The Swan

You are the swan that flew into my life

You are beautiful, strong with your magnificent wing

You captured my heart with your victorious route

Filled me with your ambitious mind

Lured me to swim  with the music of your wish

Made a perfect escapade into your hiding place.

A beautiful, sparkling lake, the  sun rays in an octave wave

The crystal water, cool and refreshing

The smell  of pine and blooming lilies

The singing birds and the whistling leaves

Drowns the night with harmonious  peace .. a  glorified retreat.

We swam and dance till midnight

witnessed the full moon until sunrise

a delightful image, a memorable sight

A  passionate romance. a dreamlike night.

Together we flew  into the blue sky

Stayed up high and followed the line

A “V”  of force, power and victory.

Thank you for the short romance

It was nice , gentle and bright

I woke up  in the morning feeling amused

I opened my eyes and look  around

dream dream dream.. my … swan… is gone…..

S A J E R O S A

Seizure after Cessation of Benzodiazepines 1

I have discussed about the how, when and what happens when taking Benzo longer than it should be and why it is addictive. Addictive in the sense that the body becomes dependent of the action of benzo. Remember the role of GABA inhibitors? How it inhibits neurotransmitters to be excited? This role is very important in managing balance in our body. When the body becomes excited and hyper, GABA reacts by balancing the situation appeasing the activity as it slowly brings back normalization. Now with the prolonged use of benzo it now takes over and replaces GABA. How? With more and more use of benzo the body thinks GABA is not needed anymore so its production is suppressed. This becomes a problem now because once the blood level of benzo is lessened/decreased, an immediate reaction takes place because GABA is so suppressed that in situation like this, it won’t be able to control hyperexcitement. How is these corrected? If it takes 4 weeks continuous use of benzo before the body becomes dependent then I can say that it will also take 4 weeks for the body to adjust once stopping benzo intake. The most critical period would be the first ten days of withdrawal since it is during this period that seizure is very inevitable and the body is unable to produce GABA inhibitors to counter react the situation. But once the critical period is surpassed, the brain now will rethink as their is cessation of the artificial GABA, it will start producing its own GABA inhibitors again. During this 4 weeks of recovery most of the time the body needs assistance in order to recover smoothly as it transitions during the cleansing period. This time it would need gradual tapering dose of benzo or any anticonvulsant like depakote to control the withdrawal symptoms at the same time provides enough time for the brain to regain control of its GABA inhibitors.

To my readers, this is pure analysis and I hope this will help anybody who are interested in giving up benzo. Do not let drugs control your life, instead control drug use and be wise. Doctors prescribe the medication with the confidence that it will help your symptoms, there is nothing wrong with that. ..But the wrong comes on the way when you pretend to be innocent and ignorant about your prescription. It is too late when you realize a damage was already done before you can even say something. But.. hope and life should be the inspiration to live again, this time be in control!!!!

Signs of Vascular Compromise in a New Stoma

A normal budding stoma should be healthy pink/red in color which indicates adequate perfusion, but a dusky looking stoma should be questioned and surgeon should be notified. A dusky stoma could mean ischemia, their is inadequate tissue perfusion and oxygenation, if not corrected, it can lead to mucosal sloughing and necrosis/death of tissue. When patient continue to ask for pain medication for persistent abdominal pain, nausea and vomiting, a GI warning sign that something is wrong calls for a re-look. Non healing wound due to lack of circulation will be imminent. A good stool output mean a functioning bowel, presence of a slough could also mean dead tissue from surgical injury. Once the slough falls off, a pink/red stoma should be uncovered.

SVT Secondary to Low Blood Sugar

Very interesting and unlikely, patient is in end stage renal disease, on hemodialysis 3x a week, history of atrial fibrillation and a recent CVA with right upper arm paralysis and right lower extremity weakness. Was ordered nothing by mouth. Admitted for pneumonia secondary to aspiration. Pt was NPO since admission. Suddenly developed SVT with HR 190’s. No fever, no signs of pain, K+ level normal, Mg 1.5, BUN/Creatinine elevated but not bad considering patient is in renal failure. Glucose serum an hour ago was 64, no h/o of diabetes. stat blood sugar down to 53, she was then given 1/2 amp of Dextrose 50%. A dramatic gradual slow down of her HR which is now afib was a surprise but educational. Analyzing the case, pt’s energy reserve has been exhausted due to the recent CVA, has not been eating well and worst was made NPO due to swallowing difficulty and aspiration precaution. That alone had depleted her glucose. My first suspicion was another bout of stroke as patient was awake but aphasic which was baseline on admission.

It is important to note not to forget to check blood sugar in any emergency situation. A simple procedure that could save life and any unnecessary diagnostic procedure as well as medications that may worsen the situation.

Again it is proven how our body amazingly communicates when it cannot manifest itself in the normal expected course.

A Healthy Kidney Wasted

A hospital is under fire due to an accidental but irreparable mistake by an OR Nurse. The nurse should not be blamed alone! We are humans, we do commit mistakes. How horrible did she felt when she found out that what she flushed was a healthy kidney waiting for transplant? She must be trying to help by cleaning up the mess. And who left the mess and did not do an appropriate red label for the kidney?.. the other nurse on break? We don’t know what really happened and we can only deduce from news report. I felt sorry about the 2 nurses and the family concerned. I only hope and pray that time will heal such an inconceivable but preventable fate. A big lesson to learn from.

A tertiary hospital like this should have been well equipped with protocols, policies and procedures about safety measures to ensure that malpractice and negligence can never be committed under any circumstances because the process is safe guarded by these 3 P’s. The only human error would be if certain measures were not strictly followed.

Always follow your curious mind
For it will lead you to unwind
the knowledge and mystery behind
Unlock the truth with your common sense
you will never regret the wasted time
After all, to dig for the answer was the goal of a smart mind…
Believe what your instinct suggests
Not to entertain ignorance
Nor a care free never mind
And be regretful your lifetime.

by S A J E R O S A

Colchicine in Renal Failure

Colchicine is a wonder drug for a gout flare. Two consecutive dose is enough to abate the inflamed joint. Hospitalized patients who have history of gout are susceptible to gout flare due to physical trauma, surgery, immunosuppressant drugs Ciclosporin and Tacrolimus, use of diuretics and metabolic syndrome. Since Colchicine is excreted 10- 20 % unchanged in the kidneys it is highly probable to cause toxic accumulation in a renal failure patient. Colchicine can not be removed through dialysis nor does it have an antidote to combat any toxic effect. For this reason prescription of this medication for an acute gout flare should be limited to 2 doses then prophylactic as needed treatment. A few of its distinctive side effects include gastrointestinal upset( diarrhea, vomiting)and symptoms of peripheral neuropathy ( tingling, burning, restless upper and lower extremities) secondary to damage of the peripheral nerves from colchicine toxicity.

What Happens during Gout Flare?
Hyperuricemia is the main cause of gout. Due to an increased uric acid in the blood and slow excretion, uric acids favorite stop are the joints causing uric acid crystal formation, because it is a foreign and an abnormal process the body protects itself from invasion by sending guards to destroy and get rid of this deposits. As plasma and leukocytes which are mainly neutrophils floods the area, an acute inflammation occurs. The area becomes red and hot due to increased blood flow, swelling occurs due to fluid build up and becomes very painful and tender because of damaged nerve endings.

How does Cochicine work?
With Colchicine, it inhibits the activity of neutrophil flooding the area, with decrease in neutrophils, inflammation slows down and pain is lessened.

How to control Gout?
Once the flare is under control, Alluporinol should be taken to block uric acid formation. Uric acid is a by product of purine metabolism, a diet high in purine should be avoided ( e.g. herring, tuna, anchovies, scallops, beer,red meat, turkey.. pls. see reference).

Case study and analysis:
My patient encounter had opened my eyes to investigate Colchicine. Patient have a history of gout and takes allupurinol daily and colchicine as needed for gout flare. In this hospitalization, many things had happened although he has chronic kidney disease hemodialysis is now his last resort of cleansing the body from toxins and waste products of metabolism as well as correcting electrolyte imbalance and fluid excess. He started to have joint pains and was attributed to gout flare. Colchicine BID was started. My second night of encounter patient was restless and was unable to sleep. Trazodone barely helped as he only started to sleep at around 4 am. The following night he complained of the same but now with jumpy burning feet which is new for him. Tracking down what could have caused this symptom pointed to Colchicine. With him who have kidney failure, colchicine toxic accumulation is inevitable. He had already taken said drug for the past 3 consecutive days. My PA that night was very helpful. Patient rested well after 1 mg of IV Ativan. Colchicine was decreased to PRN only. Because it is a weekend his next dialysis is Monday. Even then, colchicine cannot be removed through dialysis. Will he continue to have this symptom of peripheral neuropathy? Highly probable for sometime. This is my last night with him and I will be off for 3 days. But at least the culprit was found.

Reference:
1. Health;Foods to avoid if you have gout
By Anne Harding
2.Colchicine
From Wikipedia, the free encyclopedia
“In August 2009, colchicine won Food and Drug Administration (FDA) approval in the United States as a stand-alone drug for the treatment of acute flares of gout and familial Mediterranean fever.[12][13] It had previously been approved as an ingredient in an FDA-approved combination product for gout. The approval was based on a study in which two doses an hour apart were effective at combating the condition.”
3.Gout
From Wikipedia, the free encyclopedia
4.Allopurinol
From Wikipedia, the free encyclopedia
5.Hyperuricemia
From Wikipedia, the free encyclopedia

Travel Nurse 1

The airport is crowded as usual, pushing my way towards the lane a group of Koreans were in front of me. Check in was fast and I requested a seat near the window. Exhausted but excited of the trip I concentrated on my itinerary for this visit. We were in midair and the atmosphere was serene, everybody looks tired and drifted on and off. I just finished listing my to do list when suddenly somebody cried! The staff went to the business class where the sound came from, then suddenly I hear an announcement for the need of medical staff who can come forward to help. I looked around, no doctor seem to be on board. Then the feeling of urgency was creeping inside me, a familiar fear of the unknown that something is wrong.I stood up and went to check what was going on. I introduced myself, I am a practicing cardiology nurse in one of the hospital in New York. The passenger was pale, unresponsive but breathing normal, skin moist and diaphoretic, He looks familiar but I couldn’t imagine where. I checked his pulse it’s weak and thready. Blood pressure was taken and it was normal low. I told myself to calm down and think. I asked for a glucometer on board and fortunately the first aid kit of the plane is equipped. I started looking for an alert wrist band or necklace and indeed the passenger is diabetic. The meter shows a CBG of 20. I administered glucagon shot, I followed with another shot then slowly the passenger woke up. He told me he took his insulin shot this morning and decided to eat while waiting to check in. But his morning was not smooth, he arrived late due to an accident on the way. Who knows he might be up all night preparing and thinking about his family back home, so upon boarding the plane he slumped and it did not took him a while to ride in his dream. The flight attendant was serving drinks when the passenger beside him noticed something unusual thus the sudden cry.He gave me his business card and everybody went back to their seat. He was then served a snack. Inside me I was happy and satisfied, I had dreamed of becoming an ER nurse and even became certified as emergency nurse by the BCEN instead I cannot seem to get away from the appeal of the heart. All the staff were giving me a warm smile, and I reassured myself I am covered by the Good Samaritan law. But wait.. we are in the plane will it be applicable then? Well, I will check on the planes policy and google it when I get to the hotel. For me, the 12 hour trip was cut short because of the event, we are now landing any minute. The international airport of Seoul is beautiful. as I follow the lane to the immigration the man who had hypoglycemia was met by a group of men in black suite. Wow, I told myself he must be a known personality here in Korea.

N.B. Exploring…,conceiving… and creating.. a story to captivate yourself and your readers is the art of the creative mind… by S.P.A

Please follow my Series of ” The Travel Nurse.”

Coumadin and Antibiotic

When taking any form of antibiotic while on coumadin, it is important to closely monitor PT/INR. While antibiotics eradicates bacteria in the guts, Vitamin K2 is produced by the synthesis of vitamin K by the bacteria present in the colon. Washing off the bacteria in the colon depletes vitamin K source. Coumadin is then well absorbed and INR level will readily increase or double. Taking antibiotics due to infection can not be avoided. I would suggest more frequent lab draw for PT/INR.

Reference:
1. Vitamin K – Wikipedia, the free encyclopedia
en.wikipedia.org/wiki/Vitamin_K
2. Microbial Fermentation
biology.about.com/library/organs/bldigestlargeint4.htm

Chest Pain

Identifying Ischemic Chest Pain through the P Q R S T Method

P…what PROVOKES the onset of Pain..
– What was the patient doing when the pain started?
– What did he do to relieve the pain?
– What makes the pain worse?(movement..,deep breathing.. coughing… exertion?)

Q…What is the QUALITY of the Pain?
– a description of the pain, what was it like?..(burning..,pressure..,sharp..,excruciating..,stabbing?)

R…Does the Pain RADIATES to other parts of the body?
– does it radiate to..(neck.., left shoulder/arm..,jaw..?)

S…How SEVERE is the Pain?
– Gauging the intensity of pain with 0-10 scale
– Or through facial expression when patient is unable to express d/t dementia or unable to talk because of severe pain

T…What was the TIMING of the onset of Pain?
– When did the pain start?
– Is it a new pain? or a usual pain?
– Has the pain changed or has it progressed/more intense and longer?

Analysis and Important Points:
Knowing what provokes or precipitate pain would make you think of other kind of chest pain aside from Ischemic heart pain. PLEURETIC chest pain which is worse with inspiration, coughing and deep breathing secondary to inflammation of the pleura or lungs are described as sharp and stabbing pain. This is usually caused by an infection or irritant that invaded the lungs. eg.. pleurisy, PE(a clot obstructing the exchange of 02 and C02),viral or bacterial infection of the lungs or even malignancy. A chest pain reproduced by palpation of the chest could be referred as muscle pain. Ischemic chest pain is caused by lack of oxygen to the myocardium caused by insufficient and or obstruction of blood flow that supplies oxygen to the cardiac muscle. Pain can be described as pressure, stabbing, excruciating or sharp. It is usually accompanied by diaphoresis, nausea, and shortness of breath which could be secondary to severe anxiety caused by the fear of doom and the body systems reaction to an abnormality. The radiation to the proximal part of the body from the point or origin of pain is an evidence of ischemia spreading to the nearby tissue. The severity of pain becomes alarming when it becomes prolonged and unrelieved denoting high possibility of infarction or death of the cardiac muscle. The timing and onset of pain is significant for the successful intervention and maintenance of life. Immediate identification of a myocardial infarction from the time the patient presented to ER is crucial for a successful PCI and preservation of life.

Referrence:
1. Marianne Chulay,Suzanne M. Burns. Assessment of chest pain. AACN Essentials of Critical Care 2nd ed.
2. Pleuritic Chest Pain – Symptoms, Causes and Treatment
pleuriticchestpain.net/
3. Assessment of Pain: Questions to Consider during Assessment of …
pda.rnao.ca/…/assessment-pain-questions-consider-during-assessment..

The Floaters

I thought it was just an add on
With different colors,style and shape
But no.. it works like the original life vest on.
Such a bright idea,a credit to the inventor.

It boost confidence
It made parents comfortable,
proud and calm as those tinny arms paddles
with their short kicks they float
and make their progress in the blue waters.

It is safe, stylish and reasonable
An amazing gadget, a parents partner
In teaching kids how to swim and float.

At the beginning of summer
On our way home from a friends swim invitation,
My son, Timothy said,”Mom,I can’t believe I don’t know how to swim.”
My first time to see his face full of disappointment
Sadness engulfed his bright eyes
Now forming wells of unforgettable tears.

My heart sank and felt my son’s desires,
But how will I teach him? I myself don’t know how!
I plan to enroll him to learn the basics at least
But a friend recommended a floater would help.
He used a floater before but that was a year or two…

A simple arm floaters indeed was the trick!
My son flipped, floated and explored
But Yuri played with his floaters
Now its torn and cannot be restored
An expense I have to endure,
But my son reassured me, “Mom, I don’t need a floater anymore.”
I was skeptical and did not believe at first
Unable to find one I let him be himself.

Amazed, happy and mesmerized
He surprised me with the skill he displayed
He floated, flipped and dipped
To the pool not a trace of fear
But courage and confidence..
A freedom and independence learned..

My son.. I’m so proud of you!!
For the inventors of floaters..
Thank you so much..

n.b.. with or with out floaters parents/adults are advised to be with their children always.

Know the Drugs You Take Before it Harms You

BE E D U C A T E D on every medication that you take.. prescription, over the counter or herbal supplements and vitamins.

Recently,young once active yahoo man lone protester of a drug he took to stop his falling hair but crippled his manhood. Doctors may not have mentioned one of its side effect but it is also our responsibility to know what we ingest and what effect it would do to our body system. Being wise and curious could save us from any unwanted harm and long term effects. Technology is within our reach.. maximize its usage..it certainly makes a difference knowing what you don’t know.

My daughter was prescribed an adult post- operative dose of narcotic pain killers. It did not surprise me because after all my daughter’s built is almost like mine. But I did not follow what the doctor ordered, instead I opt and gave her a mild non narcotic pain medicine to start with but even then my daughter herself did not like to take any. She rather would eat Popsicle to sooth her throat after her tonsils were removed.

Many Antihypertensive medications can slow you down, let alone impotency, being unable to sustain an erection. If you are young and active, ask your doctor other options that will not affect your sexual drive. E.g…. Lisinopril.. Metoprolol are one of those that can slow you down. Think about your partner and discuss other options available in the market.

Fenasteride(Proscar, Propecia)- a drug used for benign prostatic hypertrophy for older men and Propecia to treat baldness have a side effect which include sexual dysfunction. I wish the yahoo man have read his prescription, or when he felt something was wrong patient are usually advised to call their primary doctor or go back and initiate a discussion.

Red yeast rice is a Chinese remedy for lowering cholesterol but its component are comparable with that of a statin. For this reason liver enzymes need to be checked periodically. How many knew that it can affect the Liver since its a natural remedy but the US FDA made a research that it’s considered and actually a drug? In most Asian countries, we use yeast rice to ferment and produce rice wines. Little did we know that this can be damaging to the liver!! with continued, prolonged and abuse intake of rice wine?

Those who have known Renal dysfunction and liver dysfunction are considered very vulnerable to harm because most drugs are metabolized in the liver and excreted through the kidneys. e.g.. a person who have a history of renal insufficiency was prescribed Bactrim, it further affected his kidneys by not drinking enough fluid. Now he was admitted for Acute renal failure with a GFR of 6 with a high probability of hemodialysis treatment.

Tylenol is one of the most abused over the counter pain killers that can damage the liver with overdose and prolonged consistent high dose.

Oxycodone and Hydrocodone are the most abused narcotic pain medication in North Carolina. Now a campaign to educate prescribing Doctors are being launched. Yes educate the MD’s and innocent people who are dragged to the physical and psychological dependence brought about by this supposedly pain killers.

Antidepressants are supposed to help uplift your mood to become human again but look at the back of the prescription.. it says warning.. patient may become suicidal???????

n.b…Please do your research before you trust Thanks to my readers.