genetic testing. Remember, if you are a health care professional, this a patient and consumer advocacy issue.

DTC testing: mailing addresses, etc

With regard to the recent hulla-baloo about the Food and Drug Administration's panel hearings on Direct-to-Consumer geneic testing, here are some addresses and links you might be interested in if you are planning to write the FDA or Congress.

The Center for Devices and Radiological Health (CDRH) is the division of the FDA that would be responsible for DTC genetic testing. And Office of In Vitro Diagnostic Device Evaluation and Safety (OVID) is the relevant CDRH office. The CDRH director is Jeffrey Shuren. OVID's director is Alberto Gutierrez, and OVID's personalized medicine staff are headed by Elizabeth Mansfield. Use the following to contact FDA staff:
list of CDRH personnel
contact info search form.

Dr. Jeffrey Shuren
Director, CDRH
White Oak Office Building 66
10903 New Hampshire Avenue
Silver Spring MD 20993
Phone 301-796-5900
Fax 301-847-8510
jeff.shuren@fda.hhs.gov

Nancy Stade
Deputy Director for Policy, CDRH
White Oak Office Building 66
10903 New Hampshire Avenue
Silver Spring MD 20993
Phone 301-796-5900
Fax 301-847-8510
nancy.stade@fda.hhs.gov

Alberto Gutierrez
Director of OVID
White Oak Office Building 66
10903 New Hampshire Avenue
Silver Spring, MD 20993
Phone 301-796-5453
Fax 301-847-8515
alberto.gutierrez@fda.hhs.gov

Elizabeth Mansfield
Director of Personalized Medicine
White Oak Office Building 66
10903 New Hampshire Avenue
Silver Spring, MD 20993
Phone 301-796-4664
elizabeth.mansfield@fda.hhs.gov

The Commissioner of the Food and Drug Administration is Dr. Margaret Hamburg. She's probably busy, but her chief of staff is Molly Muldoon. There is a list of the commissioner's closest staff here and an address search form here.

Dr. Margaret Hamburg
Commissioner of the FDA
White Oak Office Building 1
10903 New Hampshire Avenue
Silver Spring MD 20993
margaret.hamburg@fda.hhs.gov

Molly Muldoon
Chief of Staff, FDA
White Oak Office Building 1
10903 New Hampshire Avenue
Silver Spring MD 20993
Phone 301-796-9691
molly.muldoon@fda.hhs.gov

The Medical Devices Advisory Committee are consultants, not government employees or politicians. The Molecular and Clinical Genetics Panel of the MDAC is the group that met recently on March 8-9. The contact information of the Panel members is all listed here.

The FDA is under the Department of Health and Human Services, headed by Secretary of Health and Human Services Kathleen Sebelius.

Kathleen Sebelius
Secretary of Health and Human Services
200 Independence Ave. SW., room 120F
Washington, D.C. 20201
Toll Free: 1-877-696-6775
Kathleen.Sebelius@hhs.gov

The Congressional Committees and Subcommittees most concerned in this matter are probably the House Committee on Energy and Commerce, of which the Subcommittee on Oversight and Investigations called 23andMe to testify last summer, and the House Appropriations Subcommittee on Agriculture, Rural Development, Food and Drug Administration, and Related Agencies, which deals with the FDA's budget. There is also a House Energy and Commerce Subcommittee on Health. Wikipedia has updated lists of the members and chairpersons of these committees. Use www.House.gov to search for members' contact information.
House Committee on Energy and Commerce
House Energy and Commerce Subcommittee on Health
House Committee on Appropriations
House Appropriations Subcommittee on Agri...FDA and Related

Don't forget your own Congressional House Representative! Go to House.gov to learn how to write your representative.

There are also Senate Committees and Subcommittees that parallel the ones in the House as well as your own Senators.


what to write

There are multiple websites (Google 'em) that will advise you how to write a petitionary letter to the government. Please consult them.
  • Keep your letter/fax to one page only.
  • Keep your e-mails short.
  • Be polite.
  • State your purpose clearly and immediately.
  • Focus on only a few important points.
  • Give supporting evidence if you can (but not a page of references).
  • Use proper formatting and proofread.

In addressing the matter of DTC genetic testing, please be clear that you are strongly against having regulations that would require genetic testing and genome sequencing be prescribed by a health care provider, as well as regulations that would require these test results be released only to a health care provider. Dan Vorhaus' term for this type of regulation is "gatekeeper." The FDA's phrase for this is testing "routed through a clinician."

Work in President Obama's January 18 statement if you are clever.

Here's the letter I intend to send to the FDA. It can be tweaked a little for Congress as well... it's probably too long...

Dear __________

Following the FDA's March 8-9 advisory panel meetings on Direct-to-Consumer (DTC) Genetic Testing, I am writing to urge the FDA not to adopt a standard of regulation that would require a consumer's genetic information be "routed through a clinician." This requirement is unnecessary, unethical, and not in the national interest.

DTC genetic testing is already being done in the United States, yet no data exist to suggest that there have been adverse consequences from its use. Questionable anecdotes are not an acceptable reason to adopt a high level of regulation. Valid empirical data showing adverse consequences should be a minimum requirement before adopting such a strict regulatory scheme.

Curtailing an American's freedom to his or her own genetic information in favor of an untrained class of professionals is unethical. As a health care professional, I can attest that neither I nor those I work with have more than a cursory education in genetics. The situation is more problematic when the advisory panel and FDA itself are heavily populated by the same class of professionals that will benefit from the regulations.

The end of DTC genetic testing will end many incentives for U.S. innovation in this area, but it will not stop consumers from using these services as they look overseas to foreign companies. Strict regulation of genetic testing will result in sending more US dollars and jobs to China and India in exchange for no appreciable benefit.

Again, speaking as a consumer, a health care professional, and an American, I strongly urge the FDA: do not adopt a regulatory approach that would be economically stifling, restrict consumer choice, and provide no consumer safety. Do not require clinician intervention in Direct-to-Consumer genetic testing.

Thank you.

[this post was revised March 13 @ 10AM]

Worse than godzilla

When disaster hit Haiti, everyone heaved to, and I tried to travel down there to lend a hand. In the end, I could only blog about it from home. Disappointing. Now that an earthquake and tsunami have hit Japan, do we feel any corresponding sense of sympathy?
Looking at this photo of emergency medical services at work in Japan and others from the BBC, I was struck that my own reaction was actually that "this is what Japan is like" and "oh, another earthquake in Japan: it must be annoying for them."

This is an odd reaction, part of what I think of as the 'godzilla phenomenon'--Japan as the beautiful land of natural disasters. I realize that I think of the Japanese as something like the Eloi from Wells' Time Machine. That is, they live a charmed existence in a sort of Eden, except that they occassionally fall prey to firestorms, nuclear disaster, earthquakes--the metaphorical godzilla. I realize this isn't fair to the Japanese

This impression is no doubt supported by the fact that Japanese disasters provide us with no images of wailing and nashing of teeth. A video of a damaged store in Japan shows workers calmly cleaning up debris while a man goes about his business paying for groceries at the counter. In Haiti, it would have been distraught, helpless owners and looters.

Google has an amazing resource called Google Crisis Response. Finally. After 9-11, I tried to convince my Senators that the US government should have a crisis response web presence. My idea was that in the event of, say, Hurricane Katrina, the government would immediately put up a website at http://www.katrina.gov and collaborate with news agencies to provide ongoing updated information about casualties, volunteering, donating money, etc. To me, this was a no-brainer as it would clear up a lot of confusion. During Haiti relief, a web scam saying airlines were providing free tickets to those wishing to volunteer in Haiti almost took in some co-workers of mine.

The most amazing thing about the Google Crisis Response is their PersonFinder app, which you can imbed in your website. Look for "John," and you'll see how it works. Cool.

Write Congress: genetic testing

Here is an urgent health issue that I encourage you to write your congressman or congresswoman about...

What's going on?

There was anger and cross words yesterday in the small corner of the web devoted to genetics. The hurt feelings were over the possible end of "direct-to-consumer genetic testing" after a meeting of some advisers to the federal government's Food and Drug Administration. The people concerned are mostly nerdy science types. As health care workers, should we be concerned? Should we get involved? Yes! Let me explain...

Direct-to-consumer genetic testing (known as DTC genetic testing), refers to companies like 23andMe that will take a sample of your saliva, analyze your genetic code, and then give you information about your ethnic heritage and your risks for developing certain health problems. (23andMe was started by the wife of Google co-founder Sergey Brin. As related in WIRED magazine, Sergey has a genetic risk for Parkinson's Disease, and the couple would like to help Sergey and others with his condition to find better ways to deal with their risks.)

What's the problem?

DTC genetic testing is a recent development, so it hasn't been regulated by the federal government yet. The government's Food and Drug Administration (FDA) thinks it should be regulated as a "medical device," which according to their definition includes anything used in medical diagnoses. But there are different ways that the FDA could regulate DTC genetic testing--it could simply make sure that tests meet minimum quality standards, or it could ban testing completely. If it banned DTC genetic testing completely, that would mean that genetic tests could only be performed with a doctor's prescription.

To hear the opinions of businesses and other interested groups, the FDA has a committee of advisers made up of doctors, researchers, patients, etc. This committee recently met on March 8-9 in a hotel outside Washington, DC.

We don't know what they recommended yet, but one expert who has been following this issue thinks that the committee of advisers will recommend banning DTC genetic testing completely. If the FDA does that, the only way to save DTC genetic testing would be to influence the FDA and Congress to change its mind.

Why should I care?

DTC genetic testing provides consumers (that's you and me!) with information about our own genetic code and our genetic risks for developing certain diseases. In addition to the fact that consumers should have a right to obtain their own genetic code without the "official approval" of a doctor, there is information in your genetic code that might help you to change how you eat, how much exercise you get, or the hobbies you choose. In short, it can help you get the most healthy years out of life.

As I mentioned in a previous post, DTC genetic testing is not an addictive drug like morphine or a dangerous medical procedure like irradiating cancer cells. Since the purpose of the FDA is to protect consumers from these things, it doesn't make sense to ban the testing completely. It makes more sense just to ensure that companies meet quality standards and are truthful with their customers. This is how the FDA already regulates food. Don't you think nutrition labels work pretty well?

Why would doctors want the FDA to ban DTC genetic testing?

The doctors' lobbying organization, the American Medical Association (AMA), has told the FDA it thinks that consumers (that's you and me!) should only have access to their own genetic code if a doctor approves. This is supposed to protect you from committing suicide or doing some other stupid thing if you find out you are at risk for Parkinson's or any other disease. But it also means they get $$$$$$ and status and power because you will have to schedule a doctor's visit in order to get any information that you can already get--right now--simply by logging onto the 23andMe website. Remember, always follow the money!!

(Also remember, DTC genetic testing is already going on. Has it been causing you a lot of grief lately?)

Wouldn't having access to my genetic code make me my own doctor?


No! Since you still can't prescribe medicine for yourself or order other treatments, DTC genetic testing does not cut out the doctor. It simply means that you can have access to your own genetic information. What you choose to do with it is up to you. If you want to show it to your doctor, you can do that. Remember, it's yours!

Okay, I get it. So what do I do?

Well, people in the know think the FDA's decision has already been made, but that doesn't mean the FDA can't change its mind. But the only way it will change is if the FDA and Congress hear your voice. Otherwise, the only voice they will hear is the AMA telling them it is too dangerous for you to get your own genetic code.

You can contact by e-mail, letter, or phone. You can contact the FDA. You can contact the FDA's committee of advisers. You can contact Congress. You can write to all three!!! Then tell your friends and co-workers to do the same.

Okay, but who do I contact?

First you have to know all the players. But don't worry, it's not too complicated.

The Food and Drug Administration gets paid for by Congress. Congress is divided into the House and Senate, and each of those is further divided into committees and subcommittees. All these committees and subcommittees are needed because the government is sooooo big. No, really.

Anyhow, the subcommittees that control the FDA's budget are called the "Appropriations Subcommittee on Agriculture, Rural Development, Food and Drug Administration, and Related Agencies". There's one of these for the House and one for the Senate. Each subcommittee is made up of about 10 members.

There's also the committees called Energy and Commerce. These relate to DTC genetic testing because Energy and Commerce regulates trade. The most relevant subcommittees are the Subcommittee on Health and the Subcommittee on Oversight and Investigations. The Subcommittee on Oversight and Investigations conducts investigations into questionable business practices. This is the part of Congress that first asked why DTC genetic testing was unregulated.

Then there's the FDA, which is composed of various Center. The one that would control genetic testing is called the Center for Devices and Radiological Health (CDRH). You want to contact Dr. Margaret Hamburg, who is the head honcho for the whole FDA, but she's really busy. You could also contact the head of CDRH.

Finally, there's that committee of advisers to the FDA. It's called the Medical Devices Advisory Committee. And it is further divided into subcommittees called panels. We want the panel called Molecular and Clinical Genetics Panel.

Woah! That's a lot of people!

Just hold on... Here's a list. Start at the top and do as many as you can. Don't sweat it.


contact information and what to write

[revised]: Go to this other post for mailing addresses and advice on what to write.

Genetics : doctors :: calories : ??????

Do you like our nation's food labels? Do you find them a trustworthy and convenient way to know about the health content of your food?What if there were no food labels and you had to go to a Registered Dietitian (RD) to find out about the health value of your food? What if you had to make a $200 appointment with an RD to find out how much carb, fat, and protein was in the food you bought at the grocery store and what implications this could have for your health? Would you feel that this appointment with an RD was really protecting you from harmful choices or protecting the registered dietitians' income?

Right now, our Congress the FDA is trying to decide how the FDA should regulate genetic testing. If we don't tell them what we want, we could end up with the genetic equivalent of having to pay an RD to find out how much protein is in our steak.

You might be thinking, "well, how come we don't have to pay a health care professional to tell us about the health value of our food?" Wouldn't that be a little silly? Diet and health information is broadcast in the news, on posters in stores and hospitals, on advertisements for food, taught in schools... the information is everywhere.

The difference between food and genetics is that everyone basically knows the risks of eating unhealthy food, but almost nobody knows the risks of having genes that predispose you to diseases. The American Medical Association (AMA) is telling Congress the FDA that the only way to deal with Americans' lack of knowledge about genetics is to force them to pay doctors to get information about their own genes. But this isn't the only option...

In the old days, when the public lacked important information, the government would engage in a big "public health education campaign" and encourage doctors, nurses, teachers, journalists, and anyone else they could think of to get the word out.And to make sure companies didn't lie to consumers, the FDA would monitor and regulate the labels on products, not create a class of professionals to act as gatekeepers to the product.

There's no reason these solutions can't work today and work with genetics. As a consumer, you don't need to know the chemistry of stearic acid to know about the health value of fats, and you don't need to know all about "RNA transcription" to know about the health impact of your genes.

I tend to be a libertarian, but I like our food labels. Food labeling increased the size and power of the federal government, but it also made a more open and transparent society where consumers have better ability to make decisions. I support people who want Direct-to-Consumer genetic testing companies to give accurate and useful information to their customers, but I don't need the FDA to shut them down to feel safe.

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[Updated March 11 at 3pm]:

At Razib Khan's site, commenter SJ, who says he is a doctor, criticizes this post. Below are his criticisms and my response:


SJ Says:
March 9th, 2011 at 9:34 pm

Chris, I think it’s a bad analogy. If your mother had a lump in her breast, would you send the biopsy to an unregulated DTC company to determine if it were benign or malignant? “Genes”, when used to provide medical services, are no different in this respect from “tissues”. We live in a democracy, and if people would prefer to do that, so be it and the laws should change. Personally, I think it’s potentially harmful to the consumer, and the regulation helps more than it hurts.


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Chris Says:
March 9th, 2011 at 11:21 pm

“If your mother had a lump in her breast, would you send the biopsy to an unregulated DTC company to determine if it were benign or malignant?”

SJ,
Two responses:
(1) This is a false dichotomy. The issue isn’t whether DTC companies should be regulated but how. Should the regulation be like “the consumer can’t use this unless an MD approves” or “the consumer requires assurance that the companies’ claims are truthful”? Nobody is arguing in favor of “back-alley genetic testing”.
(2) Your question has nothing to do with DTC company genomics. You are talking about a medical diagnosis for an acute condition. 23andMe et al. is providing non-diagnostic information about possible future risks.


-----------------------------------------


SJ Says:
March 10th, 2011 at 8:05 am

To Chris

Interrogating information from a breast mass versus DNA from epithelial cells is not so different. In each case, we are using an individual’s biologic material to inform us about that person’s health. The definitions of”diagnosing” and “acute” are less clear than you think…many genetic disorders can be diagnosed by simple tests, and information gained from these tests has the potential inform about real disease risks, just like any other medical test, biopsies included.

I actually would have no problem with anything these DTC outfits are doing if they offered no interpretation, had no advertising claiming to offer you information on “health and disease”, and did not put relative risks in big, bold numbers next to disease names. But then they wouldn’t really have much of a business model, would they? The companies exist to make money, and they overstate and mislead as much as they can get away with to get more customers. As far as I know, no one makes you pay for nutrition label information. When 23andme starts giving away genotype information for free, we can consider that an apt analogy. And I would like to see the average person try to read their SNP data to parse what it means. Maybe you are well versed in genetics and don’t need a “RD” to intepret, but that’s not true for the vast majority of users of these services.

And yes, eventually someone will do something based on the information form these services that will cause them to get hurt. Not very likely, but it will happen at some point. No amount of token disclaimers should absolve these services from the responsibility to provide accurate information in a medically relevant manner, especially if they are portraying it as such implicitly.


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Chris Says:
March 11th, 2011 at 8:18 am

SJ,

“As far as I know, no one makes you pay for nutrition label information. When 23andme starts giving away genotype information for free, we can consider that an apt analogy.”

I think you are not understanding the point of my post on food labels. I am not equating food labels to 23andMe’s interpretations*. I am equating them to the SNP data. It’s an important distinction. My point is that genetic information seems confusing/medical/magical to some people because nobody is used to it. At some future point in time when people get genetics in school starting at a young age, nobody will think it is more odd to evaluate their own genetic code vis-a-vis health risk than people today think it odd to evaluate food labels vis-a-vis health risk–that is, health risk that they know about because the information has percolated through the culture.

Now, it is true that 23andMe is making you pay for the equivalent of knowing the nutrient content of your steak. HOWEVER, important distinctions are that (1) the technology employed by 23andMe is not readily available to the consumer and (2) the genetic information is specific, while food labels are based on averages. Imagine if (1) the technology needed to know the nutrient content of food was new and expensive or (2) a new technology was created that allowed the consumer to know the nutrient content of the specific steak he was buying rather than an average steak. In this case, there are people who would pay a premium to get this information. Would the FDA be justified in controlling these technologies any more than they control our knowledge of food labels today? No!!!

It is important to remember that one is not paying 23andMe to interpret data but to produce data.

Let me repeat that…

One is not paying 23andMe to interpret data!

23andMe is selling a whole package the base of which is creating the SNP data. The interpretation is only there because the information about health risk has not yet “percolated through the culture.” Yes, it is true that the interpretation is attracting customers, but it is not the basis of the business model. If it were, they would advertise differently, as in “send us your SNPs from other companies and we will use our proprietary statistical methods to tell you what your TRUE risks.” They aren’t doing this (although this is the AMA’s business model!!). At some future point in time, everyone will have their genome sequenced, and the fact that 23andMe is only testing certain SNPs will look like the quaintness of early cholesterol analysis technology, not the quaintness of 18th century doctors interpreting urine.

* If anything, at the current time, 23andMe’s interpretations are more analogous to Cheerios’ claim that it is “heart-healthy.” The FDA has a system for evaluating claims like this rather than disallowing them altogether. That would be more appropriate for DTC genetic testing than shutting down the industry.

“In each case, we are using an individual’s biologic material to inform us about that person’s health.”

You’re telling us that identifying active, ongoing expression at the cellular level is the same as defining statistical risk. So, a woman has a breast lump. You biopsy the breast lump and also send a non-lump sample to find BRCA data. The information from these two tests is close enough in your eyes to call them both diagnoses?

“And yes, eventually someone will do something based on the information from these services that will cause them to get hurt.”

So what? If a doctor diagnoses a patient with Parkinson’s and the patient commits suicide, do we hold the doctor responsible? What if the diagnosis was in error? Do we hold the doctor responsible then? No, only if the doctor recommends a wrong and hurtful course of action in response to a diagnosis.

As bloggers pointed out in response to Nancy Wexler’s presentation at the MCGP meeting, there is no data showing a pattern of harm from DTC genetic testing, and this is the only standard from which harm should be inferred. Having to argue this to a doctor is exasperating!!

Genetics is not 'snake oil'

Reading an article on today's Congressional hearings about direct-to-consumer (DTC) genetic testing, it strikes me that Congressmen are using phrases like "snake oil" and "snake oil salesmen" to describe genetic testing:
Despite a clear range in testing and business practices... the term “snake oil” was repeatedly invoked to describe all DTC genetic tests.
This is a problem. Reporting from these hearings could easily leave the impression that Congress found genetic testing was the equivalent of snake oil. While the government's investigators did find disturbing business practices in only some DTC genetic testing companies, their hearings have no relationship to the validity of genetic testing for health. "Snake oil" is a loaded phrase, and it is irresponsible of politicians and regulators to use it indiscriminantly.

ICU: nobody panics

After working in the ICU only about 6 months now, it strikes me that one of the main differences between the ICU and other units isn't that the patients crash more so much as that nobody panics. This occurred to me the other night when a patient next door to mine went into an SVT. I was helping the nurse in the room get the patient back to bed when I noted how calm and work-a-day she was. Then I noticed that I, too, was experiencing no adrenaline rush. Who is this person, I wondered? Let's compare PCU me and ICU me:

Progressive Care me: Heart rate suddenly in the 140s-160s??!! OMG, OMG, OMG, whatkindofrhythm is that? OMG,OMG,OMG, okay it's narrow compelx... OMG,OMG,OMG, what do I do?! OMG,OMG,OMG, okay I need an EKG... OMG,OMG,OMG,where do we keep the EKG machine?! Wait, should I get a BP first or get the EKG machine?! OMG,OMG,OMG...

Intensive Care me: Rapid A-fib? sweeeeet... MAP of 132??? Hmm... No way... anybody got a manual cuff... oh, and... yaaaaawn... can somebody find the EKG machine, too? Thanks...

Maybe this is just experience, but I think part of it is setting the boundary of your "normal zone." On PCU, other than an actual code, a rhythm change is about as edgey as you get. In ICU, it's like a little speed bump on the way to end of shift.

Screen Test Sexy Nurse

I came across the above photo on Flickr. It's from a punk/indie performance art/spetacle called Screen Test that apparently played a few years ago in New York City. The photographer says of the Sexy Nurse:
[Screen Test is] a vastly entertaining mish-mosh of alienation imagery, filmic metaphor, identity issues, post-apocalyptic motifs, and splendid music, all squeezed into a single stark hour.

I'm taken with Shanti Carson as the primly sexy nurse in white - even in background moments she radiates crisp presence, and it's hard to look away from her when she's on stage.
Here's a clip from the performance:

I don't really have much to say about this portrayal of "our heroine," especially as I have not seen the show and don't have any context for the imagery.

I do think, however, that this would be a good place to point out that the iconic status of the stereotypical white nurse's uniform is not simply a function of its status as a signal of the Sexy Nurse. It is actually a highly aesthetic and memorable design. This is why the iconic white uniform is iconic, despite not having been the typical nurses uniform throughout most of the history of nursing!

Twigger on intensive learning

Favored (by the gods) author Robert Twigger has a good post up on learning and the school/university system:
Intensive well designed courses are the way forward for real learning- of anything- especially if supplemented with less intense encounters with mentor figures. If you have met several real life authors, writing a book seems a normal thing to do, even an easy thing. When Hoagy Carmichael, then an amateur pianist, saw Irving Berlin fumble while playing a song he was surprised that he could do just as well- and so he was inspired to become a professional.
I have to agree completely. Nursing school is a lot more intensive and focused than other undergraduate programs, but it is still not as effective as intensive exposure. I still think I could have been better prepared for the ICU by doing 3 semesters of 2 whole days clinicals and 3 days narrow focused reading rather than 3 years of 2 half-days of clinicals and 3 days of reading for 4-5 different courses. Moreover, I think clinicals in a specialty ICU rather than a generalized one would be more effective.

More on learning and the university system at RobertTwigger.com...

Bedside game (formerly, bedside manner)

Dr. Wes links to an article in the NYTimes about a person who volunteers to let medical students auscultate her heart. It is somewhat infuriating, in that it is filled with treacle such as "The students had just learned the technical term for a heart murmur that a physician can feel: a 'thrill.' As any patient knows, the touchstone of a good doctor is the ability to feel one’s heart." The author is a science journalist and should know better. It is a perfectly reasonable expectation for patients to want doctors that treat them compassionately. It is a completely other thing to claim that "good doctors" are the ones patients like.

However, the article does have some good reminders for all health care workers. Most important: maintain your bedside game. I say "bedside game" on purpose. In more civilized times, this was known as "bedside manner," and encompassed behaviors that recognized the patient was another person with potential fear, embarassment, and ignorance of examinations and procedures. In short, it was the medical instantiation of politeness and manners.

But in today's world, bedside manner is not enough. The author wants her medical students to be interested in her first name and approves of a doctor who seems "easy-going" and has arty cuff-links. She doesn't adjust her posture to improve the students' auscultation unless she feels they've paid sufficient attention to her. (Just reflect for a moment on what she is doing there and its importance for the 1000s of patients these doctors will examine!) The author is not scared, she is a self-involved egoist who makes judgements of people based on superficial characteristics like their affect and clothes. In this day and age, you need game just to win over people enough to get them to cooperate in their own examination.

I'm not saying it's a bad idea to accommodate patients, but as our social fabric decays, it's important to remember that we aren't bad people for not wanting to be chummy with strangers. Sometimes you may just need to employ bedside game to reach your Pareto optimal patient care.

Libya and nurses: in the news

What with the protests/riots, the retaliatory air strikes, etc, Libya has been in the news a bit recently. Now I read in TakiMag that Libyan leader Gaddafi's nurse, a Ukrainian named Galyna Kolotnytska, has left Libya to return to the Ukraine. This is not the first time East European nurses have been in the news in relation to Libya: first there was the Benghazi HIV trials, involving nurses from Bulgaria.
There have been a couple Sexy Nurse photos of Gaddafi's nurse released that are of the wrong woman. An article, and what I suppose are accurate photos, are posted by the Brisbane Times.

In school, I had to do a report on Libya for our public health course. This was very difficult as it was clear at the time that certain assumptions about health care were expected, and I didn't have confidence that a good minority report would be accepted. So I ended finding nice things to say about this country that provides "universal health coverage" to its people.

The truth is that Libyan health care is a shambles, as one would expect from a destitute African country. The Benghazi HIV trials were necessary to provide cover for the fact that the conditions in the Libyan hospitals were so poor. It's not only the hospitals, however. As the editor of Retrovirology points out, Libyan health care professionals do not normal professional priviledges. And with large groups of the unemployed getting by with drugs, Libya has a tiny HIV epidemic that it tries to cover up by playing with numbers.

The Night Staff and yearly competencies

Last night, I had to do some of our required yearly competencies. These included going over proper use and documentation for medical-surgical restraints. This put me in mind of one of the entries from my other (soon-to-be-discontinued) blog The Sexy Nurse Report...

BDSM outfit Kink posted this pornography shoot (NSFW) at Wired Pussy portraying a hospital patient in restraints being molested by a nurse portrayed by adult actress Princess Donna.

From the description:
When Nicotine's husband comes to visit her in the mental ward, he is distressed to hear that her condition hasn't improved at all. In fact, it seems to have gotten much worse as she tells him of her delusions of being abused and experimented on by the night staff of the hospital. Little does he know that his wife is not delusional at all, and as soon as he leaves she will fucked and tormented with all kinds of crazy electrical toys!!!
Now, I've enjoyed other content from this outfit (shhh!), but the kinky nurse bit leaves me cold. In reality, restraints are a legally and ethically problematic intervention in health care. They are used very rarely, even in mental health, and much less often than they used to be. The main use of restraints in hospitals today is to keep confused patients from pulling out tubes and wires that have been inserted for medical purposes.

In the ICU, we use restraints primarily on intubated patients. Restraints have to be ordered by a doctor, and the doctor has to re-new the order every 24 hours. Hands are restrained only enough to keep the person from being able to reach the tube. Pulses are checked every 30 minutes to make sure the restraints are not restricting blood flow, and they have to be released every two hours to provide range of motion exercise.

Occasionally, the five-point behavioral restraints shown above are used. I've only one patient in these, though, and it was not a "normal" admission, I can tell you. These are no fun, as they require one-on-one monitoring with extensive documentation every 15 minutes. Quite boring, actually. Definitely not sexy at all.

Other unsexy nurse material posted in The Sexy Nurse Report series...