WORK/LIFE BALANCE FROM A MOM AND NURSE PRACTITIONER

L.A. Staycations

5/23/16
If you are a working mom your time and money for vacations is limited. Luckily I found some fantastic "staycations" that are family and budget friendly and all less than an hour outside of Los Angeles.

1. Point Mugu  Beach Camping

My husband and I have been going to this spot for the past 6 years. This is a state beach north of Malibu off of highway 1, with dunes, hiking and biking trails, and camping spots on and off the beach. Every year we have seen dolphins off the coast. Keep in mind these spots fill up quickly, so reservations usually need to made months in advance.
2. Crystal Cove


This is also a state park and beach right outside of Laguna Beach. There are camping sites, hiking trails and rustic preserved cottages. The reservations for the cottages are extremely difficult to get, and generally fill up the day they open seven months in advance from booking.


3. Avalon at Catalina Island
The quaint town of Avalon is a relaxing escape from L.A. which is an hour boat ride from the Port in Long Beach (which is free on your birthday). This town is quaint and people mostly get around on golf carts. There are plenty of shopping, restaurants, water sports and sight-seeing on Avalon.

On immunity review

5/22/16


I initially heard of On Immunity: An Inoculation, through an NPR interview with the author in the context of the anti-vaccine debate. As a medical provider I have become very interested in the anti-vaccine movement. Growing up I never knew anyone who didn't vaccinate their kids or encountered anyone of this ideology. My parents had me and all of my siblings vaccinated without question. It wasn't until I moved to Southern California when I became exposed (pun not-intended) to the anti-vaccine craze. The idea that vaccines were anything other than beneficial seemed so ludicrous to me at first. My pediatric clinical hours required of my nurse practitioner program were split between a private group pediatric practice in an affluent area of Orange County, and a small school-based clinic in L.A. county, serving mostly newly immigrated low-income children without an established pediatrician. The contrast between attitudes towards vaccinations at these two sites was stark. The more affluent parents in Orange county frequently refused vaccines or wanted the vaccines spaced out based on the "Sears" schedule.  The low-income families, many recent immigrants (ranging from Central America, South American, and Asia) were all welcoming and eager to receive vaccines, many of which their children had not had access to. My pediatric rotations also happened to be during the time when a Measles Outbreak occurred in Orange County. I was surprised by the convictions that these vaccine objectors had in refusing their children to be vaccinated. Discussing the benefits of vaccination was futile, in addition to the fact that most of the people refusing vaccines were well-educated individuals who already were aware of both sides. I was floored when I was pregnant and a Physician's Assistant at my work ask me if I was going to vaccinate my child. When I responded "of course" she then proceeded to go on a anti-vaccine rant about how it lead to Guillan Barre Syndrome in a patient she vaccinated, and how she was going to home-school her children if it meant she had to vaccinate to attend public schools. The public's fear of vaccinations seems to be worsening, and I constantly encounter this in practice. I had two female patients in their early twenties frightened about the HPV vaccine after a professor in their human sexuality course introduced the idea that the HPV vaccine was linked to deaths and ineffective in preventing cervical cancer. I then researched this claim and found it completely without base and verified with several OB/GYNs whom also debunked this claim. Why were so many highly-educated people afraid of vaccines? I was hoping this book could shed some light into these fears. To me understanding and educating the public about vaccine pros and cons is paramount, as I work in primary care, and a huge component of primary care is prevention of disease. As a parent, I understand the need to protect your child from everything in utero and out in the World. The fear of autism is one that is challenging as a parent, because still there is not a medical census on any causative factor. When the media highlights studies on possible links to autism, naturally there is alarm among parents and expectant parents. One small inconclusive study suggested a link between autism and vaccines, however the media-hype and damage from this study has been long-lasting. In recent news one study found evidence even folic acid, which is proven to be preventative for neural tube defects when taken prenatally, to be linked in high-levels to autism. As any concerned parent, it's natural to take whatever precautions possible to prevent autism, but at what cost?
This book was a good read, although it was not what I expected. I expected the author's account from a perspective of a once-radical anti-vaxx who after research reframes her thoughts on vaccines. The author was never a radical anti-vaccination proponent, but just a concerned parent with a healthy level of skepticism about the healthcare system. This book is in no way propaganda, but a historical and anthropological exploration of human immunity to disease, with interlaced personal anecdotes and literary references. I enjoyed this book for the fact I do love learning about the history behind medicine. She delves into the history of primitive forms of vaccines, the paradox of parents trying to protect their children from the vaccine meant to protect them, mistrust of government, environmental impact on health, and risk-benefit analysis all in an eloquent academic way. Her book although published in 2014, is even more relevant in light of the new suggestions of folic acid being linked to Autism, Zika virus, and the Flynt Michigan water crisis. She also highlights the observation I had in my pediatric rotations, that refusing vaccines is a matter of privilege, rather than an anti-establishment statement. Some interesting facts I learned from this book: Breastmilk is full of environmental toxins (paint thinners, dry cleaning fluids, flame retardants); The publication of the  Book Silent Spring lead to increase rates of malaria in Africa as a result of the decreased use of DDT; The CIA used a fake vaccination campaign in Pakistan administering hepatitis B vaccine while also gathering DNA evidence to locate Osama Bin Laden's whereabouts.
I did not necessarily change my views on vaccines from this book, but I find myself looking at the global impact of the United States vaccination policies and decisions differently. Subsequently I have become involved in a campaign called Shot@Life to increase federal U.S. funding for vaccinations abroad in countries where there are children mortalities from vaccine-preventable deaths, such as Rotavirus, Diphtheria and Pertussis. More information is available here. I would recommend this book to any parent or anyone interested in learning more on immunity and vaccination history.

Media and Children

5/18/16
My husband and I were recently out to dinner with our friends a married couple without children. The friend of ours is a teacher at a "media-free" elementary school, and was also telling us how her niece (my son's age) is limited to 20 minutes of screen time a week. I felt somewhat guilty as my toddler son was watching Thomas and Friends on my iPhone to distract him while we ate dinner. I reflected on this later... do I let my son watch too much TV and play with the iPhone too much? Before I was a parent I would pass judgement on parents that slapped an ipad in front of their children to keep them quiet, but now I completely get it. It's not often my husband and I get to go out to dinner simply for the fact that our son does not like to sit still, and we rarely get to eat in peace. One way we can sit through a dinner when we are out is giving him my iPhone to watch Thomas and Friends, his most beloved cartoon. This being said, my son also attends a media-free daycare, and we limit the amount of TV he watches at home. When he does watch TV it's mostly Sesame Street or Thomas and Friends. At this stage, I don't see the harm in letting my son watch some occasional children's programming. I myself grew up in an extremely media-free household, without any television in our home until my parents finally broke down and bought one when I was 12. I read a lot growing up, and my parents read to me often. This does mean, however, I did not get exposed to television through friends houses, school etc. When I went to a friend's house that had cable, I would try to soak up every minute of that shit before I had to go home to read Little House on the Prairie (Which are a great series of books by the way). I think the most beneficial thing I got from this type of childhood was a love for books. I love reading now and always have. I loved reading in school and college, even dry textbooks. That being said I also know other people (including my husband) my age who literally were raised in front of the TV, but also love to read and are intelligent, responsible human beings. Even though I grew up without much television, I am now an avid television watcher, and probably spend too much time online and on my iPhone. What I am trying to convey is I doubt if there is any real correlation with long-term outcomes as an adult from early exposure to television or other screen devices, although I'm sure a bunch of early child development specialists will disagree with this. As a parent I am more concerned about my son's exposure to media as he becomes an adolescent. Now more than ever there is so much as a parent to worry about with cyber-bullying, stalking, exposure to violence and hate. I think sheltering our children from media outlets is not the way to protect them. With our world so permeated with the media this is nearly impossible unless we lock them up in a bubble and home school them, which is not necessarily healthy either. Limiting media use and educating our children about safe use is essential. I use the internet for networking and reading opinions of other mothers and medical professionals. I enjoy blogging because it is a platform for me to share my own opinions and ideas. I think there is so much good that has come from the increased access that every day people have to media. I think more voices that were underrepresented before in the media are now getting a voice. I want my son to contribute and influence in his own way when he is older as well. I don't think the media is the problem, but the outlet for which the other pathologies in our society often manifest.  If we teach our children morals and values and to be critical of what they watch and hear, media can play a positive role in their lives.

Versatile Lace-Up Sandal

5/16/16



I decided to lighten up my post this week and write about my latest favorite purchase, these faux suede lace up sandals. I have been loving the lace-up sandal trend, however before I ran out and bought a pair I wanted ones that would function from dressy to casual and also be comfortable. I found these on Amazon for $29.99 and chose the gray pair ,as this color can be worn with almost any color scheme. I also liked the low heel as they are fashionable and comfortable. I put together a few outfits that go with these sandals for my everyday life.

This jersey dress and chambray shirt is a comfortable casual outfit that can be worn with these sandals to do errands, or on a family outing.

Dress//Shirt (similar)
 These distressed demin shorts with a T-shirt is another casual look that can be worn with these sandals. I got this shirt from the Ask Dr. Angela Podcast for submitting a question that was featured. I love her very informative and entertaining podcast about women's health.
These shoes can also be paired with a summer dress, such as this shift dress I got with one of my "fixes" from stichfix which is an ideal look for a brunch, shower or date.





Lastly, these sandals can be paired with office attire. These slacks (also a stitchfix piece) and sweater are a typical work-week outfit.








Year of Yes Review

5/7/16

I initially was interested in reading the Year of Yes: How to Dance It Out, Stand In the Sun and Be Your Own Person  after watching an interview with Grey's Anatomy, Private Practice and Scandal Creator, Shonda Rhimes on a talk show. Although I am somewhat embarrassed to admit it, I have been watching Grey's Anatomy from the very first episode and was not aware of who the creator Shonda Rhimes was until recently. The reason I did not know of Shonda, is up until now she maintained a very behind the scenes persona, and refused to do any public appearances. As I mentioned, I have a long history with Grey's Anatomy, starting in 2005  before I was in the medical field. I have stayed a loyal viewer despite the glaring inaccuracies in the medical aspect of the show and hospital culture (I have never in my life seen a doctor transport a patient from a CT Scan, and there are literally no nurses ever at Seattle Grace Hospital) as well the unbelievable melodrama of the show for several reasons. One reason is I really love that Grey's Anatomy brings a human aspect of medicine to the show. The surgeons in the show are empathetic, and consider all ethical implications of the medical decisions they make. They also take the time to get to know and really interact with their patients (like I said the show is not true to life). I also really love that she not only creates complex and powerful characters who are minorities, gays, and women, but also interracial and gay relationships and families are completely normalized in the show. A pet peeve of mine is so often when minorities or gays are portrayed in movies or in television, they are rarely placed in integrated settings. You have all Asians shows, (Fresh off the Boat, Dr. Ken) or all White shows (How I met your Mother, Friends), or all Black shows (Black-ish, Martin). If there are interracial relationships in most TV shows or movies, it is a central plot focus. In Grey's Anatomy a White woman and Latina woman are married, and the focus is not on the fact that they are gay, or are in an interracial relationship, but on normal problems faced in any relationship (you know normal problems such as being a victim in plane crash which leads to a limb amputation by your wife, an orthopedic surgeon, against your will). Being in a interracial marriage with a mixed child, it's nice to see families like ours portrayed on television. Having my longest TV relationship with Grey's Anatomy, I felt as if I wanted to know a little more about the elusive creator behind all of the beloved characters.
The Year of Yes starts out with Shonda at the height of her career. She has three hit shows, including Grey's Anatomy in its 10th season. With all the success in her career and the drama in her shows, her life is for lack of better term, in a rut. She has neglected friends, family, fun and her health, in the midst of being a power house writer and producer. After having the epiphany that she was always saying "no" to herself, she makes a vow for a full year to say yes to everything that scares her. I was a little turned off by the story at first. For all the melodrama in her shows, her life was a huge bore. I am more used to nonfiction being filled with more excitement and comedy, unlike this book. What I realized as I read on, however, the intent of this book is not for entertainment, although some parts are very funny, but more as a self-help or self-motivation book. Her stories of balancing her life as mom of three children and a writer/producer are down to Earth and realistic. She doesn't sugar-coat her inadequacies or insecurities, and by the end of the book I felt like as though she was an Aunt (in my mind as Wendy Williams says) and we were sitting down drinking wine together as she gave me life advice. Overall I would recommend this book not for entertainment value, but as a self-motivation piece.

Nurses nurture their young

5/6/16
This week marks the beginning of nurses week, and thus I would like to address a nursing topic. Every nurse has heard the expression "Nurses eat their young" which refers to the hostile culture new nurses are often faced with starting their first job. Most every nurse has a story that can reflect this phrase as well. I can personally say I've experienced this from former preceptors, instructors, and coworkers alike, as I entered into the world of nursing young and na├»ve. I am in no way advocating nurse on nurse hate, however I now have a better understanding of why the bullying targeted towards new nurses can happen. Nurses are notorious for getting the blame from everyone; the patient's angry family, the doctor, the nursing supervisor, etc. Staffing ratios are often not adhered to, shifts are long, work demands on nurses keeps increasing. Nurses are not paid to precept a student or a new hire in the hospital in most cases. Even in my clinical rotations in my Master's program, my clinical preceptors were volunteer positions. Having a student and giving them thorough guidance takes time and patience, which often isn't available in the busy life of a nurse. I have however, so much respect for the seasoned nurse, even when they are burnt out and angry. I know they have put up with so much more in their career than I ever have, and have so much knowledge from their many years of nursing. For every time I was bullied or thrown under the bus as a new nurse, there were 10 more instances a seasoned nurse came to my rescue or gave me the guidance I needed in that particular moment. I have seen the nursing culture and education move away from this more hardened approach toward new nurses, and I hope this does continue as we need more compassionate and competent nurses.
5/2/16


I have wanted to write a post about prescription drug abuse, as it is such a real and worsening problem that I encounter on daily basis, however I felt challenged by the breadth of the problem. On twitter and other social media outlets, I often see posts from people in the medical field addressing this issue. This issue is tough to tackle, as it's so complex and there are so many driving factors behind this problem. This article I loved because it really dives into all the pieces behind the prescription drug abuse epidemic. Prescription drug abuse has been an epidemic for years, however only recently have policies and political awareness increased around this issue. The most commonly abused controlled substances I encounter are opioids (Norco, Percocet, Morphine) benzodiazepines (Klonipin, Ativan, and Xanax), and stimulants (Adderall, Zenzedi, Dexedrine). Working as a ER nurse I saw the worst-case scenarios prescription drug abuse, and it didn't take long to become completely jaded and fed up with the problem. Of course there were plenty of overdoses on opioids and sometimes benzodiazepines. So many times a patient would have run out of  narcotics prescribed by his primary care doctor or even pain management doctors, and in desperation turn to the ER to fill a prescription or get a IV dose of narcotics. These particular patients use sob story after sob story to get the medications they want. If the sympathy card didn't work the patients often resorted to temper tantrums, or at worse case scenario threats against the staff. I also saw people working in the medical field fall victim to prescription drug abuse. A coworker of mine in the ER died from a drug overdose, and another coworker of mine was caught stealing opioid narcotics from the medication dispenser. The access to these controlled substances makes nurses and doctors especially more susceptible to this type of abuse.


Although it is awful to see people in desperation as their physical dependence on prescription drugs worsens, as a ER nurse dealing treating drug-seeking patients was more of an annoyance than a concern. Taking care of a drug-seeking patient takes up precious time away from actual sick patients. Having to go withdraw morphine from the medication dispenser or pixus, find another nurse that wasn't busy with charting or patient care to cosign the drug, monitor the patient for adverse reaction, and then reassess the pain in another 15 minutes, takes a lot of time. Trying to tell a patient after receiving a dose of Morphine, they cannot have another dose and need to go home, also takes time and energy.
I was rarely concerned about administering high doses of IV narcotics to patients in the ER setting (which I did literally on a daily basis) mostly because the patient was in such a controlled situation to monitor heart rate, respiration and oxygenation status. If a patient was to go into respiratory depression, the reversal agents were readily available, as well as a crash cart, doctors, nurses and other trained staff. In the ER the indications for IV high dose opioid narcotics, such as appendicitis, dislocated bones, kidney stones, etc were mostly appropriate. Now that I am a provider that is able to prescribe controlled substances, I do feel concerned about the danger of narcotic abuse for myself as a prescriber and for the patients prescribed these drugs. I don't have the ability to monitor the patient in a controlled environment when I write a prescription for a controlled substance. I have no way of knowing if that patient will take the 30 tabs of Norco I prescribe for a month all at once and wash it down with a fifth of vodka, or if they will sell them on the street. There is a California state tracking system (CURES) that shows the controlled prescriptions filled, and there are standardized screening tools for potential for drug abuse which can be helpful tools to prevent abuse, but both are not fool-proof. I am conservative with my prescription of controlled substances, however the problem arises when patients have been prescribed controlled substances, in particular benzodiazepines and opioids (and often are on both of these) for years and years and have not been reassessed for the need for the long-term use of these medications. Granted, there are valid reasons for long-term use of these medications, and in these cases where documentation and records have been provided and no history of substance abuse exists, I am comfortable refilling certain controlled medications. When these physically addictive drugs have been continued for years and years, withdrawing abruptly from them can be life-threatening, and usually requires detox at hospital or other medical facility. The dilemma is if they are continued on these medications unnecessarily and an adverse event or overdose occurs, I am liable. On the other hand however if I discontinue the medication and an adverse withdrawal affect occurs, I am also liable. The other concern is a patient who does not receive a refill of their medication legally, will go to buy them on the blackmarket (I have had a patient tell me straight to my face she intended to do this when I wouldn't refill a prescription in the ER).  Now with the concern of Fentanyl showing up on the black market and being sold as Norco, the danger of overdose from  prescription drugs sold illegally is even more serious.  Convincing a patient to taper down from a medication they have been physically dependent on for years, is a huge challenge. The ideal situation for patients is to have pain management specialists control and manage patients on long-term narcotics, or have psychiatry manage patients with long-term need for benzodiazepine and stimulant use. These are specialties that have expertise in managing chronic pain and panic and anxiety and thus have a better understanding of when and how to use these particular controlled substances. The problem is waiting times for these specialties can take several months and require additional time and money expenditure for the patient. In the end these patients often bounce back to primary care or ER, even when not appropriate. I don't know how all of these issues will be addressed to create a more safe culture of prescribing controlled substances, however I hope changes will continue for the improvement of patient safety. Here is the link for the updated CDC guidelines for prescribing opioids for chronic pain.