Our podcast today is with Cindy McPhee, RN. Cindy McPhee has been a registered nurse for over 33 years. She attended Youngstown State University and graduated with an associate degree in registered nursing. After passing the NCLEX-RN, she began working as an OR nurse. In her career, Cindy trained as a Circulating Nurse, Scrub Nurse, and First Assistant.
In her interview today Cindy answers questions about her OR experience and also explains the role of registered nurses (RNs) and licensed practical nurses (LPNs) in the operating room.
Cindy’s responses to our questions provide insight on the following topics:
The courses involved in training for the operating room.
How experience could be gained.
The responsibilities of an RN or LPN in the operating room.
The difference between a scrub nurse and a circulating nurse.
The types of surgeries an OR nurse might participate in.
What they don’t show on television.
What school may not prepare an OR nurse for.
The best nursing degree to obtain if you want to work in the OR.
Cindy mentions LPNs, RNs, and surgical technologists as part of various surgical teams. If you’d like to learn more about any of those careers, check out the following articles:
Interested in becoming a healthcare professional – nurse, surgical technologist or perhaps a surgeon? Learn, enhance or perfect your skills with one of these kits.
The Apprentice Doctor® Phlebotomy Course and Kit is a resource that will teach you how to confidently perform phlebotomy procedures in a couple of hours! If you want to become a great medical professional – why not learn how to perform venipuncture procedures now?
The Apprentice Doctor® Academy has also developed and perfected an Online Course for Future Doctors to assist then towards fulfilling their dreams of becoming great medical professionals. The For Future Doctors Foundation Medical Online Course with accompanying Medical Kit has helped launch the career of thousands of want-to-be doctors!
I really want to become a Doctor – Is there anything I can do straight away?
The day was going relatively well. I had just closed a heartfelt texting conversation with my friend, who was wonderfully in a good mood, and I had moved on to studying my venipuncture course. Short Notes On Other Bodily Fluids. Complications.
I was reading about catheter related infections when the phone rang, and it invited me to go over to my grandmother’s apartment.
“You can check my glucose level and I’ll tell you how much insulin to give me.”
“Great. Coming.”
Five minutes later I was at her door, jacket been put on, block been walked, elevator been ridden, and door been knocked on.
“Hello doctor!”
(Not quite)
I set up her lancet device, swabbed her preferred finger, and,
“1-2-3”
Prick
Blood(!)
I let the blood drop onto the disposable blood glucose test strip, and mission accomplished!
Okay, let me not hide the honesty. There was an “ERROR,” but an easy one to correct. I squeezed some more blood, victory in town. She told me how much insulin to draw up, and I did just that, while she–with her many years of efficient experience–revealed her abdomen and wiped it with an alcohol prep swab. After another round of-
“1-2-3”
Prick
(No blood)
The needle went in and I was as happy as my shoes were when I took them off after a five-mile jog (that never happened). I even remembered to aspirate! (That is only an accomplishing excitement in my brain.)
She thanked me and I thanked her. She was relieved that I’d be of assistance if she ever needed my help. I was happy to get to prick actual flesh.
On the way home, less in a rush than before, I realized how privileged and superior it was to actually get to administer a subcutaneous injection before receiving a diploma or degree. (Unless you count elementary school graduation.) (Don’t count elementary school graduation.) And that even if I won’t get to be a real doctor, but hopefully something in healthcare one day, this put a warm smile on my face and bubbled up my insides. And I am thankful that I was able to do at least that (…for now).
I can imagine how pathetic this must sound to anyone who has ever done anything more amazing than this, but this is my start and I like it. Because it’s one such prick that wraps up an average day in a big glitter bow and sunny smiles. And it’s an incident like this that puts you to sleep with a smirk and an imaginary victory dance.
Written by B Green
I really want to become a Doctor – Is there anything I can do straight away?
Does technology put your health at risk? There are seven ways it could be.
Light from your devices could impact your sleep and make you more hungry when you normally wouldn’t be.
Eye strain, neck, and shoulder pain are common complaints of people who use computers for long hours.
Use of social media and spending time surfing the net can create depression and anxiety in some people.
Headsets, as great as they are, can contribute to hearing loss.
The good news is that there are simple, inexpensive hacks to combat each of these problems so you can continue to use and benefit from all your technology.
Can technology really put your health at risk?
In the early 60s, The Jetsons, a space-aged cartoon pulled kids to television sets on Saturday mornings. The futurist gadgets the family used inspired wonder and possibilities. Today many technologies shown in the animation exist. Most of us own them and use them. They are a natural part of our lives. But does technology put your health at risk? Research seems to indicate it does.
Listed are 7 ways digital technology may destroy your health. All 7 lead to rising costs of healthcare. But we’re giving you 7 easy prevention hacks, too. Implementing all of them can safeguard your physical well-being.
1. Sleep Deprivation
Being fully present during your waking hours means nabbing at least eight hours of sleep. However, many of us only grab six hours or less. The presence of digital technology in almost every room of the house discourages sleep. Bright light interrupts sleep patterns because it reduces the amount of melatonin the body produces. Without melatonin, you remain alert. In turn, this shifts your body’s natural sleep rhythms, keeping you tossing and turning.
Night-lights, television light, or the glow emitted from your digital clock all contribute to sleep deprivation.[1] Using a night mask is an excellent way to block sleep-impairing light. If you don’t like anything covering your eyes, try leaving your phone or laptop in another room at bedtime. Make your bedroom a device-free zone. Turn off the television before burrowing under the covers. Both actions are quick, no-cost steps you can take to catch an extra hour or two of sleep.
2. Weight Gain
The same light that disrupts sleep also makes you hungry. So when working on digital devices, there’s a tendency to snack. Eating while sitting at a computer may cause you to snack more, especially if you’re looking at pictures of food.[2] In 2014 Stanford University conducted a National and Nutritional Examination Survey. Researchers found that the percentage of inactive women in American rose from 19.1 to 51.7 between the years of 1994 and 2010. During that same time, the rate of inactive American men rose from 11.4 to 43.5 percent.[3] With the increase in device use, that number could get higher.
Not even today’s technology has found a way to burn excess calories without exercise. Sitting more and moving less almost always results in weight gain.
Flip your technology into a healthcare benefit. Hundreds of exercise routine apps are available on smartphones. Finding one that fits your personality and activity preferences, even if you travel a lot, is easy. The routine doesn’t have to be difficult or take hours of time. Thirty minutes a day can make improve your cardiovascular health more than you think. Through trial and error, you can find a favorite exercise app at zero to no cost. By offsetting some of your screen time with movement, you’ll be able to lose, or at least stabilize your weight.
3. Eye Strain
Most people spend five or more hours a day viewing digital screens. Did you know you forget to blink when working at a computer for extended periods? Research studies reveal blinking occurs ten times less than usual when sitting at a computer display. Lack of blinking deprives your eyes of necessary moisture.
Almost 7 out of 10 Americans who routinely use computers complain of eye irritations. Signs of strain include dry eye, burning, itching, and even blurred vision. Although most symptoms are temporary, they are uncomfortable and can lead to headaches.
Try these quick fixes. Adopt a 20/20/20 system. Set your smartphone for a 20-minute time block. When it buzzes, look away from your computer. Focus on something 20 feet across the room for 20 seconds. Then return to work and repeat the cycle. Another helpful activity is intentional blinking. Train yourself to blink, using your breathing pattern as a reminder. Blinking goes a long way toward keeping your eyes moist and pain-free.
4. Neck and Shoulder Pain
Most of us know leaning over laptops, smartphones or tablets for extended periods tightens the muscles between the shoulders. Even something as simple as tilting your head pulls tendons and ligaments in your back and neck.
An average adult head weighs anywhere from 10 to 12 pounds. When tilted toward a computer even 15 degrees, that weight increases to 27 pounds. If you bend it at a 30-degree angle, your back and neck support 40 pounds. Multiply that by five or more hours a day, and it’s not surprising many people go to the doctor for neck, back, and shoulder pain.
You can combat any pain, and even any poor posture working at a computer creates. When walking, pull back your shoulders and stand as straight as possible. Or, when you’re taking a vision break, shrug your shoulders. Moving your muscles in a different direction keeps you flexible and loose. Lastly, stretch your muscles by tiptoeing the fingers of each arm as far as you can slowly up a door jam. Do the same on the other side. The stretch feels amazing.
5. Depression
Does digital technology cause depression? Some research indicates it does. Other research suggests people who are lonely and possibly depressed, use digital technology more. In this case, digital technology primarily refers to social media outlets.
If you suspect your online time lowers your mood, ask yourself some simple questions. Do you feel sad, annoyed or even angry after reading postings? Does your body feel sluggish or tired when you’re interacting with sites? Do the lives of other people seem better than yours? If your answers are positive, they may suggest the amount of time you spend engaging in social media negatively impacts your mood.
The fix is little digital detox. Reduce the amount of time you spend reading posts. Another way is to “unfollow” people who are consistently negative. Avoid videos seeped in anger and other negative emotions. Verbal aggression, even on screen, can pull down your mood. The good news is that you have 100% control over your screen time and what you read or watch. By absorbing less, your outlook could improve. And you may find you have more energy and time to do other things that interest you.
6. Anxiety
Although the Internet provides a lot of useful information, can it put your health at risk? It can, especially if you are self-diagnosing suspected medical problems.
If you suspect something is amiss within yourself, a family member, friend, or pet, avoid rushing to the computer to look up symptoms. Researching medical difficulties is rarely a good idea for two reasons. The first is, if you don’t find the symptom(s), you may assume you’re fine. That could be true, but what if you’re not? On the other hand, what you learn could lead you to believe something is very wrong – even if you’re fine. Your stress and anxiety will increase because the human tendency is to conclude the worst.
If you think you are ill, take two simple actions to prevent excessive anxiety and possible panic. The first is: don’t research your symptoms. The second is: call your primary care provider and make an appointment for a proper diagnosis.
7. Loss of Hearing
The number one cause of hearing loss in America is excessive noise. According to the Hearing Health Foundation, the number of Americans experiencing hearing loss doubled between the years of 2000-2015. Sixteen percent of our teens complain about hearing loss.
Too much noise directly into your ears can cause damage to tiny hair cells inside the inner ear. These hair cells do not repair themselves, creating an irreversible hearing loss. Headphones are the primary culprits. Headsets for your computers, phones, and tablets direct all noise (no matter how much we enjoy the content) straight into your ears. They amplify sounds up to and above 85 decibels, which deteriorates your hearing.[4]
The prevention hack here is “noise-canceling” headsets. Simple earbuds can’t drown out sounds around you. So there’s an inclination to crank it up. From a healthcare standpoint, that means it’s probably too loud. Older, earmuff style models block out background noises and lower the volume. They may be big and a bit cumbersome, but they protect your hearing better.
Regardless of the headset you use, ensure your volume is set to a reasonable level. And take regular breaks from your headphones.
Don’t let technology put your health at risk. Protect your health from these 7 digital challenges with a few simple healthcare hacks. Then enjoy your technology without sacrificing your well-being.
The Apprentice Doctor® Academy has developed and perfected an Online Course for Future Doctors to assist them towards fulfilling their dreams of becoming great medical professionals. The For Future Doctors Foundation Medical Online Course with accompanying Medical Kit has helped launch the career of thousands of want-to-be doctors!
For those of you who’ve decided the healthcare field is right for you, enhance your skills with one of these kits.
The Apprentice Doctor® Suturing Course and Kit is a resource that will teach you How to Suture Wounds in a couple of hours! If you want to become a Surgeon or other medical professional – why not learn how to suture wounds now?
Value-based medicine is an upcoming healthcare delivery system centered on the patient, and patient outcomes.
The goals, gender, age, and even culture of the individual are taken into account.
Volume-based care, our current system of fee for services rendered, will be replaced over time.
Five factors drive value-based medicine. A primary one is the demand by patients to be more involved in the decisions affecting their health and wellness.
It’s expected that value-based care will result in better healthcare at lower costs.
The shift to value-based medicine has already started. For example, by 2018 the Department of Health and Human services plans on moving 50% of traditional Medicare payments to value-based models.
Implementation of value-based care will require a shift in how we think about and approach healthcare.
Value-based medicine is changing the landscape of the healthcare delivery system. It focuses on the goals of the patient and their perception of the value of care they receive. Payment to providers is based on how well they adhere to delivering value to the patient. As value-based healthcare takes root, medical professionals will be expected to provide evidence of outcomes before being paid.
Why change to value-based medicine?
In the United States and in many countries across the world, the value of the healthcare delivery system is proving inadequate to meets the needs of its primary constituency – the patients. This inadequacy is not malicious or intentional. Instead, it’s because over time, layers and layers of outdated systems have lagged behind trends and an ever-growing population. Even obsolete technology plays a factor. The result is skyrocketing costs for patients, healthcare professionals and medical organizations.
Currently, we operate in a volume-based healthcare system. In other words, we pay for individual services. For every visit, test, medication, and treatment we receive, we are charged. It is a reactive system centered on illness rather than wellness. Little attention is paid to outcome measures. Payment is made regardless of how the patient perceives or experiences the outcome.
What does volume-based healthcare look like? A case study
Let’s review an actual case study. In 2017 Sally went to her primary care physician for her annual physical. The sequence of events that followed was not only expensive, but kept her on the sidelines.
After a panel of blood work, Sally’s physician was concerned about a sluggish thyroid. To rule it out, or confirm it, he referred her to an endocrinologist.
The endocrinologist reviewed Sally’s blood work and dismissed the thyroid condition. But he noted she had low salt, something Sally had lived with her entire life without negative impact. The endocrinologist believed one of her medications was the cause. Over the next 21 days he switched her prescription three times. Over the same period of time the symptoms the original medication controlled all returned.
The continued changes in medication overloaded Sally’s body and landed her in the hospital for a 24-hour stay. When she was released, the hospital doctor put her back on her original pharmaceutical with the following advice, “Don’t fix what isn’t broken.”
From start to finish, Sally waded through 19 different services and seven different care providers. None of the medical professionals in Sally’s case intended the ineffective outcome. Each believed they were doing what was best for Sally. The real culprit was the disjointed care. No one person knew what the other was doing and Sally trusted that each step was necessary.
If the professionals had interacted with one another, Sally’s $10,000 hospital stay might have been avoided. Multiply that cost by thousands of people across the health care system experiencing the same type of disconnected care and you’ll end up with a staggering number. That’s the cost of volume-based case. In other words, each additional service anyone receives from allied health professions increases the amount, or volume of care, and the price tag.
Sally is not alone. The core of the healthcare delivery structure is not negligence. It is working within, and navigating a broken system built on lack of coordinated, patient-centered care.
How does value-based medicine differ from volume-based medicine?
Let’s continue with Sally’s scenario. In value-based care, Sally would have gone to her physical and had the lab work done. She may have been referred to an endocrinologist. However, at that point rather than paying for each service separately, Sally may have been quoted a bundled or an episode-payment. This is an all-inclusive reimbursement model where the initial visit, the services, and any subsequent visits would have been one fee. Complications resulting from a decision to switch out her medications three times would have been absorbed by him – not Sally and her insurance company.
Let’s take a look at a more straightforward scenario. If an orthopedic surgeon determines a patient needs a knee replacement, in value-based medicine, a single fee for all the services associated with the knee replacement is quoted to the patient. The cost pays for the surgery, the pre- and post-operative visits, the physical therapy, hospital stay, tests, etc. If something happens and the patient has to be readmitted (within a specific and reasonable length of time), the additional cost is on the provider – not on the patient. Payment is not based on each service, but instead upon ensuring the patient is well and returned to the best state of health possible. The health of the individual is the evidence-based outcome measure, which has high value, especially to the patient. The individual gets the best health care at the lowest cost. When the focus is on the individual and their needs rather than on multiple services, patient satisfaction increases and outcomes improve. Costs decrease.
The shift to value-based medicine is driving both public and private payers to redesign payment models. There are several options under review, but all stress accountability for high quality care and lower healthcare costs.
The Boston Consulting Group created an engaging, five-minute video presenting what healthcare looks like now and compares it to the value-based care of the future. Take a look here: Value in Healthcare – A Case for Change.
What is driving value-based medicine?
Five factors are contributing to the shift into value-based medicine.
Advocacy – Patients want to be more involved in managing their healthcare. Healthcare specialists must take time to listen to their patients and respond to them with all the information available.
Demographics – There is an increase in the number of people 65 and older (baby boomers) who need healthcare.
Diseases – An increase in chronic diseases and conditions around the world requires better delivery of healthcare.
Resources – Lack of resources, or inadequate resources drive up costs while pressure is applied to keep them down. Overall there is a shortage of skills and healthcare staff such as nurses.
Trust – Currently patients trust their healthcare professionals less and less. Fewer and fewer patients are willing to follow instructions blindly. As adults, and the ones footing some of the bills, they want rationale.
What does value-based medicine mean for patients?
Although no system is perfect, the current system can improve. Value-based healthcare is seen as a step in the right direction. A more patient-centric approach will result in:
Better healthcare for you and your family.
Clear and more transparent communication with you.
Closer attention to you as an individual. Consideration is given to your culture, gender and age. Healthcare is no longer one-size-fits-all.
Focused insistence on proper nutrition. Better nutrition leads to healthier lifestyles, generating improved health outcomes.
Healthcare teams managed by coordinators. You’ll no longer have to coordinate everything yourself.
Lower costs for everyone.
Partnerships between you and your healthcare provider(s).
Technology that connects your medical records with other allied health professions involved in your care.
Can value-based care be delivered in a volume-based system?
Medical professionals, and patients, can achieve a measure of value-based care in today’s service-rich system. High-value care can be delivered without fixing the entire system.
For physicians, focusing on the patient requires thoughtful intention. Although there are many ways a patient-centered approach can be accomplished, here are three.
Include the patient in the standard of care – Involve the individual in decisions. Listen to what she or he has to say. Take into consideration gender, culture, and even personal preferences.
Coordinate medical services centrally – Help patients navigate the system by assisting them with the coordination of multiple services and care providers. An integrated effort facilitated by someone in the medical system improves the quality of care. It also may return patients to the best level of health possible in less time.
Be transparent – Many times patients feel they don’t have all the information. Provide honest, clear communication on their status, progress, and prognosis. Promote prevention when possible.
Thoughtful intention is also required by patients. Here are four ways individuals can help.
Be ready with your questions – Be specific when possible.
Ensure you have your answers – Leaving a doctor’s office without them creates unnecessary frustration and may result in additional visits.
Move on with your day – Once you know your next steps, it’s important to exit. It may be tempting to socialize, but you’re partnering with your doctor in a professional capacity, not as a close friend.
Follow through – Embrace wellness by following through with medical advice and recommendations. You’ll feel better and may need to see a medical professional less.
Value-based medicine is a partnership. Physicians and patients have to work together as a team toward the common goal of better outcomes. With better outcomes, everyone wins.
What does value-based medicine mean for next-generation doctors?
Value-based medicine will change the future of healthcare. It is likely that future doctors will work in some kind of value-based medical system. For example, by 2018 the Department of Health and Human Services plans to move 50% of traditional Medicare payments to value-based models.[1] By 2020 Aetna plans on having more than 75% of their reimbursements going to doctors and hospitals practicing value-based care [2]. Even medical education will train both students and faculty in quality and safety improvements as well as the broader implications of value-based medical management. Future doctors will need to:
Act with the highest levels of integrity, keeping the patient in the picture.
Communicate with transparency to the patient and the patient’s family.
Embrace the use of technology and analytics.
Encourage innovation and keep striving for it.
Expect higher levels of accountability for outcomes. Doctors will sign off on results rather than number of services.
Form improved and more effective partnerships between the public and private sectors. Consider retailers, and financial and IT organizations as viable healthcare partners.
Improve upon the value, cost and quality of healthcare.
Lead cross-disciplinary teams.
Promote wellness and prevention, including a stronger focus on nutrition as prevention.
Seek additional education to keep up with skills, technology and other advances in medicine.
Try new ideas.
View continued education as a way to genuinely improve skills rather than CEU boxes to be checked.
To see how an IT entrant into the field of medicine is approaching value-based healthcare through technology, take a look at Forward in Silicon Valley. The levels of individual, patient-centric care they achieve through the use of high tech may surprise you.
Where does value-based medicine go from here?
Value-based care is not bad news. It merely means that the primary focus of healthcare shifts to high quality and wellness care, including prevention, rather than illness. It also redefines the use of medical technology outside hospitals. Acceptance of new players into the healthcare field is a must.
Perhaps the first step and one today’s doctors can take immediately includes gaining the cooperation of the patient. By establishing bona fide partnerships with each individual in their care, physicians can improve what is now fading trust. Trust is one of the primary pillars of strong healthcare values.
If you’d like to see how a hospital organization transformed their system from volume-based care into value-based care, take a look at what Sweden’s Karolinska University Hospital did. Karolinska’s New Operating Model – Value-based care.
Can you begin your career to becoming a value-based medicine health professional today?
Indeed yes!
The Apprentice Doctor® Academy has developed and perfected an Online Course for Future Doctors to assist them towards fulfilling their dreams of becoming great medical professionals. TheFor Future Doctors Foundation Medical Online Coursewith accompanying Medical Kit has helped launch the career of thousands of want-to-be doctors!
The Apprentice Doctor® Phlebotomy Course and Kit is a resource that will teach you how to confidently perform phlebotomy procedures in a couple of hours! If you want to become a great medical professional – why not learn how to perform venipuncture procedures now?
The Apprentice Doctor’s Venipuncture Practice Arm helps you gain the experience needed to become a Phlebotomist. The phlebotomy training simulation arm is perfect for phlebotomy instruction and student use for real hands-on learning with phlebotomy procedures.
Medical students drop out of medical school for any number of reasons. Behind each medical student who makes this difficult decision is a name, a face, and a personal story. Starting and completing medical school is a commitment that can last anywhere from eight to ten years in the United States. During that time life circumstances can change in unexpected ways. The quantity of possible changes is why it can be challenging to pinpoint primary reasons for medical school attrition. However, homesickness, financial concerns, and lack of adequate academic preparedness can contribute to someone dropping out of medical school. Other reasons include absenteeism, feelings of displacement, and overall depression.
Nevertheless, there remains a core of 7 serious reasons medical students drop out of medical school.
Less than 15% of students applying to medical school will be accepted (the figure varies from one medical school to the next – here are the figures as in October 2020 as per individual medical schools). Before choosing medical studies and a medical career, assess your vulnerability to all seven reasons. You may not be able to prevent some of them from happening, but by being aware, you may be able to plan what to do should you encounter any of them.
1 – Changes in life circumstances
Medical students spend anywhere from eight to ten years in medical school.[3]. Your life circumstances at enrollment may change as you progress through different levels of medical studies. Once you finish high school, you’ll have four years of pre-med curriculum at a college or university. This is followed by medical school and then a residency and/or fellowship period.
Think about the last ten years of your life. Is anything the same today as it was ten years ago? Or even five years ago? Entering medical school doesn’t stop life from happening, so you have to make adjustments along the way. Sometimes events in your life can negatively impact your ability to stay in medical school. Finances, the death or severe illness of a family member, or even falling in love are all things that can pull you away from staying in school. Before starting medical school, be sure you have sufficient support, whether that is financial, emotional or both, to get you through moments that may be more challenging than others.
2 – Academic capacity
Academic capacity does not necessarily refer to someone’s academic or intellectual ability. It can mean anything from insufficient academic preparedness in high school and college to an inability to retain sufficient amounts of difficult and complicated material.
The Medical College Admission Test® (MCAT) does a credible job of measuring someone’s “academic ability to be successful in medical school. It assesses problem-solving, critical thinking and knowledge of natural, behavioral, and social science concepts and principles prerequisite to the study of medicine.” (https://students-residents.aamc.org/applying-medical-school/taking-mcat-exam/about-mcat-exam/) By passing it, medical schools know you have the capability needed to become a successful medical student. But this admissions test is not foolproof, nor does it measure your stamina to deal with stress, long periods of study and the other pressures of medical school.
Assessing your academic preparedness
When considering your academic preparedness, take a look at your high school and college curriculum. Did you take a lot of science, biology and chemistry courses? If not, it’s possible your science foundation is not strong enough to enter medical school.
How are you at sitting for long periods of time and absorbing vast amounts of information? While aspects of learning can be enjoyable, the main reason for going to medical school is to learn to practice medicine. Some students enroll only to find, after struggling for a while, that they can’t assimilate all the material. If you are to absorb all the academic material, you must have consistent high levels of focus. You must also be willing to sacrifice personal time in favor of study time.
This kind of requirement leads to intensive studying regimes over prolonged periods of time. In many cases the result is burnout, loss of focus, and even depression. This was also confirmed by a recent study, “Burnout and serious thoughts of dropping out of medical school: Multi-institutional study”[4]. A serious loss of focus and feelings of depression lead to poor academic performance and, in many cases, dropout.
Even if you’re good at a variety of subjects, studying content such as anatomy, physiology, pathology, microbiology, biochemistry, and pharmacology, may prove to be extraordinarily difficult to even the most dedicated medical students.
Talking to a medical school dean or director and reviewing your curriculum first can help you assess your foundation. Further discussion with this same person can help you determine what changes in study habits and life style you may need to prepare for to be a successful and ongoing medical student.
3 – Working part-time to pay tuition fees
When entering medical school, you may have no financial concerns. But over time a previously worry-free financial condition may change into one fraught with anxiety. Worries about money and paying for tuition can impact your focus on classes and clinical work. Money concerns can create sleepless nights, poor nutrition, and even depression.
The Public Agenda Report[1] identifies tuition fees as one of the leading causes of medical students dropping out of school in the United States. Studying medicine is expensive and increases in tuition fees each year can be overwhelming, up to the point where you’re forced to drop out.
Medical students try to finding part-time jobs that can support the cost of medical studies. However, the rigor of medical school both in and out of the classroom makes it almost impossible to juggle both a job and the curriculum. Stress and worry mount until the day comes when there may be no choice but to exit.
4 – Absenteeism and leave of absence
There is little doubt that failure to attend classes, lectures and scheduled labs will result in more time studying and less comprehension about the content. The further behind a student gets, the more overwhelmed a student becomes until catching up feels hopeless. That’s when dropping out may occur.
As a medical student, although you are old enough to make your own decisions and determine your schedule, you are also old enough to make your own rules. Successful medical students make allowances for a social life but always put the classroom and homework first. You are paying for a medical school education. So skipping classes and not taking advantage of every opportunity to learn is throwing away that money. Medical students who remain in school and achieve academically sometimes view the link between tuition and education with a sense of consumer savvy. They are going to get what they are paying for. So they spend their time learning.
What is a leave of absence?
You may also hear of something called a leave of absence. A leave of absence is a period colleges, and universities allow students where they take a break from medical school. But they must return by a predetermined date. During a leave of absence, the stress and pressures of medical school are absent. Life is simpler and students frequently succumb to a more relaxed lifestyle and just don’t go back. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3565981).
When committing to medical school, controlling what you can control is often the difference between failure and success. Attendance rests with you. So, make a promise to attend all your classes. And, avoid taking any leave of absence.
5 – False perception of their medical specialty before enrolling
Favorite medical television shows, pressure from friends or family to enter what is perceived as a lucrative profession, or even inspiration from books and articles can spur you to go into medicine. You may also imagine yourself being a surgeon or oncologist because you like a specific character on television who performs that kind of work. While all these subtleties can lead you to making good choices about a medical career, they can also lead you into making those decisions without knowing how such a long-term goal is achieved. When we see doctors, even those on television, they are accomplished physicians. We forget they didn’t start out that way. They all began as students without any knowledge or experience.
Is becoming a medical student right for you?
So, how do you know if you’ll like medicine or not? One thing you can do is shadow someone in the field for a week or so. Get an idea of what it’s really like. Talk to the dean or the director of a medical school. See if you can audit a class. Interview some medical students. Most people are willing to help you by providing accurate information.
If none of those tasks are possible, consider your characteristics. Do you like studying for long periods of time? Is school something you enjoy? Does learning something new energize you? A “yes” to these questions are signs that you possess the right perspective to be successful in medical school.
Next, consider the physical demands. There are long hours of sitting and standing. There is a certain amount of stress to learn, compete and achieve. Social life is minimal. Are these sacrifices you can manage for multiple years? If so, you may be someone who can make it through medical school.
Lastly, consider your sensitivity to human anatomy. What is your response, or reaction, to needles? What about the sight of blood? If you’ve ever dissected anything, what was your reaction? You’re required to go to anatomy dissection halls, which are specific rooms filled with cadavers (human corpses) specially prepared for medical students’ practical classes. Some students are repulsed by the smell of certain chemicals like formaldehyde and human body parts, etc. Although continued exposure can desensitize some students, others can’t get past feeling ill. You have to figure out which kind of person you might be.
Occasionally students in medical school struggle with the dawning realization that they just don’t like it. Maybe they don’t have the right passion, or the motivation to become a doctor. Some students in this situation continue their studies, and incur additional expenses, even if they don’t like it. Pressure from family or fear of disappointing them contributes to this kind of a decision. But in most cases, without enjoyment or passion for the field, most students choose to dropout early in their studies.
6 – Lack of discipline and self-organization
When graduating from high school, you may have a general idea that college is a place to have fun and make lifelong memories. While this is true, you need to be aware that in medical school you are often pushed to your limit. To do well as a medical school student, you need to dedicate plenty of time, focus, and energy to study. If you are aiming at a competitive residency, such as neurosurgery, you will have to ensure that you are in the top 5% of academic excellence in your class.
As a medical school student, you must be very disciplined and well-organized to succeed. This is critically important for those medical students trying to balance work, family, and studies.
When enrolling in medical school, do so accepting the fact that you will have very little free time, especially during surgical rotations. If a carefree, fulfilled life is your preference, then pursuing a less demanding career path may be a better decision for you. Talking with friends and family who can be honest with you, and not project on you what they would do, can often help you make this significant decision.
7 – Behavioral related reasons: drug addiction, alcoholism, illegal activities, conviction
As unlikely as it seems, there is one final group of reasons that contribute to dropping out of medical school – chemical dependency, engaging in illegal activities to gain financing for studies, and potential legal issues, which may include one or more bouts with the criminal justice system.
Students may view these activities as ways to cope with the financial hardship, long hours, stress, and pressure inherent in medical school. Even if none of them cause a student to drop out, they can result in permanent expulsion from medical school, without forgiveness of any debt incurred.
Conclusion
Although these seven reasons can cause someone to drop out of medical school, awareness of them before starting can help you prevent some of them. Without awareness, they can sneak up on you and overtake you before you realize it. If that happens, one or more of them can be difficult to manage and overcome.
The Public Agenda Report found that 65% of medical school dropouts think about returning to college or medical school. They feel that they failed to accomplish something important in their lives by dropping out of school and want to return. However, life obligations sometimes prevent that from happening, and they experience a certain sense of loss and regret. They may like their second best career choice, but it may never measure up.
Although there are many challenges on the path to becoming a doctor, most physicians will tell you the ultimate achievement is well worth the sacrifices. There are very few professions that can give you both the personal and professional rewards that being doctor provides.
I want to become a doctor – Is there anything I can do right now to get started?
Absolutely!
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Overall, anesthetists, also known as anesthesiologists, are responsible for administering one of three different types of anesthesia to patients undergoing specific procedures that require numbing. It is critical to note that an anesthesiologist doesn’t merely assess the safety of anesthesia before, during, and after surgery, but also assesses the combined risk of anesthesia and the planned operation.
Types of anesthesia
Regional anesthetic – Regional anesthetic numbs a specific portion of the body. Cesarean sections are done with a regional anesthetic.
Local anesthetic – A local anesthetic blocks sensations in small areas. Dentists use local anesthesia when numbing a jaw or gums.
General anesthetic – A general anesthetic renders the patient unconscious.
An anesthesiologist in an operating room administers the anesthetic and is responsible for the ongoing, and overall well being of the patient throughout the operation. For example, after putting a patient to sleep, the anesthetist correctly positions the patient for the operation. Proper positioning provides the best visualization of, and access to, the surgical site while minimizing any physiological challenges to the patient. Positioning must also protect the patient’s skin and joints. During training, an anesthesiologist learns standard positioning practices that effectively reduce the chances of patient complications related to positioning.
An anesthesiologist must also monitor the patient throughout a surgical procedure. Monitoring tasks require the continual evaluation of the patient’s oxygenation, ventilation, circulation, and temperature throughout the procedure. If any of these falls outside acceptable ranges, an anesthesiologist must notify members of the surgical team immediately so appropriate intervention can be taken.
Basic principles of anesthesia
An anesthetic plan, also known as a perioperative plan, encompasses the following three phases:
Preoperative – before the surgery
Intraoperative – during the surgery
Postoperative – after the surgery
Patient needs, the experience of the anesthesiologist and the constraints of the proposed surgical procedure are addressed in a perioperative plan. In particular, a trauma anesthetic needs to be dynamic and responsive to rapid changes in patient condition.
Preoperative prior to an initial assessment
During a preoperative assessment, the overall fitness of the patient for the intended anesthetic and upcoming surgery is determined. Occasionally the urgency of the operation reduces the how long an anesthesiologist can spend with a patient. However, when surgery is scheduled, and the anesthetist can spend an appropriate amount of time with the patient, specific guidelines are followed that determine the patient’s readiness for the procedure. This includes uncovering any medical conditions which might impact the management of the selected anesthetic.
Some of the more common goals of a preoperative exam are [1]:
Assessment of the patient’s overall health status.
Development of an appropriate perioperative care plan.
Discovery of any conditions putting the patient at potential risk for complications during and after surgery.
Discussion of postoperative care, including pain treatments in the hope of reducing anxiety and promoting recovery.
Confirmation of the need for the surgery.
Education of the patient about the surgery, anesthesia, intraoperative care.
Preoperative after an initial assessment
With an initial assessment in hand, the anesthesiologist will review the plan for a patient’s upcoming surgery. The plan may include one, or more of the following items [2].
Anesthesia options (general, regional or local).
Pain management options after the surgery.
Risk of anesthesia for the patient given the type of surgery and any other medical conditions the patient may have (such as heart or lung disease).
Special circumstances that may require additional care or equipment (i., extra monitors, need for intensive care after surgery, etc.).
Length of time to fast (no eating or drinking) before surgery.
Review of patient’s medications, and nutrients, and if they can be taken prior to surgery.
If you’re wondering why a patient must fast before surgery, it’s because the anesthetic causes a patient’s muscles to relax, including the valves between the esophagus and the stomach, allowing stomach content to flow via the esophagus into the airways lungs. Stomach content is very acidic and contains enzymes that will digest the delicate lung tissue which then becomes a life threatening-situation.
Likewise, certain medications and nutritional supplements need to be avoided prior to surgery since they can affect bleeding and swelling during surgery. Some may also create blood clots, cause bruising or even prevent healing after surgery. So it’s important that the anesthesiologist receive a complete list of anything the patient is taking in order to minimize risk.
Intraoperative
The responsibilities of an anesthesiologist during the intraoperative phase are extensive. It is during this time that a patient under general anesthesia is unable to communicate, so the role of an anesthetist is vital if the safety, well-being, and health of the patient are to be safeguarded.
Although the following list is not all-inclusive, it does represent the duties of anesthesiologists during almost all surgeries.
Administer the appropriate anesthetic.
Continuously monitor vital signs including pulse, blood pressure, temperature, and respiration.
Control IV for intravenous fluids which control dehydration and allows the administration of medications through the drip.
Ensure the safety of the patient and take appropriate steps to avoid any injuries to the patient’s body during the anesthetic period.
Manage any anesthetic complications.
Monitor the level and depth of anesthesia; make adjustments as needed.
Perform blood transfusions when necessary.
Recognize potentially life-threatening emergencies and perform timely interventions.
Postoperative [3]
Ideally, the anesthesiologist visits the patient between 12-24 hours after surgery. By then the effect of the anesthesia has passed or nearly passed. If the postoperative visit was discussed with the patient during the preoperative assessment, the patient would be expecting this visit.
During postoperative care, the anesthesiologist watches for any signs of developing postoperative complications, as well as recovery from the anesthetic.
When conversing with a patient, an anesthesiologist may cover some of the following points:
Discovery of any side effects, including pain, the patient may be experiencing so that treatment can be delivered.
Inquiry about any awareness the patient may have undergone during the surgery.
Review of any complications related to the anesthesia that may have occurred.
Sometimes these conversations include questions about the overall satisfaction of the patient. Although these can be managed through impersonal questionnaires, a patient may be more candid if he or she speaks face-to-face with the anesthetist.
Types of anesthesiologists
According to the American Society of Anesthesiologists, there are several types of anesthetists. Each performs different tasks when part of an anesthesia care team. The positions are:
Physician Anesthesiologist – Highly skilled medical doctors who specialize in anesthesiology and are qualified to make anesthesia-related decisions for the period of time starting when the patient goes into the hospital and concluding when the patient is discharged.
Anesthesiologist Assistant – Skilled and certified healthcare professionals who are trained in the delivery and maintenance of anesthesia care and monitoring.
Nurse Anesthetist – The primary duties of nurse anesthetists are to provide anesthesia and related care before and after surgical, therapeutic, diagnostic and obstetrical procedures.
Disciplines in the field of anesthesiology
Like many other allied health professions, it is possible to specialize in certain surgical areas as an anesthesiologist. Anesthetic sub-specialties include:
Cardiac and thoracic surgery
Dental
Maxillofacial surgery
Neurosurgery
Obstetric surgery
Orthopedic surgery
Otolaryngology
Pediatrics
Plastic and reconstructive surgery
Trauma & emergency surgery
Intensive care medicine and pain management are two other sub-specialty areas, both of which involve a significant amount of work outside the operating room environment.
What are the advantages of anesthesiology as a career?
You may wonder if going into anesthesiology is the right career move for you. The following benefits are often part of job satisfaction.
Ability to focus on one patient at a time – Although you may have a number of surgeries scheduled, when the surgery is over, your interaction with the patient is completed, allowing more focus on the patients you have since the relationships aren’t ongoing.
Financial security – In most countries anesthetists are in high demand assuring a financially rewarding career.
Free time – Anesthetists/anesthesiologists often rotate on an emergency after-hours roster, giving them free time to spend with their families. It is also relatively easy to work on a part-time or even a standby basis which provides opportunities for extended holidays.
Fulfillment – The ability to contain and control the patient’s pain and anxiety using both communication and medical skills make for a fulfilling career.
Mobility – Anesthetists/anesthesiologists may belong to a large group practice with offices in multiple locations within the region or country. This allows for easier relocation.
Variety – The practice of anesthesia encompasses a diversity of cases as well as a broad range of patients. Anesthetic is administered to people of all ages and all health conditions, and may be involved in anything from minor outpatient procedures to heart transplants and brain surgery.
What are the disadvantages of anesthesiology as a career?
All jobs have a downside and anesthesiology is no different. Although the advantages may outweigh the disadvantages, you have to assess what’s most important to you for contentment with any career.
High levels of stress – Ensuring the well-being of a patient, especially one that is under the effects of anesthesia, is stressful. A person in this position must have outlets to manage stress successfully.
Lengthy period of education – Training to become an anesthesiologist could be as long as ten years.
Long or unusual hours – Scheduled surgeries and procedures often determine working hours. Some surgeries may last as long as eight to ten hours, which may be fatiguing.
Malpractice – Anesthesia carries a higher medical-legal risk profile, and insurance can be expensive.
Mistaken image – The image of anesthesia may seem less attractive compared to other surgical disciplines.
Potential routine – Pre- and postoperative tasks keep anesthetists busy. But during surgeries, especially lengthy ones, there are extended periods of perceived inactivity.
Short-term patient relationships – Anesthesia does not allow for the establishment of long-term doctor-patient relationships. If ongoing patient relationships are important to you, consider a career in one of the other branches of medicine or pursue an anesthetic career in an intensive care unit or a pain clinic.
Even with its drawbacks, most anesthetists will agree it is a rewarding career that pays well and ensures you remain in demand no matter where you choose to live.
What can you learn right now?
Related to this article, you can complete or review the following practical projects on The Apprentice Doctor’s for Future Doctors Course.
The course reviews:
Physical examinations – Examine the body using the time-honored examination skills that an anesthetist uses every day.
Respiratory rates – Accurately determine the respiratory rate, and learn the importance of this in monitoring a patient’s well being.
Heart rates – Accurately determine the heart rate and its importance when monitoring a patient’s vital signs.
Blood pressure readings – One of the most fundamental and valuable patient monitoring skills, learn how to take accurate readings.
Breathing Movements – Learn the difference between diaphragmatic and costal breathing and the clinical relevance of this distinction.
When a surgical wound heals properly, the sutures around its edges stay intact while new tissue, known as “granulation tissue,” starts forming. One of the most common complications of surgical wounds is when the surgical incision breaks along the suture. In other words, the wound splits open, a condition known as wound dehiscence.
Why does wound dehiscence occur?
Wound dehiscence is caused by many things such as age, diabetes, infection, obesity, smoking, and inadequate nutrition. Activities like straining, lifting, laughing, coughing, and sneezing can create increased pressure to wounds, causing them to split. Chronic use of corticosteroids (steroid hormones made in the adrenal cortex or synthetically), previous scarring, the presence of radiation at the incision site, improper stitch usage, unsuitable suture type, fluid-coagulant balance, cancer, and surgical errors can also contribute to wound dehiscence.
Dehiscence can also occur due to poor wound undermining throughout the surgery. Wound undermining means that damaged tissue extends under the skin and can’t be seen on the surface.
The location of the wound can also cause dehiscence. For example, wounds located on the legs, shoulders or back, or in mobile areas or areas prone to high tension, are at increased risk of rupturing.
Patients diagnosed with Ehlers-Danlos syndrome are more likely to experience dehiscence. Ehlers-Danlos syndrome is an inherited disorder that affects connective tissue, particularly skin, joints and blood vessel walls.
Symptoms of wound dehiscence
Some common symptoms of dehiscence are:
Broken sutures that don’t heal.
Bleeding from wound and bleeds at the surgical wound entry points.
Fever.
Inflammation.
Pain at the wound site with high sensitivity to touch.
Sudden opening of the wound.
Swelling.
Wound drainage – pus-filled and frothy.
A frequent effect of wound dehiscence is arterial bleeding. Blood from an arterial bleed is brighter in color and may spurt, or pulsate. Arterial bleeds occur more often in patients who are overweight or suffering from diabetes.
Causes of wound dehiscence
One of the leading causes of wound dehiscence is infection. Some characteristic signs of infection are:
Abscess – swollen area that contains pus.
Erythema – abnormal redness of the skin.
High body temperature.
Large amounts of exudates – seepage from the wound area.
Odor.
Severe pain.
How is wound dehiscence treated?
Dehisced wounds require immediate attention. After the wound is sutured closed, doctors primarily use one of two methods to treat dehiscence.
Antibiotics – Use of an antibiotic ointment over a newly sealed wound may prevent any possible future infections.
Debridement – Removal of any dead or damaged tissue from the surgical wound. Doing so creates a better seal for a new surgical closing. It can also improve the development of healthy skin tissue.
If a wound has previously suffered a dehiscence, it must be monitored closely. Careful observation minimizes any issues that may occur during this second healing process.
13 possible reasons for wound dehiscence
Although there are many reasons that contribute to wound dehiscence, what follows are the most common.
Utilization of inappropriate knot
The importance of proper suture knot techniques
When it comes to suturing, knots are much more than tying off the ends of materials passed through body tissues. Maintaining appropriate tension on the suture is vital to healing, so knots have to be set properly to ensure stitches remain intact.
Surgeons determine what type of knot to use when closing wounds. In the picture below [1], from left to right, are three frequently used:
Simple knot – incomplete basic unit
Square knot – completed common knot
Surgeon’s or friction knot – completing tension
How suture material and suture experience affect knots
The knotting technique used depends mainly on the nature of suturing material. For example, multifilament materials are those that are made by braiding or twisting so that the coefficient of friction rate is high. As a result, knots hold well and remain tied as they are created. Monofilament materials consist of only one strand of fiber, and their coefficient of friction rates are much lower meaning that they tend to come untied more easily. Also, synthetic polymeric monofilament suture materials have “memory” which means they tend to return to their original shape instead of lying flat, which is a desired quality in suturing.
The quality of suture knots is also a product of the skill of the person applying them. The positioning of knots is determined by the suture technique and wound being treated. These decisions determine how secure the knot remains. Using the wrong knots or tying them too hastily compromises knot quality.
Potential problems caused by improper suture knots
Proper suture knots are vital to the overall suturing process to ensure that wounds heal effectively.
Improper suture knotting techniques can cause the knots to loosen or come undone entirely. This, in turn, relieves the holding tension of the suture, allowing the wound to open. An open wound will not heal correctly, causing infection or excessive scarring. Incorrect knotting techniques can also leave too much material remaining which not only becomes a snag hazard but can produce more significant irritation and discomfort to the patient.
Knowing which suturing knot technique is appropriate is essential since the primary focus of wound suturing is to create closure for the wound. When suturing is done correctly, it reduces bacterial entry, heals properly, and produces the least scarring possible.
Tying knots too loosely
If suture knots are applied too loosely, they can allow the suture to slip and lose tension. Loose knots snag easily during daily activities which can cause the stitch to break, increasing the possibility of the wound opening. If a suture is not held under its ideal tension by a correctly tied knot, the healing properties of the wound will be compromised. This can lead to improper healing, and bacteria may enter the wound creating infection, excessive scarring, and greater discomfort.
Sutures and knots can become loose even when they have been applied properly. The objective is to repair the suture before any lasting damage occurs to the wound. Suture tension must be regained to keep the wound closed, allow for full healing, resist infection, and minimize discomfort and scarring.
Employment of improper suture material
Heavier suture materials provide the best tension strength for holding wounds closed, and require fewer and more secure knots. Lighter materials cause less tissue irritation and damage and glide through wounds more efficiently. But they need several knots for adequate closure. Thin suture materials, therefore, are selected for cosmetic areas, such as the face, to produce less scarring. If a thick suture material is used on the face, more noticeable wound and suture track scars are the results.
Also, using absorbable versus non-absorbable or braided versus non-braided suturing materials incorrectly can lead to problems. Absorbable materials dissipate over time and do not require removal. Such materials can be somewhat unpredictable in their breakdown which, if used on surface wounds, can occur early leaving them prone to opening or tearing.
The choice between using braided or non-braided sutures is just as important. Braided materials are woven together and provide better knots and wound tension, but are also considered causes of more adverse skin reaction. Additional, they can present a higher risk for infection due to the presence of grooves where germs can enter the wound.
Selection of the incorrect needle
One of several types of needles can be selected for the suturing process. Two primary ones are cutting needles and round body needles.
Cutting Needles – Cutting needles have two sharpened point edges that oppose one another. This design is for use on dermal tissue that is tough and difficult to penetrate, such as dense, thick and irregular connective tissue. Variations include conventional cutting needles and reverse cutting needles. Traditional cutting needles have a three-blade, triangular-shaped tip that is sharpened on the inner convex for better penetration and a flattened body which is more easily grasped by a needle holder. Reverse cutting needles have sharpened edges on the outer convex and are used to suture extremely tough yet delicate dermal tissue such as oral mucosa and tendon sheath.
Round Body Needles – These suture needles have a tapered, sharpened tip and a round body designed to pierce instead of cut skin tissue. The grasping end is rectangular or oval for better holder control. Round body needles are used in soft, easily penetrable tissue, such as subcutaneous layers, abdominal viscera, peritoneum, myocardium tissue, etc.
Cutting needles cause less injury to tough types of tissue because it will penetrate the tissue with minimal force as opposed round body needles where excessive force is needed to penetrate the tissue – but it may actually cause more damage in softer tissue like fascia – by tearing through the tissue causing damage and scarring. When this happens, it may indirectly increase the risk of infection.
Some bodily structures are quite thin and friable, so always remember a cutting needle can cut through the tissue like a scalpel. Consider using a reverse cutting needle in certain situations.
Over-tightening of sutures
The importance of not suturing wounds under tension is emphasized in most surgical skills and suturing courses. Excessive pressure may cause the suture to break and could cut tissue which leads to the wound opening. Practice in avoiding too much tension leads to the successful use of finer gauge materials.
The following case study illustrates what happens when sutures are overtight.
Case study
A 56-year old Caucasian male presented with a recurrent basal cell carcinoma of his scalp. The lesion was incompletely removed by a general practitioner six years previously, and subsequently excised by a dermatologist twice – but recurred again. Although basal cell carcinoma may be considered a very “innocent type of cancer” because it rarely metastasizes, it is notorious for recurring locally.
The patient was then referred to a plastic and reconstructive surgeon who booked the patient for a more radical excision of the 10 x 12 mm lesion.
A couple of days later the lesion was removed under sedation in O.T with about 1 cm clean margins making the defect about 2 x 3 cm. The adjacent tissue was undermined for a reasonable distance and closed primarily with 3-0 monofilament resorbable suture material.
The wound appearance at different stages:
Scalp wound after 2 x 3 cm excisionWound 4 days post-operativelyWound dehiscence (10 days post-op)
The wound was initially treated with a topical antibiotic ointment and dressed – but later allowed to dry. Initially, the healing progressed according to plan – but about seven days post-operatively, one of the sutures snapped. The patient reported that: “it sounded like a guitar string snapping in his skull – ZINGGGG.”
On inspection, the wound started to open up and dehisced quite severely. It was decided to allow the wound to granulate and thus heal by secondary intention.
Complications are unpleasant to anyone involved in this kind of a situation, but specifically so to the practitioner and the patient. However, as you may notice, it is not always a train smash. In this case, the wound eventually healed rather nicely with an acceptable aesthetic result.
In the imagines, you will note that the red color marking the dehisced wound fades almost entirely in time as the final stages of wound healing occur and scar maturation progresses.
Discussion
The surgeon opted for a primary closure but may have considered using:
A free skin graft – In my opinion, this would have given a much worse aesthetic outcome. But if the defect was anything more substantial, the surgeon may have had to use this option. Should this procedure be selected, the donor site should be kept in mind since it becomes a secondary surgical site with all the possibilities of complications developing.
A local pedicled scalp flap – This may have been a better choice because the defect margins could be increased. This option minimizes the tension on the wound margin since it “spreads” the wound defect more evenly over a larger area.
Alternative suture materials and techniques – The surgeon could have undermined the wound edges even more and then used a deep layer of resorbable and non-resorbable sutures on the surface for the final closure. This choice gives the surgeon control over the length of time to keep the suture in place. Vertical and/or horizontal mattress suture may have been a better suturing method to use as it would have added a bit more “hold” to the wound closure.
Retrospective wisdom is valuable because it allows for evaluation of choices made – what worked, what didn’t, and what could have been done differently. In my opinion, the surgeon achieved an acceptable and reasonable functional and cosmetic result.
Placement of sutures in an infected wound
Three goals comprise proper wound management.
Provide for a favorable environment for hemostasis.
Prevent any infection.
Arrive at a scar that is aesthetically acceptable.
Infection is a crucial consideration when treating wounds, and all wounds are considered to be contaminated since underlying tissues have been exposed to outside conditions that generally thrive with bacteria. Sutures should not be applied to infected wounds. Suturing wounds is about closing the dead space between severed tissue walls so that they can undergo the natural process of hemostasis. If infected wounds are sutured, or wounds are sutured without being thoroughly cleaned and debrided, an infection will grow and spread, compromising the healing process. Therefore, any infection must be effectively treated before the sutures are applied.
Misplacement of sutures
The most common cause of wound dehiscence is placing sutures very close to the wound edges. Experimental studies show that the more distance there is between the lips of a wound and the suture, the lesser the chances of wound dehiscence. This is because the lip or edge area of the wound displays inflammatory changes, swelling, increased blood supply and reduced collagen structure. The introduction of collagen fibers during the healing phase also puts pressure on the surrounding area, thereby increasing wound tension. Finally, necrotic tissue and aponeurotic tissue zones within the area can also affect suture hold.
Adoption of incorrect suture technique
If the wrong suture technique is used, it can create wound complications such as infection, improper healing, circulation issues, or puffy, broad, or dark scars. Suture breakage is one of the most common problems when improper suture techniques are used. Breaks in sutures can occur due to inappropriate materials, irregular application angles, improper suture material or suture size, and excessive suture tension.
There are eight basic suturing techniques.
Line of interrupted sutures.
Running suture line.
Running locked suture.
Vertical mattress suture.
Pulley stitch, type 1.
Far-near near-far modification of vertical mattress suture, creating pulley effect.
Improper suture techniques can also lead to infection by allowing bacteria to enter the wound. Infection can compromise the healing process and even require that the wound be reopened for cleaning.
Removal of sutures too soon or too late
For a wound to heal properly, it must be assessed and treated correctly. This involves proper cleaning, debridement, and suturing of the wound. Part of the healing process includes applied sutures being removed at the right time which can vary depending on the stress placed on the wound and where it is located. Although the specific situation determines when sutures are removed, they are customarily taken out between 5 to 14 days. If sutures are removed too soon or are allowed to remain too long, complications may arise.
Removing sutures too soon
Sutures are applied to close a wound to keep bacteria out and to allow tissue colligation. If sutures are removed prematurely before underlying tissues have bonded sufficiently, then the wound could reopen (dehisce), damaging newly colligated tissue and allowing bacteria to enter. Deep wounds are particularly vulnerable to dehiscence if they do not have adequate absorbable sutures buried in the underlying tissues providing more tensile strength to hold the wound together.
Removing sutures too late
There are several problems which can arise from sutures being left in too long. First of all, because sutures are looped around wound edges, scar tissue can begin to form around them if they are left in too long. Also, scarring of the wound closure as well as “railroad tracks” from the sutures themselves can be excessive if the sutures remain past the prime removal time. This can be quite problematic if the laceration is in a sensitive area such as the face – therefore, in most cases, facial sutures are removed no longer than five days post-operatively.
The risk for keloid scar formation is also increased when sutures are allowed to remain for too long a period. Keloid scars consist of firm tissue that is much larger than that which forms normal scar tissue and are common occurrences in wounds of the chest, waist, shoulders, elbows, arms, and ears.
African Americans and those having a history of keloid scarring must have their wounds monitored closely so that sutures can be removed promptly to reduce keloid formation. The risk of keloid formation is also higher if the wound dehisces due to premature removal of sutures. It is difficult to be precise on timing, which is why diligently watching the healing process is vital if keloid formation is to be avoided.
The existence of foreign object in the wound
Any wound should be thoroughly cleaned and, if necessary, debrided to remove all foreign material from it. Foreign objects may include wood or metal splinters, glass shards, bone fragments, thorns, gravel, hair, cloth fibers, etc. If external items are not detected during the initial assessment, and the wound is closed, they can present problems such as bleeding, inflammation, infection, and excessive pain.
It is far better to remove all foreign materials during the initial assessment and before closing the wound because objects are more visible. Once a wound is closed with foreign material sutured inside, problems such as inflammation, granulation, infection, and scarring may occur.
Signs of embedded foreign objects
Quite often, patients can feel if a foreign object is present during the initial treatment of wounds. If this is the complaint, providing a more thorough assessment at that time may be beneficial to the patient. However, if foreign bodies are missed and remain in the wound, the following signs/symptoms will ensue:
Local inflammation.
Impairment of healing.
Pain.
Bleeding
Bruising
Persistent draining of an inflammatory exudate or pus.
If signs of remaining foreign objects occur after a wound has been sutured closed, the clinician may opt to use special investigations like X-rays, MRIs and CT scans to assess for the presence of foreign material remaining in the wound.
The longer the object remains in the body, the more it incorporates ingrowth of tissue. An abscess can form, and fistulas may develop between organs. The foreign body reaction may be immediate or may be delayed for years. Diagnosis is sometimes difficult and costly, and removal of the object usually requires major surgery.
Retained sponges can be removed through laparoscopic surgery if they are discovered before adhesions develop.
Determining if foreign bodies should be removed
Once a foreign body is detected, a determination is made if it should be removed at all. If more damage will occur by removing it, the decision may be to leave it in. Other times foreign objects can be removed rather easily. In other cases, the body may dissolve, absorb or expel them naturally over time.
Case study
A 45-year old male presented with vegetative material extruding from a laceration at the superior orbital rim. He had sustained a mechanical fall into a bush three months before presentation. He arrived at an outside ED, where the laceration was repaired. His exam revealed a well-healed periorbital laceration and 20/20 vision on the Snellen chart. A CT scan showed a linear foreign body with its proximal end in the medial orbit.
This object traversed the medial orbital wall, ethmoid sinus, and sphenoid sinus. A dehiscence of the posterior sphenoid sinus wall was noted adjacent to the posterior edge of the foreign body. A CT-A confirmed that there was no apparent injury to the carotid artery. Due to the risk of vascular injury, the procedure was performed in the IR suite. Given the proximity of the foreign body to the carotid artery, an angiogram and balloon occlusion test were completed before the attempted removal and a sheath was kept in place.
A combined endoscopic and open approach was performed by the ophthalmology and otolaryngology services department. A septoplasty with posterior septectomy, left total ethmoidectomy and bilateral sphenoidotomy was required to expose the object. Following this, the team was able to see a stick entering the ethmoid sinus at the lamina paprycea and extending to the right lateral sphenoid sinus. Next, a periorbital incision was made, and dissection was performed along the medial orbital wall until the stick was encountered.
The object was then able to be removed by grasping its proximal end in the orbit and pulling it out. The patient had no neurological deficits postoperatively and was discharged the following day.
Formation of a large blood clot (hematoma)
Uncommon hereditary coagulation disorders can lead to wound dehiscence. In the first month after transplantation, most infections are caused by the same hospital-acquired bacteria and fungi that infect other surgical patients (e.g., Pseudomonas sp causing pneumonia, gram-positive bacteria causing wound infections).
The most significant concern with early infection is that organisms can infect a graft or its vascular supply at suture sites, causing mycotic aneurysms or dehiscence.
Presence of arterial bleeds
When arterial bleeds exert immense pressure inside the wound, it opens. Bleeders are controlled either by ligation (typing bleeding vessels off), or diathermy (burning them closed with an electric current).
Insertion of sutures in a malignant tumor
One of the attributes of a cancerous growth is the loss of cellular adhesion. Sutures placed in a malignant tumor prevent healing.
Prevention
Wound dehiscence may be prevented by taking the following measures [2]:
Avoid unnecessary stress or strain to wound area such as heavy lifting, exercise, vomiting, coughing, or constipation.
Brace the body with a hand or a pillow at the wound site to relieve stress to the wound when doing an activity.
Comply with the doctor’s post-operative instructions and prescribed medication.
Employ wound care, dressing, cleaning and hygiene as prescribed by the doctor.
Maintain good hydration and a healthy diet which can lead to faster healing and prevention of constipation.
Know how wounds normally heal [3]
A normal healing process after surgery can be divided into three stages.
Stage One:
Lasts one to six days.
There may be redness and swelling.
The wound may feel warm and slightly painful to the touch.
Stage Two:
Lasts four days to a month.
A scar begins to form.
Edges will pull together and there may be some thickening. There may also be some red bumps inside the wound site.
Stage Three:
Lasts six months to two years, depending upon the type of surgery.
Wound fills in and a new surface is present.
Scarring becomes thinner, flatter, and whiter.
Any deviations from this healing process, particularly between five to ten days postoperatively, could indicate possible dehiscence. Most dehiscences occur four to fourteen days after surgery. Contact your healthcare professional if there are any concerns about the healing progression.
Be proactive and prepared
Left untreated, wound dehiscence can lead to more serious or life-threatening conditions. By understanding the healing process and being attentive to it, you’ll recognize if it’s falling outside typical parameters. Then you can get in touch with your healthcare provider for early intervention. Through this simple, proactive measure, you may avoid dehiscence and contribute to an optimal healing outcome.
Immunotherapy is a growing area of cancer treatment that uses the body’s immune system to attack cancer. Currently, immunotherapy accomplishes this in one of two ways [1]:
Stimulating your immune system to work harder or smarter to attack cancer cells.
Giving your immune system additional components, such as synthetically-made immune system proteins, to help it effectively fight cancer cells.
You probably have a good idea of how the immune system functions. In straightforward terms, the immune system helps protect you from infections and other diseases. Immune cells continuously travel through the body ensuring that any germs that create ailments don’t get a strong foothold.
Your immune system has a sort of computer database that tracks all the cells and other substances normally found in your body. So, when it senses an element out of place, it runs the element through the database. If it’s not found, the immune system investigates by sending out a type of scouting part. If the scouting party confirms the substance doesn’t belong in your body, it gives out a battle cry and attacks.
The immune response can destroy almost anything, including some cancer cells, which is how it keeps you healthy. That’s why maintaining your immune system in good working order through a healthy lifestyle is essential.
Why can’t the immune system kill cancer cells?
Cancer cells have high IQs because they used to be healthy cells in our bodies. As a result, they understand how the immune system works. Scientists aren’t sure what causes normal cells to mutate into cancerous ones. But they do know the mutation includes a disguise that makes cancer cells still appear normal to the immune system. The immune system scouting party sees them and thinks they are friendly cells, and so passes them by without attacking. Failure to strike results in the cancer cells growing and spreading throughout the body.
Even if the immune system recognizes them as cancerous, it has difficulty targeting them. The defense system of cancer cells contains a special membrane that is almost impenetrable. Even the best immune system isn’t strong enough to fight it effectively.
How does immunotherapy work?
Immunotherapy is not a new concept. Research on it began in the early 1890s. However, scientists are just now beginning to understand how to change the interaction between white blood cells, called T-cells, and cancerous cells.
Immunotherapy drugs, known as checkpoint inhibitors, remove the disguise from cancer cells so that when T-cells, or the scouting party, approaches, it recognizes cancer as an enemy substance and attacks.
One of the most promising immunotherapy methods is chimeric antigen receptor (CAR) t-cell therapy. With this approach, immune T-cells are taken from the patient’s blood and modified in the lab by placing specific antigen receptors (called chimeric antigen receptors, or CARs) on their surface. Antigens are toxins or other alien substances that induce an immune response in the body, specifically the production of antibodies.
The reprogrammed T-cells are injected back into the patient. This reformed scouting party now recognizes cancer cells and can launch an assault against them. Tests reveal that each modified immune T-cell can multiply to as many as 10,000 new cells and survive in the body for years resulting in high remissions rates [2].
CAR T-cell therapies are now being studied for the following types of cancer:
Acute Myeloid Leukemia
Brain tumors (especially glioblastoma)
Breast cancer
CLL
Hodgkin’s Lymphoma
Multiple Myeloma
Neuroblastoma
Pancreas cancer
CAR T-cell therapies being studied are not available in clinical trials for all cancer patients. Only those patients whose cancer is not responding to treatment or has returned after treatment are eligible. Although primary outcomes are promising, not enough time has passed to know if this is a path to long-term cures. Research is also still being done to determine if there are any side effects.
In this two-minutevideo, the team at The Parker Institute talks more about how cancer immunotherapy works and how they’re approaching it.
What is immunotherapy used for?
Because immunotherapy encompasses treatments that work in different ways, researchers know that it works better for some types of cancer than for others. Sometimes it’s used by itself for certain cancers. Other times combining it with related treatments works better. Some approaches boost the body’s immune system in a general way while other therapies help train the immune system to attack cancer cells specifically. Use of immunotherapy for cancer is still a relatively new science. Consequently, it could be as long as ten years before it’s understood well enough to be considered a standard treatment option.
According to theCancer Research Institute(CRI), immunotherapy can have an impact on the following types of cancer:
Bladder cancer
Brain cancer
Breast cancer
Cervical cancer
Childhood cancer
Colorectal cancer
Esophageal cancer
Head and neck cancer
Kidney cancer
Leukemia
Liver cancer
Lung cancer
Lymphoma
Melanoma
Multiple Myeloma
Ovarian cancer
Pancreatic cancer
Prostate cancer
Sarcoma
Stomach cancer
The future of immunotherapy [3]
The future of cancer immunotherapy may lie in combining types of cancer vaccines with checkpoint inhibitors. Either way, a method of eliminating the disguise cancer cells use to suppress the immune system could be the optimal pathway to treating cancer. However, researchers don’t understand enough about how checkpoint inhibitors function. Through more research, scientists and doctors will learn more and possibly produce a way to target specific cancer cells more precisely. The vaccine for cervical cancer is one such example.
The next 20 years will see breakthroughs in immunotherapy approaches. The use of computer prediction with molecular analysis will play a significant role when evaluating the effectiveness of cancer vaccines. Additionally, the potential power of combined immunotherapies may allow doctors to target cancer while avoiding toxicities and other side effects.
If you’d like to learn more about cancer immunotherapy, you may be interested in the following TED Talk by Arthur Brodsky, Ph.D. with the Cancer Research Institute (CRI).
Where can I find more information on immunotherapy?
In spite of the progress that has been made in immunotherapy, results are different for each person. The same is true with more conventional therapies like radiation, chemotherapy, or surgery. If you or someone you know has cancer that is not responding to traditional treatment and you’d like to find out if there is an FDA-approved immunotherapy for your specific cancer, talk to your oncologist. You may be eligible for a clinical trial. A listing of active clinical trials can be found by clickinghere.
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Associate Degree versus Bachelor Degree – the initial question for student nurses
If you want to become a registered nurse, is it better to enter a two-year associate degree program (ADN) or a four-year bachelor degree program (BSN)? Graduates of either one are eligible to become registered nurses. So most students who want to become registered nurses ask the same question – why would I go to school four years when I can get the same registered nursing license in two? It’s a fair question, and the answer depends upon your career goals and financial resources.
First let’s look a basic nursing education ladder.
Nursing Education Ladder
Name of Nursing Degree
Details about Credential
Diploma in Nursing
• 12-18 months to complete.
• May trained in a hospital.
• Less common today.
• Gradually being phased out.
Associate Degree in Nursing (ADN)
• 18-24 months to complete.
• Offered in community colleges and career/trade schools.
• Sometimes there is a waiting list to get in.
Bachelor of Science in Nursing (BSN)
• 4 years to complete.
• 18-24 months to complete if applicant has an associate degree in nursing.
• Offered in colleges, universities and some career schools.
• Some lecture classes may be offered online.
Doctorate in Nursing
• Depending upon type of doctorate, can take 3-6 years to complete.
• Can be completed on ground or online.
• Offered at universities.
• Three possible credentials:
• Doctor of Nursing (ND)
• Doctor of Nursing Science (DNSc)
• Doctor of Nursing Philosophy (PhD)
As you can see, if you embark upon a nursing career, you can start at a diploma level and gradually advance to the next nursing credential. But there are limitations on what you can do with each one. Each successive degree takes longer to complete and requires a greater financial investment. However, the more education you have, the better your income and career opportunities.
Beyond the BSN there is the MSN (master’s of science in nursing) and doctorate degrees as well as specialized nursing certifications. The minimum of a BSN is required to pursue many of them.
In November 2017, a survey was facilitated byNurse.Org. Results revealed the current top ten nursing specialties. The pie chart below shows you those, many of which require at least a BSN plus an additional certification to get started. The information on the chart may assist you in determining whether to start your education at an associate degree level or if it’s better to enroll in a BSN program right away.
What advantages are there to being a BSN-prepared nurse?
It’s important to understand that regardless of your initial degree (AND or BSN), once you pass the National Council Licensure Exam for Registered Nurses (NCLEX-RN) you will be a registered nurse. You can learn more about the license through theNational Council of State Boards of Nursing.
With an ADN you’ll provide basic patient care and may work under the supervision of an RN who possesses a BSN. While there may be some advancement, options are limited. But a BSN opens more doors, and opens them more quickly.
A typical registered nurse position includes some or all of the following tasks:
Conducts more complex procedures than an ADN-trained RN.
Consults closely with doctors.
Educates patients.
Provides basic nursing care.
Records patient symptoms and medical history.
Supervises staff.
Supports the family of the patient.
Uses simple medical equipment.
With a BSN you’ll often be seen as a leader and may be promoted faster. If you choose, you can go into nursing fields outside hospitals. You could become a nurse educator or public health nurse. You can more easily step into one of the nursing specialties, which enables you to earn higher salaries. With a BSN you’re also only a step away from a master’s in nursing (MSN), which makes you eligible for additional nursing certifications.
The following charts provide a quick view of the primary advantages of both degrees. If you strictly compare the number of advantages between the two, the BSN is the optimal choice. But numbers cannot make all decisions. How an additional two years of education versus four years of education impacts your life and your financial resources is an intangible you have to consider in your decision.
The main advantages for obtaining a BSN
BSN Advantage
Explanation of BSN Advantage
Some nursing careers are open only to BSNs.
• A BSN is necessary if you want to go to graduate school (MSN).
• Advancing into one of four of the highest paying nursing jobs requires a BSN. (These are: nurse anesthetist, clinical nurse specialist, nurse midwife, and nurse practitioner.)
• A BSN is required to move beyond providing basic clinical care.
• Only BSNs can move into administration and supervision.
BSN curriculum goes beyond teaching of clinical skills.
• BSN curriculum includes communication, critical thinking and leadership skills – all required for higher paying nurse employment.
• Research by the AACN as well as theHealth and Medicine Division(HDM), appears to validate a BSN nursing education translates into better patient care, including lower mortality rates.
• AACN research indicates BSNs have better proficiency in making good diagnoses.
BSN may be a future requirement.
• The HDM recommends that the number of nurses holding BSN degrees be increased from 50% to 80% by 2020.
• The HDM strongly encourages nurses to get their BSN within five years of earning an ADN.
• The AACN is following the HDM’s recommendations.
• Many healthcare providers will only hire BSNs.
BSNs are eligible for a wider range of professional advancement.
• With a BSN, you can enter specific nursing specialties such as surgery, gynecology or oncology.
The main advantages for obtaining an ADN
ADN Advantage
Explanation of ADN Advantage
Obtaining an ADN gets you into nursing practice quicker.
• An ADN only takes 18-24 months to obtain.
• An ADN enters the field of nursing practice quicker.
• Less time is spent in theory and more time is spent in practical application while in school.
• Less time in school means you enter the job market sooner.
Because an ADN program is shorter, tuition costs are lower.
• Less time in school means less tuition to repay.
ADNs who pass the NCLEX-RN are still registered nurses licensed to practice nursing.
• Although an ADN takes less time, you still acquire the skills you need to be a registered nurse and to pass the NCLEX-RN.
Why do hospitals prefer BSN-trained nurses?
Because healthcare is such pervasive topic in the United States, all providers strive to meet the highest clinical practice guidelines possible. The less arbitrary the practice, the more consistent medical care becomes. As a result, the Institute of Medicine (IOM), now known as the Health and Medicine Division (HDM), a part of theNational Academies of Sciences, Engineering Medicineadopted, and published eight care standards. Now hospitals and other allied health providers conduct self-evaluations to ensure they meet those criteria. One of the guidelines is to hire only BSN-trained nurses. You may wonder about this distinction if the registered nursing licenses are the same.
Ongoing research appears to validate that BSN-prepared nurses administer a higher quality of care to patients. As a result they achieve better patient outcomes. The two additional years of education students in BSN programs experience provides greater rigor, depth, and scope of training and clinical experiences. This creates positive differences when starting to work with patients on a nursing floor.
The following video gives you more information on the HDM (formerly IOM) standards and their development.
Is a BSN mandatory?
You may have heard discussions that registered nurses who don’t have a BSN will have to get one. The HDM is applying much pressure on the healthcare industry to make a BSN the minimum requirement for nurses. Their recommendation is for 80 percent of all nurses to hold a BSN by the year 2020. Although no formal requirement is yet in place, it seems likely that this qualification will become standard. As a result, many employers, especially hospitals, are voluntarily making the BSN a minimum requirement for their nursing staff.
The following video from The Robert Wood Foundation provides additional information, and insight, on this discussion.
What are the educational differences between an ADN and a BSN?
The education in an ADN program and the one offered in a BSN program is vastly different. There are two immediate distinctions.
Length of time – An ADN can be completed in 12-18 months. Most BSN programs take 48 months. So, entering the nursing field is quicker for ADN-credentialed nurses.
Financial investment – The longer a program takes, the more expensive it is for a student. Additionally, the longer a person is in school, the longer it takes to enter the field and start earning a salary.
According toAmerican Association of Colleges of Nursing(AACN), traditional ADN and BSN programs both teach the competencies of nursing. Both also require nursing clinical experiences, which provide direct patient-care learning and application in healthcare settings.
But BSN programs also give students more gives students a more comprehensive vision of patients and patient care. Clinical experiences are more extensive, and include the practical application of leadership and supervisory skills
BSN programs provide:
Advanced classes – Advanced classes provide higher and more in-depth detail about the complex issues affecting patients and the overall healthcare environment.
Leadership training – Specific training on leadership, management, public health, social sciences, and critical thinking helps nurses gain employment as administrators, researchers or educators.
Nursing informatics – Advanced courses teach new technologies present in the workplace.
Nursing theory – Nursing theory teaches nurses how to see a broader picture of healthcare and how they fit into that picture.
Because healthcare must be viewed in light of cultural, economic and social issues, a BSN curriculum also incorporates how those factors impact medicine and healthcare delivery systems. These additional courses contribute to why better patient outcomes and higher standards of care are attributed to BSN-prepared nurses.
However, not everyone is in a position to start out in a four-year program. So earning an associate degree in nursing and then passing the NCLEX-RN is an excellent place to start. Then, with time and experience, practicing nurses can go back to school and obtain their BSN.
What are bridge programs?
Current ADN registered nurses who want to earn the BSN credential in less time can complete something called an RN to BSN bridge program. A bridge program is exactly that – an educational “bridge” that moves RNs from an associate degree to a bachelor’s in 12 to 18 months. The number of courses an applicant has satisfactorily completed in their associate degree program that can also transfer into the bridge program determines its length.
Individuals seeking a second career as a nurse may also find a BSN bridge program helpful. It can assist in adapting someone’s acquired skills to the skills needed for entry into a formal nursing program.
Still undecided?
Committing to two or four years of school is a big decision. So sitting down with trusted friends and family and reviewing your options may be helpful. Creating a support system to help you with transportation, homework, and other life obligations can create the time and environment you need to take on the demands of professional nurse training. Whether you start out with an ADN or a BSN, you will find this kind of preparation makes a positive impact toward achieving your goal.
Take time with your decision, and then make the one that best suits your needs.
What’s next?
Would you like to get started on a path to nursing right away? No problem. The Apprentice Doctor offers two different kits that can help you take your very first step.
The Apprentice Doctor® Suturing Course and Kitis a resource that teaches you how to suture wounds in a short period of time. As a nurse, you’ll use this skill, so why not get started now? The kit contains everything you need to get started. Take a look at the following video for a closer view of kit items.
The Apprentice Doctor® Phlebotomy Course and Kitis another handy resource at your fingertips. This kit teaches you how to confidently perform phlebotomy procedures. Drawing blood is another skill nurses need – and they have to be very good at it to minimize discomfort to the patient. If you want to start your education in nursing, why not begin phlebotomy training right away? Take a quick look at the following video to see all the items contained in the kit.
The Apprentice Doctor offers more articles on nursing. You may be interested in the following:
When we go to the doctor, several things happen when reach an exam room. A nurse, or medical assistant takes our temperature and blood pressure and listens to our heart – all tests measuring our vital signs.
We ask about the numbers, and more often than not have an idea if they fall within acceptable ranges. But do we know why measuring vital signs are always part of any examination? Are they performed just to keep us busy, or are there valid medical reasons behind them?
As you may suspect, there are significant reasons a doctor needs to know our vital signs before performing additional aspects of a physical examination.
4 primary vital signs
Vital signs measure functions of the body that are essential for good health. There are four vital signs nearly all physicians measure before beginning any physical examination. They are:
Body temperature
Pulse rate
Respiration rate
Blood pressure
When vital signs fall within normal ranges, it indicates that your body is operating as it should. But ranges falling outside of what is typical for your age, can be a sign of a medical problem.
Body Temperature
The amount of heat contained in the body is its temperature. Most people maintain a body temperature anywhere between 97.7°F to 99.5°F (36.5°C to 37.5°C). Gender, age, time of day and even physical activity can impact your body’s temperature. Additionally, some people always seem to be hot while others always seem to be cold. So what’s normal for you may be different than what’s typical for someone else. You can determine your baseline temperature by taking it at the same time every day over a week or two.
The body is very good at maintaining whatever your normal temperature is. It makes adjustments regardless of the weather. But if your temperature is too high or too low, it can signal an underlying medical condition.
Your body temperature can detect:
Fever and if a medication is effectively reducing it.
Hyperthermia – very high body temperatures in people who have been exposed to heat.
Hypothermia – very low body temperatures in people who have been exposed to cold.
Excessively high or low body temperatures signal that it may be in distress. With the use of a medical history, a physician can determine whether there is cause for concern, or if the condition can be eliminated through a standard treatment option.
Pulse Rate
When you measure the number of times your heart beats per minute, you measure your pulse rate. Your pulse rate also measures:
Heart rhythm – between 60 and 100 beats per minute in most adults.
Strength of the pulse – how efficiently your heart works.
Your pulse rate may fluctuate with exercise, illness, injury, and emotions. Age, gender, and athleticism can also impact a pulse rate. Changes in pulse rate are expected as a person ages, but too much change, or an unexpected change at any age may signal that a heart condition, or other medical concern is developing.
Your pulse/heart rate can reveal:
Dehydration or overhydration.
Diabetes or internal body conditions that, if untreated, could lead to diabetes.
Excessive caffeine.
High levels of stress.
Lack of exercise – An indicator of heart-health and level of fitness is the ability of your heart to quickly lower back to a regular beat after intense activity. Healthier hearts recover faster than unhealthy ones or ones unaccustomed to physical activity.
Medication – The addition of medication, or changes in medication can impact the heart rate.
Under- or overactive thyroid.
Respiration Rate
Similar to counting the number of times your heart beats per minute, your respiration rate is the number of breaths you take in a minute. And, like other vital signs, respiration rates may be impacted by fever, illness, and other medical conditions. One thing medical personnel check when taking a respiration rate is if a person has any difficulty breathing. An average respiration rate for an adult person at rest ranges from 12 to 16 breaths per minute.
An abnormal respiration rate, increased or decreased, may be symptomatic of an underlying condition which must be treated. Some of these conditions are included below.
Increased respiration rate
Some of the more common causes of an increased respiratory rates include:
Asthma – Asthma attacks may increase respiratory rates. Even the smallest increase in respiratory rate could signal a worsening condition.
Dehydration – Dehydration can result in more rapid breathing.
Fever- When a fever is present a person will breath faster trying to lose body heat.
Infections – Flu, pneumonia, and other infections can result in rapid breathing.
Decreased respiration rate
A decreased respiratory rate can also be a sign of concern. Some causes include:
Sleep apnea – With sleep apnea, people often have episodes where they stop breathing mixed with bouts of decreased and elevated breathing rates.
Medications
Use of alcohol
Use of narcotics – prescribed and illegal
It’s important to note that rate of breathing is not the same as feeling short of breath. Sometimes a person can feel short of breath and have an unusual respiratory rate, but the two may be unrelated. Only your healthcare provider can determine if they are linked.
Blood Pressure
According to theAmerican Heart Association, “High blood pressure (HBP or hypertension) is when your blood pressure, the force of the blood flowing through your blood vessels, is consistently too high.” [1]
High blood pressure, diagnosed as hypertension, is often referred to as the silent killer because a person generally doesn’t experience any symptoms. Uncontrolled it may lead to some of these more common medical conditions:
Aneurysm
Heart attack or heart failure
Stroke
Trouble with memory or understanding
Blood pressure consists of two numbers. The top number, systolic blood pressure tells a physician or other qualified healthcare provider how much pressure your blood is exerting against your artery walls when the heart beats. The bottom number, diastolic blood pressure reveals how much pressure your blood is exerting against your artery walls while the heart is resting between beats.
Although both numbers are significant, doctors tend to pay more attention to systolic blood pressure, or the top number because it could mean a person is at risk for cardiovascular disease. The risk is particularly true if the person is 50 years or older.
140 mm Hg or greater systolic pressure (top number).
90 mm Hg or greater diastolic pressure (bottom number).
In 2003, the NHLBI added a new blood pressure category which they called prehypertension, which means a person is at risk of developing hypertension. But in late 2017, the NHLBI published a new comprehensive set of guidelines which eliminates the prehypertension category.
Understanding the newest blood pressure guidelines
In the new blood pressure guidelines, the NHLBI lowered the range of what is considered high blood pressure. The new range means approximately 46 percent of the U.S. adult population can be diagnosed as hypertensive. Younger people are the ones most impacted by the new definition, with the prevalence of hypertension doubling for women under 45 and tripling for men under 45. [2].
The following chart shows the new guidelines and associated stages of hypertension[2].
Stage
Ranges
Normal
Less than 120/80 mm Hg.
Elevated
Systolic between 120-129 and diastolic less than 80.
Stage 1
Systolic between 130-139 or diastolic between 80-89.
Stage 2
Systolic at least 140 or diastolic at least 90 mm Hg.
Hypertensive crisis
Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.
In a corresponding analysis of the guidelines’ impact, Paul Muntner, PhD, et al. [3], suggests, “the 2017 ACC/AHA hypertension guideline has the potential to increase hypertension awareness, encourage lifestyle modification and focus antihypertensive medication initiation and intensification on US adults with high CVD risk.”
Bear in mind these are only guidelines. Age, family history, insufficient exercise, excessive sodium in your diet, high stress and a variety of other factors can affect your blood pressure. Some of these factors are situational. When the situation resolves, blood pressure may return to normal ranges. So, an isolated high blood pressure reading may not be indicative of a problem. If readings remain elevated after a series of measurements taken over days or weeks, then see your healthcare professional for possible treatment.
Can your blood pressure ever be too low?
Having high blood pressure is a more common condition than having low blood pressure. More often than not, the lower your blood pressure, the better off you are. There are no guidelines suggesting someone’s blood pressure is too low. Consistently low blood pressure is a high-risk situation only if accompanied by one or more of the following symptoms:
Blurred vision
Cold, clammy, pale skin
Dehydration and unusual thirst
Depression
Dizziness or lightheadedness
Fainting
Fatigue
Nausea
Lack of concentration
Rapid, shallow breathing
As with high blood pressure, some situational factors can create a single reading of lower than average blood pressure. Certain medications, pregnancy, allergic reactions, or inadequate nutrients such as Vitamin B-12 can result in low blood pressure numbers. If you are experiencing physical symptoms along with low blood pressure, it’s best to see your physician to determine your risk of a health condition.
Want to learn more about vital signs?
Tests measuring your vital signs are quick, and the methods relatively easy when compared to other tests. If you are interested in learning how you can take your vital sign measurements at home,The American Heart Associationcan tell you how on their website.
[3] Munter P, Carey R, Gidding, S, Jones D, Taler S, Wright Jr., J, Whelton P, (2017) Potential U.S. Population Impact of the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline. (Retrieved fromhttps://www.onlinejacc.org/content/early/2017/11/01/j.jacc.2017.10.073)
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times less than usual when sitting at a computer display. Lack of blinking deprives your eyes of necessary moisture.
7. Loss of Hearing
What does value-based medicine mean for next-generation doctors?
According to the 
