DiversityNursing Blog

BY JENNIFER WALKER

In a Johns Hopkins Outpatient Center exam room, medical interpreter Julie Barshinger is working with a Spanish patient, a woman in her early 40s with a stocky build and a dark ponytail, who is concerned about complications related to her recent nose surgery.

But first, the woman must complete a medical history form. “¿Qué significa vertigo?” (“What is vertigo?”) she asks, as Barshinger goes through the list of symptoms on the form, verbally interpreting them from English to Spanish. Then later, “No sé qué es un soplo cardiac … ” Barshinger interprets the question — “I don’t know what a heart murmur is” — for the nurse who is preparing a nasal spray for the patient that will allow the doctor to look inside her nose.

“If it doesn’t apply to her, don’t answer it,” the nurse says kindly.

“I just want you to know that I have to interpret everything she says,” explains Barshinger, who is one of 18 full-time interpreters in Johns Hopkins Medicine International’s Language Access Services office. Part of Barshinger’s job is educating providers about her role. 

Later, the nurse starts to leave the room to see another patient before the woman has completed her medical history form. “I can’t continue if you’re not in the room with me,” Barshinger says. The patient is consistently giving additional information about her symptoms: She doesn’t see well since her operation; she has some nasal bleeding; she sees the room spinning when she lies down. It’s crucial for Barshinger to communicate these potentially important details to the nurse, who stays in the room, answering questions when needed, until the form is complete.

Throughout the interaction, Barshinger knows little about the full scope of the patient’s health history. But she doesn’t need to know. “I’m not in charge of her care,” she says. “I’m only her voice. I want to make sure her voice is being heard by the right people. I’m also the voice of the provider, so she can communicate the very necessary and important information that she has to the patient.”

While Johns Hopkins, like other hospitals that receive federal funding, has been providing interpretation services for 50 years — since passage of the Civil Rights Act of 1964, which prohibits discrimination based on national origin — requests for interpreters at The Johns Hopkins Hospital have grown dramatically since 2010, jumping from 23,000 to more than 50,000 annually.

This is due in part to the slightly rising limited English proficiency population in Baltimore City, which grew by about 4,000 people between 2000 and 2012, according to the U.S. Census. Today, the hospital also serves more refugees, about 2,500 of whom settled in Baltimore City between 2008 and 2012.

But Susana Velarde, administrator for Language Access Services at Johns Hopkins Medicine International, says the increase in requests is also due to the growing understanding among health care providers that they can do a better job treating their patients with limited English proficiency with the help of interpreters. 

Because they prevent communication errors, certified interpreters improve patient safety. A 2012 study in the Journal of General Internal Medicine found that patients with limited English proficiency who did not have access to interpreters during admission and discharge had to stay in the hospital between 0.75 and 1.47 days longer than patients who had an interpreter on both days. Moreover, when the interpreter has 100 hours of medical interpretation training — a qualification that researchers have found is more important than years of experience — they made two-thirds fewer errors than their counterparts with less training, according to a 2012 Annals of Emergency Medicine study.

The Language Access Services office’s full-time interpreters—who speak Spanish, Chinese-Mandarin, Korean, Russian, Arabic and Nepali — participate in an extensive two-year training program, which includes classes, tests and shadowing. Fifty percent of the team is certified; the rest are working toward certification, if available in their language. The office also has 45 medical interpreter floaters, and interpretation services are available 24/7 in person, over the phone or through a video monitor for patients with limited English proficiency who live in the Baltimore area and international residents who come to Johns Hopkins for treatment.

“We are the conduit, but also the clarifier,” says Spanish interpreter Rosa Ryan. “We are not simply repeating words but making sure the message is understood.”

For example, at the end of her visit on the otolaryngology floor, Barshinger walks to the front desk with the ponytailed Spanish woman to help her make a follow-up appointment. With Barshinger interpreting, the woman learns that she must get a Letter of Medical Necessity from her current insurer or change insurance companies before coming back to Johns Hopkins. When the administrator walks away, Barshinger checks in with the woman to make sure she understands the instructions.

“The patient might nod, but the information might not be registering,’” she says. “I try to check for clarification if I sense there is a disconnect.”  

Interpreters are also cultural brokers. Yinghong Huang, a Chinese-Mandarin interpreter, remembers when a nurse in labor and delivery tried to give a Chinese patient a cup of ice water. “In China, for a woman who has just delivered a baby, we don’t want her to touch anything cold, let alone ice,” Huang explains. This is one of the many rules that Chinese women abide by for a month to help the body recover from childbirth. With Huang present, providers knew to give the patient hot water with her medicine instead.

Despite the increasing demand for interpreters, their expertise too often goes untapped, says Lisa DeCamp, assistant professor of pediatrics at the school of medicine. She is the lead author of a 2013 Pediatrics study that found that 57 percent of pediatricians who completed national surveys in 2010 still reported using family members as interpreters.

This is a bad practice for many reasons, she says. For one thing, family members often don’t have specialized knowledge of medical terminology. Moreover, both patients and family members may censor information. “If you’re talking about something that is intimate or personal and your son is translating for you, you might not want to disclose something about your sexual activity, your drug use or anything else sensitive that could be contributing to your problem,” says DeCamp, who is also a pediatrician at Johns Hopkins Bayview Medical Center.

Even physicians with basic skills in a particular language should use an interpreter to prevent misunderstandings. “I [know] some high school Spanish, but I’m nowhere near fluent, so I need an interpreter,” says Cynthia Argani, director of labor and delivery at Hopkins Bayview, where about 70 percent of her department’s patient population speaks Spanish. “It’s not fair to the patient not to use one. The message can get skewed.”

DeCamp, who has passed a test certifying her as a bilingual physician, offers a real-life example from the literature that shows how this can happen. A pediatrician with limited Spanish language skills instructed parents to use an antibiotic to treat their child’s ear infection. In Spanish, “if you use the preposition, it really means, ‘put in the ear,’” she says. “So the family was putting the specified amount of amoxicillin that should be taken by mouth in the ear. That child is not going to die from an ear infection, but he’s having pain and a fever, and the family doesn’t have clear instructions on how to provide medication.”

On Barshinger’s rounds, after her otolaryngology visit, she walks at an impressively fast pace to The Charlotte R. Bloomberg Children’s Center, where a mother recognizes her and asks her to be her interpreter. The provider who requested Barshinger’s services is not ready yet, so she has time to help.

A doctor carrying a sheaf of papers joins them in a busy hallway. She points to a long list of care instructions translated into Spanish, then begins to explain them to the mother. Because the doctor is verbally giving the instructions, Barshinger interprets. The mother needs to buy an extra-strength, over-the-counter medication and give her daughter a second medication three times a day, which she will need to “swish and spit,” the doctor says. A third medication will be applied to the daughter’s face two times a day, and a special shampoo is needed to wash her hair. Before an upcoming dentist appointment, she’ll also need to give her daughter three amoxicillin. When the doctor steps away, the mother asks Barshinger a question about her daughter’s dental visit, which Barshinger interprets when the doctor returns.

While interpreting, Barshinger stands to the side of the patient’s mother, allowing the doctor and the mother to face each other and communicate directly with one another. This simple tactic encourages providers to develop a rapport with their patients with limited English proficiency.

The goal? “To make the patient feel like the appointment is with him and not with the interpreter,” says Velarde. “The interpreter is just the voice. We want providers to have a bond with their patients, like they do when everyone is speaking English.” 

Bonding Moments

Tapping the expertise of interpreters doesn’t have to complicate things for physicians, says Lisa DeCamp, a bilingual physician at Johns Hopkins Bayview Medical Center. Her advice for colleagues:

• Educate the interpreter about what you’re doing so they’re not going in blind. Say a patient has severe abdominal pain. Providers can quickly explain to the interpreter that the first job is to rule out appendicitis.

• Sit across from the patient, with the interpreter standing at the patient’s side, and talk directly to the patient. The goal is for the provider and the patient to feel like they have a relationship with each other despite language barriers. When possible, use short phrases to help the interpreter keep up with the conversation. 

Found In Translation

Arabic translator Lina Zibdeh remembers the first time she saw the recommendation in a patient education document that leftover medications should be discarded in used cat litter or coffee grounds.

There isn’t a direct translation for this concept in Arabic, a language that is spoken in different dialects by 22 countries but written in one common form. “It can take hours and extensive research to make sure a concept like this is translated correctly,” says Zibdeh, who translates written materials, such as informed consent forms, welcome packets, care instructions, brochures, video scripts and more. In this case, Zibdeh had to add an additional sentence to explain that medications should be disposed of in this way so they are not enticing to children and pets. 

While translation programs like Google Translate are readily available and easy to use, they often produce inaccurate translations, which can confuse patients and lead to poor health outcomes. This is because words in sentences can be organized in different ways from one language to another. Thus, when online programs translate those sentences from, say, English to Chinese, they can change the meaning, says Chinese-Mandarin interpreter and translator Yinghong Huang. Some English words, such as discharge, also have multiple meanings. “It’s very rare for a program to get the right meaning,” Huang says. Even Huang has to use tools, such as her cellphone and an online dictionary, to produce accurate translations.

Along with improving health outcomes, documents that are available in a patient’s own language can make him or her feel more comfortable and secure, says Zibdeh, who organized the American Translators Association’s first webinar for the Arabic Division on Arabic Medical Translation in early 2014. “It helps that patient feel closer to home,” she adds.

Source: www.hopkinsmedicine.org

A Dutch organization called "Ambulance Wens" (Ambulance Wish) fulfills the last wishes of terminally ill patients free of charge thanks to its 200 medical volunteers.

The company says, "There are still too many patients who die without getting to close everything. One of those reasons is the inability to achieve certain desires because the patient is no longer mobile and other existing facilities are inadequate for this purpose."

Special ambulances and stretchers help transport the patients safely and comfortably. Typical excursions include a visit to the beach, a visit to a neighbor who is also no longer mobile, and various places where the patient has special memories.

This woman's final wish was to visit the Rijksmuseum in Amsterdam.

Another woman enjoys the view from her favorite vacation destination in Tuscany.

This gentleman asked for one last view from the Euromast observation tower.

And this man asked to see the mills in Kinderdijk one last time.

Amsterdam is not the only place doing such wonderful things. A hospice outside Seattle made an old forest ranger's dying wish come true.

"Ed expressed one last hope to the hospice chaplain: He wanted to commune with nature one more time."

As the hospice wrote on its Facebook page, "People sometimes think that working in hospice care is depressing. This story ... demonstrates the depths of the rewards that caring for the dying can bring."

Source: www.sunnyskyz.com

Catharine Paddock PhD

Drug development is a costly and lengthy business, not helped by the fact there is a high failure rate in drug testing due to the reliance on animal models. Animal biology is not an ideal substitute for human biology, but until something better comes along, it is all we have. Now, a new study suggests the organ-on-a-chip method may offer a more ideal model.

Study leader Kevin Healy, a bioengineering professor at the University of California-Berkeley, says:

"It takes about $5 billion on average to develop a drug, and 60% of that figure comes from upfront costs in the research and development phase. Using a well-designed model of a human organ could significantly cut the cost and time of bringing a new drug to market."

As around one third of the candidate drugs that are ditched are those that seem to have a bad effect on the heart, Prof. Healy and colleagues decided to design a model based on the human heart.

They conclude that their work is a major step forward in the development of faster, more accurate ways of testing drug safety. Prof. Healy believes that:

"Ultimately, these chips could replace the use of animals to screen drugs for safety and efficacy."

In their study, they describe how they devised the model and tested it with cardiovascular medications.

'Heart-on-a-chip' contains a network of pulsating cardiac muscle cells

The human heart model that Prof. Healy and colleagues devised is a "heart-on-a-chip" comprising an inch-long silicone device with a thin network of pulsating cardiac muscle cells.

In the journal Scientific Reports, the team says their heart-on-a-chip - which they call a "cardiac microphysiological system (MPS)" - is an ideal tool for testing toxic side effects of new drugs on the human heart because it ticks four important boxes:

1. It uses cells that have human genes
2. The cells are aligned in a way that reflects the structure of human heart tissue
3. It mimics the dynamics of blood flow in heart tissue
4. It can be used for biological, electrophysiological and physiological analysis.

The authors note that using animal models to predict human reactions to drugs often fail because of fundamental differences in biology between species. For example, the ion channels that conduct the electrical pulses that heart cells send out can vary in number and type between animals and humans.

"Many cardiovascular drugs target those channels, so these differences often result in inefficient and costly experiments that do not provide accurate answers about the toxicity of a drug in humans," Prof. Healy explains.

Device is populated with heart cells made from human-induced pluripotent stem cells

The heart-on-a-chip is made of heart cells generated from human-induced pluripotent stem cells - the adult stem cells that can be coaxed to differentiate into various types of tissue.

The heart-on-a-chip has a 3D geometry and spacing that is comparable to that of connective tissue fiber in a human heart. The researchers then populated this with layers of differentiated heart cells, which in the confined geometry were forced to align in one direction.

Microfluidic channels on either side of the cell-populated area perform like blood vessels and mimic the same dynamics of nutrients and drugs diffusing from blood vessels into human tissue.

Such a setup could also serve as a model of how the cells get rid of their waste products, note the authors.

Lead author Dr. Anurag Mathur, a postdoctoral scholar in Healy's lab and a fellow of the California Institute for Regenerative Medicine, explains:

"This system is not a simple cell culture where tissue is being bathed in a static bath of liquid. We designed this system so that it is dynamic; it replicates how tissue in our bodies actually gets exposed to nutrients and drugs."

Heart-on-a-chip tested with four drugs and reacted as expected

The authors explain how within 24 hours of populating the device with heart cells, the engineered heart tissue was beating on its own at the normal rate of 55-80 beats per minute.

The team tested four well-known cardiovascular drugs on the device: isoproterenol, E-4031, verapamil and metoprolol. They used changes in the pulse rate of the tissue to measure the response to the drugs.

The changes in pulse rate were as expected for the drugs. For example, after half an hour of being exposed to isoproterenol - a drug used to treat slow heart rate, or bradycardia - the pulse rate of the heart-on-a-chip increased from 55 to 124 beats per minute.

Multi-organ testing devices could have hundreds of microphysiological cell systems

The engineered tissue remained viable and worked for several weeks. Such a timescale is sufficient for testing several different drugs, Prof. Healy says.

He and his colleagues are now investigating whether the method can be used to model multi-organ interactions. Prof. Healy notes:

"Linking heart and liver tissue would allow us to determine whether a drug that initially works fine in the heart might later be metabolized by the liver in a way that would be toxic."

The team anticipates the "widespread adoption" of organ-on-a-chip for drug screening and disease modeling and foresee devices containing hundreds of microphysiological cell systems. 

The project is funded through the Tissue Chip for Drug Screening Initiative, which is sponsored by the National Institutes of Health.

In October 2014, Medical News Today learned how the University of Kansas is leading the development of a  lab-on-a-chip that promises to detect lung cancer - and possibly other deadly cancers - much earlier. That method, which only uses a small drop of a patient's blood, is also based on microfluid technology. It analyzes the contents of exosomes - tiny bags of molecules that cells release now and again.

Source: www.medicalnewstoday.com

Heather Stringer

In 2010, the Institute of Medicine issued eight recommendations that dared to transform the nursing profession by 2020. This year marks the midway point for reaching the goals outlined in the report “The Future of Nursing: Leading Change, Advancing Health,” and statistics at halftime offer a glimpse into nursing’s progress so far.

Although the numbers in some areas have altered little in the first few years, infrastructure changes have been set in motion that will lead to more noticeable improvements in the data in the next several years, said Susan Hassmiller, PhD, RN, FAAN, the Robert Wood Johnson Foundation senior adviser for nursing. The RWJF partnered with the IOM to produce the report. 

“I am a very impatient person and would like things to move faster, but we have to remember that we are changing social norms with these goals,” Hassmiller said. “We are trying, for example, to convince hospital leaders, nursing students and educational institutions that it is important for nurses to have a baccalaureate degree, and that takes time.”

Hassmiller is referring to Recommendation 4 of the report, which calls academic nurse leaders across all schools of nursing to work together to increase the proportion of nurses with a baccalaureate degree from 50% to 80% by 2020. The most recent data collected from the American Community Survey by the Future of Nursing: Campaign for Action found that the percentage of employed nurses with a bachelor’s degree or higher only climbed 2% between 2010 and 2013. However, Hassmiller suggested the percentage is likely to increase rapidly in coming years because nursing schools have increased capacity to accommodate more students. As a result, the number of nurses enrolled in RN-to-BSN programs skyrocketed between 2010 and 2014, from about 77,000 nurses in 2010 to 130,300 students in 2014, according to the American Association of Colleges of Nursing — a 69% increase. 

New education models

Campaign for Action leaders also are optimistic about the profession’s ability to approach the 80% goal because nursing schools are beginning to experiment with new models of education, such as bringing BSN programs to community colleges. 

Traditionally, students spend at least three years in a community college earning an associate’s degree to become an RN — at least a year for prerequisites and another two to complete the nursing program, Hassmiller said. These RNs may work for a few years before returning to school to earn a BSN — and some may not return at all, said Jenny Landen, MSN, RN, FNP-BC, dean of the School of Health, Math and Sciences at Santa Fe Community College in New Mexico. To avoid losing potential BSN students, leaders from New Mexico’s university and community colleges began meeting to discuss a new paradigm: students who were dually enrolled in a community college and a university BSN program. 

The educators started by forming a common statewide baccalaureate curriculum that would be used by all community colleges and universities, Landen said. The educators also discussed how to pool resources, such as offering university courses online at local community colleges. “This opens the opportunity of earning a BSN to people who need to stay in their communities during school,” she said. “They may have family commitments locally, and they can take the baccalaureate degree courses at the community college tuition fee, which is much less expensive.”

Four community colleges in New Mexico have launched dual enrollment programs within the last year. At Santa Fe Community College, there are far more applicants than the program can hold, Landen said. Community colleges and universities in other parts of the country also are working together to create programs in which nursing students can be dually enrolled. In addition to nursing schools buying into the need for more BSN-prepared nurses, there also is evidence that employers are moving toward this new standard as well. According to a study released in February in the Journal of Nursing Administration, the percentage of institutions requiring a BSN when hiring new RNs jumped from 9% to 19% between 2011 and 2013. 

Beyond the BSN

So far, the national data related to Recommendation 5 — double the number of nurses with a doctorate by 2020 — suggests there have been minimal changes in the number of employed nurses with a doctorate, yet there has been a significant increase in the number of students pursuing this level of education. According to the JONA article, on average about 3.1% of employed nurses in all institutions had a doctorate in 2011. This rose to 3.6% in 2013. This percentage likely will increase in the coming years because of the proliferation of doctor of nursing practice programs since 2010. These programs are geared for advanced practice RNs who are interested in returning to the clinical setting after earning a doctoral degree. Between 2010 and 2013, the number of students enrolled in DNP programs doubled from just over 7,000 students to more than 14,600. There was a lesser increase in the number of students enrolled in PhD programs, up 12% from 4,600 to 5,100, according to the AACN. 

“When the DNP degree became an option, it opened the opportunity of a higher level of education to the working nurse, not the researcher, and that was attractive to many nurses,” said Pat Polansky, MS, RN, director of program development and implementation at the Center to Champion Nursing in America. “Getting a research-based PhD takes longer and not every nurse can do that, so the DNP has become a wonderful option.”

Leaders at the Campaign for Action, however, acknowledge that it is important to find strategies to boost the number of PhD-prepared nurses because the profession needs those nurses in academia and other administrative, research or entrepreneurial roles where they are contributing to the solutions of a transformed healthcare system, Hassmiller said. To encourage more nurses to pursue the path of a PhD, in 2014 the RWJF launched the Future of Nursing Scholars Program, which awards $75,000 per scholar pursuing a PhD. This is matched with $50,000 by the student’s school, and the funds can be used over the course of three years. 

Forging ahead

In December, the nursing profession will have another opportunity to assess progress on the recommendations when the IOM releases findings from a study that is under way to assess the national impact of the Future of Nursing report. The changes happening in areas such as education are remarkable, Hassmiller said, and she is eagerly anticipating the results from the current IOM study. 

“I would never modify the goals because you need something to strive for in order to affect change,” Hassmiller said. “I am extremely encouraged because we have never seen anything like this. For the first time in history, more than half of nurses have a bachelor’s degree, and it is going to keep climbing. The most challenging part has been the number of people that need to be influenced to make the business case as to why it is important, and it is finally happening.” 

Key recommendations from “The Future of Nursing: Leading Change, Advancing Health”

1) Remove scope-of-practice barriers.
2) Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. 
3) Implement nurse residency programs.
4) Increase the proportion of nurses with a baccalaureate degree to 80% by 2020. 
5) Double the number of nurses with a doctorate by 2020.
6) Ensure that nurses engage in lifelong learning.
7) Prepare and enable nurses to lead change to advance health. 
8) Build an infrastructure for the collection and analysis of interprofessional healthcare workforce data.

Source: http://news.nurse.com

Jonathan Winston Jones

The disconcerting news was the doctor had to Google the issue first to figure out the best medical advice.

"My provider just did a Web search to figure out what dose of hormones I should be on, and put me on the highest dose," Sallans said. That could have been a dangerous choice. "Starting too high of a dose too quickly can cause a lot of health problems, particularly to cardiovascular health."

Fortunately, Sallans didn't have any health complications.

But his experience left him with a mission. He volunteers to speak with medical institutions, as well as with businesses and colleges, to urge them to be more LGBT inclusive. 

While a growing number of medical schools are teaching future doctors how to address health concerns that can be specific to the lesbian, gay, bisexual and transgender communities, studies show current doctors only get about five hours of training, if they get any at all.

For members of the LGBT community who live in more rural and conservative areas like Nebraska, the struggle to get good, or at least up-to-date, medical care may be even more difficult. 

In general, legal protections and institutional supports for LGBT Nebraskans are already thin, spotty or nonexistent.

On March 2, the United States District Court struck down Nebraska's ban on marriage for same-sex couples, but that ruling is on appeal. 

Without the legal institution of marriage, LGBT Nebraskans typically lack family health benefits, unless their employers provide them to same-sex partners.

A 2014 study from the Williams Institute at the University of California Los Angeles found that states without LGBT legal protections in place see lower rates of health insurance coverage for LGBT residents than states with protections.

That plays out in Nebraska. 

A 2014 study from researchers at the University of Nebraska Omaha found that LGBT residents in the rural parts of the state have lower rates of health insurance coverage than their counterparts in urban areas. 

Even when LGBT Nebraskans have health insurance, they struggle to find providers versed in lesbian, gay, bisexual and transgender heath care needs. 

Research shows that LGBT individuals often experience health issues linked to being regular targets of discrimination or social stigma. Discrimination has been linked to higher rates of substance abuse, suicide and stress-related illnesses, which can include heart problems, obesity, eating disorders and cancer. 

If the available doctors are not familiar with the increased rates of these issues, they may provide inadequate care.

Patients who find their doctors do not understand their issues may also delay treatment, often with bad health outcomes, said Jay Irwin, an assistant professor of sociology at the University of Nebraska-Omaha and a researcher in LGBT health. 

Sometimes patients are turned away by providers who don't want to treat LGBT patients, particularly if there are no laws to prohibit such discrimination. 

Irwin has completed studies that focus on the health care challenges of lesbians in rural areas and found that many people feel isolated and are afraid to come out -- or risk discrimination in the medical office.

Nebraska's sheer size doesn't help. Sixteenth largest in the nation by geography, members of its LGBT community often live far from large cities with significant LGBT populations and with teaching hospitals with staff members who have experience working with members of that community.

The Human Rights Campaign's 2014 Healthcare Equality Index named four Nebraska health care facilities, all in Omaha, as leaders in LGBT health care equality. 

Omaha is on the state's eastern border with Iowa. LGBT residents in western Nebraska -- for instance, places like North Platte -- have to travel 270 miles in either direction, to Omaha or Denver, Colorado, to reach facilities designated as leaders by the Human Rights Campaign. 

People who work within the health care system have seen some improvement when it comes to treating members of the LGBT community. 

Jill Young is the client services manager at Nebraska AIDS Project's Scottsbluff, Nebraska, office in the western part of the state.

She recalled when she started working there in the late 1990s she saw medical staff refuse care to LGBT people with HIV/AIDS. 

"We had nurses, for example, who said they wouldn't serve patients with HIV/AIDS," Young said. "But we've come a long way since then." 

Young has seen more hospitals in the region adopting policies that are supportive of LGBT residents, including one that just started recognizing same-sex partners' wills as legal documents that will allow them access to their partners when they are being cared for in areas restricted to immediate family only.

But she said she still sees too many LGBT residents traveling great distances to get care and she still sees too many patients who don't seek medical care until it is too late. 

"We still go to the hospital," she said, "and see people who are days away from dying."

Eric Yarwood, 44, has more experience than he would like with Nebraska's health care facilities. 

He spent over 100 days last year at hospitals in Omaha for complications related to germ cell cancer.

He had nine rounds of chemotherapy, three stem cell transplants, his third surgery two weeks ago and five more days for followup last week. 

For all but four of the days he was in the hospital, his partner, Aaron Persen, 36, was at his side every evening. "Aaron and I are a unit," Yarwood said. "I can count on my fingers the number of times he didn't come." 

While the couple has found the overwhelming majority of physicians and medical staff to be "genuinely supportive" of their relationship, there still were a few instances when they felt uncomfortable and unaccepted, once with a physician and another time with a nurse. 

"I'm not sure how often the medical staff works with gay couples or receives training on how to work with gay couples," Yarwood said. 

Yarwood's prognosis is good, and the couple looks with optimism to a future of having more access to LGBT-inclusive health care facilities and a more inclusive state overall. 

"Hopefully, by the time we get through the cancer and save a little money," Persen said, "Nebraska will follow most other states and allow our relationship to be legally recognized."

Source: www.cnn.com

Liberia released its last Ebola patient, a 58-year old English teacher, from a treatment center in the capital Thursday, beginning its countdown to being Ebola-free.

"I am one of the happiest human beings today on earth because it was not easy going through this situation and coming out alive," Beatrice Yardolo said after her release.

She says she became infected while caring for a sick child.

"I was bathing her. I used to carry her from the bathroom alone because nobody wanted to take any risk. That is how I got in contact," she said.

Yardolo, a mother of five, said she had been admitted to the Chinese-run Ebola treatment center in Monrovia on Feb. 18.

"I am so overwhelmed because my family has been through a very difficult period from January to now. And to know that it's all coming to an end is a very delightful news. I'm so happy," Yardolo's son, Joel Yardolo, told reporters.

Tolbert Nyenswah, assistant health minister and head of the country's Ebola response, says there are no other confirmed cases of Ebola.

"For the past 13 days the entire Republic of Liberia has gone without a confirmed Ebola virus disease," Nyenswah told reporters. "This doesn't mean that Ebola is all over in Liberia."

After a 42-day countdown - two full incubation periods for the virus to cause an infection - the country can be declared Ebola-free. Officials are monitoring 102 people who have been in recent contact with an Ebola patient.

Since the epidemic started a year ago, Liberia has recorded 9,265 cases of Ebola, with 4,057 deaths. But the World Health Organization says there are almost certainly more cases than that. WHO says close to 24,000 cases have been recorded, and close to 10,000 deaths, in the entire West African epidemic.

-- The Associated Press and Reuters contributed to this story

Source: www.nbcnews.com

  PAULA SPAN

What she wanted, the patient told the geriatricians evaluating her, was to be able to return to her condominium in Boston. She had long lived there on her own, lifting weights to keep fit and doing her own grocery shopping, until a heart condition worsened and she could barely manage the stairs.

So at 94, she consented to valve replacement surgery at a Boston medical center. “She never wanted to go to a nursing home,” said Dr. Perla Macip, one of the patient’s geriatricians. “That was her worst fear.”

Dr. Macip presented the case on Saturday to a meeting of the American Academy of Hospice and Palliative Medicine. The presentation’s dispiriting title: “The 30-Day Mortality Rule in Surgery: Does This Number Prolong Unnecessary Suffering in Vulnerable Elderly Patients?”

Like Dr. Macip, a growing number of physicians and researchers have grown critical of 30-day mortality as a measure of surgical success. That seemingly innocuous metric, they argue, may actually undermine appropriate care, especially for older adults.

The experience of Dr. Macip’s patient — whom she calls Ms. S. — shows why.

Ms. S. sustained cardiopulmonary arrest during the operation and needed resuscitation. A series of complications followed: irregular heartbeat, fluid in her lungs, kidney damage, pneumonia. She had a stroke and moved in and out of the intensive care unit, off and on a ventilator.

After two weeks, “she was depressed and stopped eating,” Dr. Macip said. The geriatricians recommended a “goals of care” discussion to clarify whether Ms. S., who remained mentally clear, wanted to continue such aggressive treatment.

But “the surgeons were optimistic that she would recover” and declined, Dr. Macip said.

So a discussion of palliative care options was deferred until Day 30 after her operation, by which time Ms. S. had developed sepsis and multiple-organ failure. She died on Day 31, after life support was discontinued.

The key number here, surgeons and other medical professionals will recognize, is 30.

Thirty-day mortality serves as a traditional yardstick for surgical quality. Several states, including Massachusetts, require public reporting of 30-day mortality after cardiac procedures. Medicare has also begun to use certain risk-adjusted 30-day mortality measures, like deaths after pneumonia and heart attacks, to penalize hospitals with poor performance and reward those with better outcomes.

However laudable the intent, reliance on 30-day mortality as a surgical report card has also generated growing controversy. Some experts believe pressures for superior 30-day statistics can cause unacknowledged harm, discouraging surgery for patients who could benefit and sentencing others to long stays in I.C.U.s and nursing homes.

“Thirty days is a game-able number,” said Dr. Gretchen Schwarze, a vascular surgeon at the University of Wisconsin-Madison and co-author of an editorial on the metric in JAMA Surgery. Last fall, she led a session about the ethics of 30-day mortality reporting at an American College of Surgeons conference.

“Surgeons in the audience stood up and said, ‘I can’t operate on some people because it’s going to hurt our 30-day mortality statistics,’” she recalled. The debate is particularly urgent for older adults, who are more likely to undergo surgery and to have complications.

Those questioning the 30-day metric point to potential dilemmas at both ends of the surgical spectrum. Surgeons may decline to operate on high-risk patients, even those who understand and accept the trade-offs, because of fears (conscious or not) that deaths could hurt their 30-day results.

At a hospital in Pennsylvania, for instance, a cardiothoracic surgeon declined to operate on a man who urgently needed a mitral valve replacement. He wasn’t elderly, at 53, but he was an alcoholic whose liver damage increased his risk of dying.

Dr. Douglas White, the director of ethics and decision-making in critical illness at the University of Pittsburgh School of Medicine, was asked to consult. According to Dr. White, the surgeon explained that “we have been told that our publicly reported numbers are bad, and we have to take fewer high-risk patients.”

Other surgeons at the hospital, under similar pressure, also refused. A helicopter flew the patient to another hospital for surgery.

An outlier case? A study in JAMA in 2012 compared three states that require public reporting of coronary stenting results to seven nearby states that didn’t report. Older-adult patients having acute heart attacks had substantially lower rates of the stenting in the reporting states. Doctors’ concerns about disclosure of poor outcomes might have led them to perform fewer procedures, the authors speculated; they might also have weeded out poorer candidates for surgery.

Perhaps as important for older people, when things go wrong, surgical teams concerned about their 30-day metrics may delay important conversations about palliative care or hospice, or even override advance directives.

“There are no good published studies on this, but it’s something we see,” Dr. White said. “Surgeons are reluctant to withdraw life support before 30 days, and less reluctant after 30 days.”

That may have been what happened to Ms. S. Or perhaps her aggressive treatment resulted from a surgical ethos that has little to do with mortality reports.

“We want to cure patients and help them live, and we consider it a failure if they don’t,” said Dr. Anne Mosenthal, who heads the American College of Surgeons committee on surgical palliative care.

With surgeons already prone to optimism and disinclined to withdraw life support, the effect of reporting failures, if there is one, is subtle. Surgeons tell themselves, “Maybe if we wait a little longer, he’ll improve; there’s always a chance,” Dr. Mosenthal said.

But many older patients, and their families, have different ideas about what makes life worth sustaining and might welcome a frank discussion before a month passes.

“The 30-day mortality statistic creates a conflict of interests,” said Dr. Lisa Lehmann, an associate professor of medical ethics at Harvard Medical School. “It can lead to the violation of a physician’s duty to put patients’ interests first.”

Leaders at the nonprofit National Quality Forum, which just endorsed 30-day mortality as a measure for coronary bypass surgery, find such fears overblown. The forum evaluates quality measures for Medicare and other insurers, and went ahead with its endorsement despite some physicians’ objections.

“There is some concern,” said Dr. Helen Burstin, the chief scientific officer of the forum, but “certainly no evidence” that the metric is unduly influencing patient care.

“Is it better not to measure and compare, just because we can’t get it perfect?” added Dr. Lee Fleisher, a co-chairman of the forum’s surgery standing committee.

But critics think other quality measures might serve better. Perhaps the benchmark should be 60- or 90-day mortality. Perhaps patients having palliative surgery to relieve symptoms should be tracked separately, because comfort is their goal, not survival.

Maybe quality should include days spent in an I.C.U. or on a ventilator, Dr. Schwarze said.

“Medicine isn’t just about keeping people alive,” she said. “Some of it is about relieving suffering. Some of it is about helping people die.”

Source: www.nytimes.com

A University of Missouri nurse researcher is working to ensure people who use hearing aids for the first time are not bombarded by sounds that could be overwhelming and potentially painful. 

Individuals who wear hearing aids for the first time can potentially hear sounds they have not heard in months of even years, according to a University of Missouri news release on the research. The study, published online Dec. 17, in the journal Clinical Nursing Research, looked at the feasibility and initial effect of Hearing Aid Reintroduction to assist people 70 to 85 years old to adjust to hearing aids.

Some of the noises hearing aids enable their users to hear are not always easy to embrace, researchers found. These include air conditioners, wind and background conversations which can be annoying, painful and tough to ignore, the release said.

Kari Lane, PhD, RN, MOT, assistant professor of nursing at MU Sinclair School of Nursing, studied a group of elderly adults’ satisfaction with hearing aids after participating in HEAR, according to the release. Study participants recorded the total time they wore hearing aids for 30 days. Participants gradually increased the amount of time they wore the hearing aids and the variety and complexity of sounds they experienced, including household appliances or sounds from crowded areas, the release said. 

“Hearing loss is a common health problem facing many aging adults that can have serious effects on their quality of life, including heightened chances of depression and dementia,” Lane said in the release. “Hearing aids are not an easy fix to hearing loss. Unlike glasses, which provide instant results, it takes more time for the brains of hearing-aid users to fully adjust to the aids and new sounds they could not hear before.”

All participants at the start of the research reported being unsatisfied with their hearing aids, Lane said. At the end of the study, more than half of participants reported being able to increase their hearing aid use and 60% of them said they were satisfied with their hearing aids, the release stated. 

“It is common practice for audiologists to have their patients wear hearing aids all day when they first buy them, but not all persons are able to do this comfortably,” Lane said in the release. “Prior research shows there is a need for alternative ways to teach people how to use hearing aids like the HEAR intervention, which allows hearing-aid users to gradually adjust to using the aids while receiving support and coaching from health professionals and family members.”

Healthcare providers should give patients guidance on conditions they might experience during the aging process, such as hearing loss, according to the release. Such proaction could help to reduce the stigma surrounding hearing aids, Lane said. 

“If healthcare professionals begin discussing hearing loss with their patients sooner, before problems arise, the use of hearing aids could be normalized, and individuals would be better prepared for the transition when it is time for them to begin use,” Lane said in the release. 

Source: http://news.nurse.com

EMILY SHAPIRO

A nurse who contracted Ebola at the Dallas hospital where she worked plans to sue the hospital's parent company, Texas Health Resources, hoping to be a "voice for other nurses," her lawyer said today.

In the suit, which Nina Pham plans to file Monday, the 26-year-old nurse alleges that Texas Health Presbyterian Hospital didn't train the staff to treat Ebola and didn't give them proper protective gear, which left parts of their skin exposed, her lawyer Charla Aldous said.

"One of the most concerning things about the way [the hospital] handled this entire process is you've got a young lady who has this disease which she should not have. And if they properly trained her and given her the proper personal protective equipment to wear, she would not have gotten the disease," Aldous said.

Aldous said Pham hopes the suit will "help make sure that hospitals and big corporations properly train their nurses and healthcare providers."

"This is not something that Nina chose," Aldous said, but "She's hoping that through this lawsuit she can make it a change for the better for all nurses."

Pham is still coping with Ebola's after-effects, including nightmares and body aches, her lawyer said.

"She has not gone back to work yet and she is working on recovering," Aldous said. "I don't know if she'll ever be a nurse again."

Texas Health Resources spokesperson Wendell Watson said in a statement: "Nina Pham bravely served Texas Health Dallas during a most difficult time. We continue to support and wish the best for her, and we remain optimistic that constructive dialogue can resolve this matter."

Last fall, Pham cared for Liberian native Thomas Eric Duncan, who flew to the U.S. and was diagnosed with Ebola at Texas Health Presbyterian Hospital.

Pham took care of Duncan when he was especially contagious, and on Oct. 8, Duncan died from the virus.

Pham tested positive for Ebola on Oct. 11, marking the first Ebola transmission on U.S. soil.

On Oct. 16, Pham was transferred to the National Institutes of Health's hospital in Bethesda, Maryland. She was discharged on Oct. 24.

At the news conference announcing Pham's discharge, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the NIH, said she tested negative for Ebola five times, and that it wasn't clear which treatment saved her because they were all experimental.

"I want to first tell you what a great pleasure and in many respects, a privilege ... to have the opportunity to treat and care for and get to know such an extremely courageous and lovely person," Fauci said, adding that she represents the health care workers who "put themselves on the line."

Pham's dog, Bentley, was also quarantined for several weeks, over fears that he, too, would develop Ebola.

Source: http://abcnews.go.com