Traveling In A Heatwave

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Soaring Temperatures

Temperatures have been high for weeks and if you're traveling in Europe this summer, it means toughing it out through a heatwave. Usually with no air conditioning. Few of the mid-range B&B's or hotels have air conditioning and this is also true of most restaurants and stores. 

Even if by some chance you manage to find a hotel with air conditioning, it is of no use when you're in town waiting in tour lines with no shade and with hot concrete rising up to meet the sun beating down on your head and shoulders. Or when you're hauling luggage on to the train, getting packed into a subway or walking across town.

Even places in Europe not accustomed to higher temperatures, like Scotland, saw the mercury climb with unexpected results.

“Glasgow, which had been suffering its hottest day on record, came in at 89.4 degrees Fahrenheit.
Glasgow wasn’t built to withstand such heat, and the record-breaking day caused the roof of the city’s science center to “melt” rubbery goo down the sides of the building.”
— Mary van Aue from Inverse

It's A Sweaty Time

During long, hot days, we are always losing water through insensible loss – meaning a loss of water from the body in ways that we can't see or measure.

“Insensible Water Loss
A loss of body fluid that is not easily measured, e.g., the moisture released in exhalation and perspiration. The amount of fluid typically lost is about 200 mL a day. Insensible fluid losses increase in any disease or condition that increases diffusion of liquid from the skin or the lungs, e.g., in burns, climatic changes, fever, or heavy exercise.”

Combine insensible water loss with heavy sweating, soaking through your hair and clothes while on a tour of a castle or hiking in a blazing sun and you're at risk not only for dehydration, but an imbalance and loss of electrolytes. Sweat is basically water, sodium chloride, and potassium – all of which you have to replenish after sweating heavily.

This is of particular concern for the elderly, people with heart conditions that depend on well-balanced electrolytes and pregnant women.

We can drink water to offset the dehydration, but plain water doesn't help much to replenish electrolytes in the body. In the United States, you could stop by a corner store and pick up some Gatorade, but that's not easy to come by in a foreign country. And it's not practical to carry it around while traveling.

Nuun To The Rescue

You need to replace the lost electrolytes, but how best to do this when you're traveling? 

Nuun Hydration, Electrolyte Drink Tabs are a great option. A cardiologist I know recommended Nuun as an excellent source to replenish electrolytes. 

Nuun is great for traveling. Just add a small tab to 16 ounces of water, it fizzes a bit like an Alka-Seltzer tablet, and your electrolyte "sports drink" is ready to go. Nuun is lightweight and compact and easy to fit into your luggage.

I traveled in Europe during part of the heatwave and the heat was not much fun. Despite dodging into shady spots whenever possible, some heat-filled days were a water bath of sweat. In the evening, when I got back to my hotel, I pulled out my 16 ounce Klean Kanteen bottle, filled it with water, and popped in a Nuun tab. Voilà!

Electrolytes For The Road

Nuun is a refreshing drink that is not overly sweet. There is a slightly salty taste, but that's just a reminder that the electrolytes are there for your benefit. I've tried several flavors and all of them have tasted fine. 

“each electrolyte tablet contains:

sodium: 360 mg
potassium: 100 mg
magnesium: 25 mg
calcium: 13 mg
vitamin c: 38 mg
10 calories
1 g of sugar
other ingredients include:

plant based sweetener monk fruit and a touch of stevia leaf extract to provide a crisp and light sweetness
non-gmo sourced dextrose to increase the speed of absorption and hydrate you faster
avocado oil for clean, plant-based production”
— Nuun website
Nuun dissolved in a glass of water.

Replace Electrolytes When You Workout

Nuun is also helpful when you're back at home especially after big workouts or when there is a local heatwave and you have to spend time outdoors with lots of sweating.

You can find Nuun tablets at their website or on Amazon.

Update: Nuun has new packaging of their Nuun Hydration tablet.

Note – I am not affiliated with Nuun nor do I receive any renumeration for mentioning their product. Please always consult your own medical provider if Nuun would be a good choice for you.

 

A Dementia Evaluation Tool

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Dementia and Alzheimer's

How do we know where someone is within the world of dementia? It's as varied as the people experiencing it. 

Some people can talk about it. Some can even say, "I have Alzheimer's."

Others don't really know they have it. Or, it's too shameful to say out loud. 

The Greatest Generation

Our younger generations think everyone can say anything about everything, at any time, wherever they want. There seems to be a serious lack of verbal filters now-a-days. 

In contrast, our older generation, often referred to as The Greatest Generation, is our World War II generation. These parents of the Baby Boomers – they don't really talk about things. 

Like when they returned from World War II.

They didn't talk about it. They came back and went to work. They used the GI Bill, pursued education, bought houses, started families and got busy creating the middle class in America.

But, they didn't talk about it. 

Most of them also don't talk about end-of-life processes and many don't admit dementia.

Dementia Ravages The Mind

Furthermore, if they are suffering with dementia, their ravaged minds often don't allow them to articulate the process. This disease strips away the very neurons they need to describe it to us.

We lack any lab tests that can tell us where we are in the wide ranges of dementia. No enzyme level or blood test can identify its degree of severity.

So, how do we evaluate where they are? How can we talk about it amongst family members and with healthcare providers?

The use of vague terms like "late stage dementia" versus "end stage dementia" are frustratingly unhelpful. How do you really define late stage or end stage?

How do you define moderate or severe cognitive disease? They are all nebulous descriptions at best, subject to each person's interpretation and qualitative view.

We need something quantitative, something we can all see and agree upon. 

The FAST scale is just that. 

FAST = Functional Assessment Scale Tool

It was exasperating when we met with my mother's neurologist and he told us, "Well, she is probably in late state dementia, but not yet in end stage."

Excuse me? And just what is going to tell us when she is in end stage?

He didn't have an answer.

We left his office and vowed never to go back. It was a waste of our time and money just to have him tell us she has dementia. Yeah, we already knew that.

The greatest help came when the Palliative Care Nurse Practitioner presented us with the FAST scale. Finally, something we could quantify.

Here was a way to make sense of this intangible, yet devastating, disease. We were grateful that we could see where our loved one fell on the scale. Family members could discuss it with clarity.

"Here's where we are. Here's where we're going."

We didn't know how fast or slowly we'd get to the various stages, but we could see the inevitable steps that were coming.

And we could see the end result.

Stages Of The FAST Assessment

As shown on the FAST scale, Stages 1 through 5 are simple numbers with a description. Once you get to Stage 6, it breaks down into categories of 6a through 6e. Then, at Stage 7, it is divided into 7a through 7f.

When someone enters Stage 6, Palliative Care might be an option. Once someone enters into Stage 7, it is usually considered appropriate to be in Hospice. 

If you know anyone with dementia, take a look at the FAST Scale. It clarifies where your loved one is with the disease process.

The FAST scale provides a useful tool when we communicate with healthcare providers. Better healthcare decisions are made when we are all on the same page and use the same terms.

FAST scale for Alzheimer's Disease

 

The Myth Of Not Aging

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Myths About Aging

Pick up any article about aging and you'll see that 50 is the new 30 and 70 is the new 50.

As Baby Boomers head into, dare I say, old age, they're approaching it like they've attacked everything in their lives: head on and with a determined, "We're gonna change this!"

Have a good attitude!

Do this exercise!

Drink that vegetable juice!

It will keep you young! You won't age!

How many other products and ideas can you name that you "should" be doing? One more face cream, one more lip filler or Botox treatment, one more yoga pose. If you could just do one more something, then maybe you won't die. 

The Baby Boomers' can-do attitude worked in the 1960s, many things did change. And it will even work now, 50 – 60 years later, but only up to a certain point.

 
 

The Card Of Death Is Still In Play

We will still experience aging. We will still die.

Perhaps Baby Boomers will promote changes that allow for better measures to prevent extended suffering. We hope they will add enough voices that aging people will have a better quality-of-life and have more end-of-life choices available to them.

With all of our advances in medicine, we are able today to force human bodies to stay on the planet, whether they should or not, long after our bodies would have naturally let go. Then, there's the added complication of dementia that strips away our ability to have a vote in the matter. 

So, we are left to ask the difficult questions. When is it simply too much?

When are we needlessly suffering? 

When do we say a last good-bye? 

Everyone Will Die

There is not one physical body that has not slipped off the mortal coil of old age and into death. There is not one "attitude" that stopped anyone from dying eventually.

Somehow, when we die earlier, we berate ourselves for not being able to muster up "enough right attitude" to prevent it, when in fact, it was the natural process of the break down of our bodies. Not due to our attitude at all.

I don't think we have to worry about sending old people off to their demise based on the criteria of age alone. However, we have to have some frank discussion about how we will define qualify-of-life.

 
 

We Are Mortal

Atul Gawande explores the many facets of aging and end-of-life decisions in his book, Being Mortal: Medicine and What Matters in the End.

This book was recommended to me by the eye specialist treating my mother for wet macular degeneration. In his specialty, the majority of his patients are in their last 10 years of life. His entire staff read the book to better help and understand their patients. 

Although trained as a surgeon, Gawande writes at a level that all of us can understand. He breaks down the aging process of our bodies so that it makes sense. No, we can't stop aging, but we can help. If we have an idea of what's coming, we can take steps to prepare for it.

He's not afraid to ask the question: how are we going to die? How do we die when so many interventions exist that can force us not to? 

Gawande explores this slippery slope that medicine finds itself on. His book is not about giving us an answer, but rather increasing awareness to better be able to make decisions for ourselves and our loved ones. 

Acute Care Versus End-of-Life

I'm a Women's Health Nurse Practitioner and all my healthcare practice is about "fighting the good fight" – doing everything to fix and heal my patients and beating back death at every step.

As my mother experiences an extended end-of-life process, this book helped me to understand the breakdown happening in her body. It helped me to see the parts of aging that I can't fix.

Being Mortal even provided a sort of comfort that I wasn't failing in my mother's care. Gawande describes how the aging process profoundly effects each and every organ. No part of us is spared.

Being Mortal: A Must-Read Book

If you are aging, or if you know anyone who is aging, Being Mortal is a must-read.

And since we're all aging, no matter what we may think, we all need to read this book. 

It's worth more than one read.

 

Winter Storms And Healthcare Personnel

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Winter Storm Blasts East Coast

One of the biggest winter storms on record came rumbling into the East Coast in January 2016. Although we only had some "sympathy rain" in California – watching the intense news coverage made me feel like I should stay home, if nothing else, as a show of solidarity. Actually, that sounded good to me.

Any excuse to bake, prepare nourishing soups and catch up on reading. The to-do list also included practical things like sorting through drawers, but whoever does practical things at times like this?

Winter Soups

Soups in winter nourish and warm our hearts. It harkens back to the collective memory of an ancient hearth with wide bubbling pots hanging on iron hooks over a crackling fire. Homemade soups I prepared were Roasted Beet/Garlic Soup and Pasta e Fagioli (pasta and bean soup).

Essential Personnel

One thing I didn't miss was being identified as "essential personnel." Over many years I have been essential personnel; the folks who don't get to hunker down and stay home during a storm. Nurses and healthcare workers who provide direct patient care still have to get to work.

While elective surgeries can be cancelled and rescheduled, patients in hospital units still require round-the-clock, skilled medical care. Wound dressings need to be changed, tracheal tubes must be suctioned, and medications still need to be delivered on time.

Travel Bans

The news media went wild trying to fill up over 24 hours of constant video of the storm. There are only so many falling snowflakes that you can watch. With 24/7 coverage, I was hoping to see some stories on how they were manning hospitals, especially when New York City called for a travel ban.

“Road travel ban in effect in New York City starting at 2:30 p.m. ET.
Anyone not authorized to be on the roads will be subject to arrest, and their car will be towed.”
 

Alas, despite my tweet suggesting the story line to CNN and ABC, I didn't see any in-depth reporting on it. Oh well, so much for the suggestions of the little people.

Working In The Storm

When I lived in Maryland, I was a Registered Nurse at Johns Hopkins Hospital on the Pediatric unit. A winter storm careened into the area, it was the December 1992 nor'easter. Perhaps not as large as the recent one, but, it was a storm that, nonetheless, would shut down the area.

I was scheduled to work several 12-hour night shifts during the storm. Plans were coordinated for personnel to sleep over at the hospital between shifts, if they desired, as it was not at all certain one could make it home or back again. Abandoning fellow workers and forcing them to carry on past their already completed 12-hour shifts was simply not an option.

Get To The Hospital

I packed a small bag and prepared a lunchbox to help tide me over the long 36 hours. Volunteers in the community with 4-wheel drive vehicles offered to transport healthcare workers to and from the hospital. I hitched a ride with a local driver and we chatted aimlessly as we inched our way along snowy roads. 

We made it through the storm, patients were cared for and my shifts completed. I managed to get some sleep despite the odd circumstances and I was happy to return home once the storm had passed.

Thank You To Those Who Serve

Police, fire, medical personnel look out for us. In this recent storm, the National Guard were also called up as well as municipal workers.

I often think of those who quietly provide our healthcare and public services. They work nights while we snuggle in sleep and they cover 3-day weekends that the rest of us enjoy. They care for us in the background while we carry on in our daily lives of sturm und drang. I deeply appreciate them, especially now that I can stay home during storms.

Thank you for your service.

 

Man walking in snow: Carlos Barria/Reuters
Shoveling snow: Shannon Stapleton/Reuters
Umbrellas in snow: Joshua Roberts/Reuters

Pap Smear Results In Medicine

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Schedule A Colposcopy

The smooth glass doors swooshed open, welcoming Jadin into the sprawling medical center. Chilly, hyper air-conditioned air engulfed her and washed over her bare arms. She briefly wondered about the energy bill to keep such a large building so cool even as the outside temperatures soared.

Jadin turned left and headed for the elevators that would transport her to the Gynecology (GYN) clinic. Her appointment was in 20 minutes. Pushing the up button, she thought about the phone call she received two weeks ago. She placed one hand on her abdomen to help with the jittery feelings that were building.

The words floated through her cell phone, "Your Pap is abnormal." 

Oh.

The result that every woman dreads and, here, the words were being said to her. Her cervical Pap smear result was abnormal.

Jadin entered the elevator and pushed the third floor button. Keeping her hand on her abdomen, she willed herself to take a deep breath.

"What does that mean?" Jadin gripped her cell phone with one hand.

Call It Colpo For Short

Her GYN nurse practitioner continued, "The results are low-grade. That means it's mild, but we still have to take a look to make sure. You need to schedule a colposcopy."

"A what?"

"A colposcopy," repeated the nurse practitioner through the phone. "It's a procedure. We take a few biopsies of the cervix and send them to lab for evaluation. It's really not anything to worry about."

Why did she always feel like she was dying when faced with any abnormal medical results? It’s easy for healthcare providers to say it's nothing to worry about.

As the elevator lifted her through space, she closed her eyes for a moment.

"We call it colpo for short." Her nurse practitioner spelled it out for her. "C.O.L.P.O. When you call the front desk to schedule your appointment, tell them you spoke to me and that you need a colpo. They'll know exactly what it is and get you set up. We'll see you soon."

Not-Always-Helpful Google

Once jadin hung up, she googled everything in sight regarding abnormal cervical Pap smears. Words like HPV, cancer, biopsy, and additional words like low grade, high grade, and LEEP swirled in front of her.

At one point, she stopped looking. The more she read, the more she was convinced she was dying of a wicked disease. She was pretty sure that was not true. She'd wait and ask questions at her appointment. 

The elevator doors opened. Her heart skipped a beat as she stepped out and turned the corner to enter the GYN clinic.

Those familiar "why me" feelings jostled their way into her thinking. Focus.

Check In For Your Appointment

Jadin stepped up to the front desk of the GYN clinic.

"Good morning. Checking in?" asked the clerk with a cheery voice. 

"Yes," Meagan put on a brave face that belied her true feelings. "I've got an appointment for a colpo." She felt oddly savvy using this word.

The clerk confirmed her identification and clicked and clacked her mouse at the computer. "Okay, you're checked in. Go ahead and have a seat. Your tech will call you shortly."

Jadin settled into a seat in the waiting room. She had both hands on her abdomen now to help with the increasing nervousness. 

The inner clinic door swept open to reveal a smiling woman wearing bright pink scrubs. 

"Jadin?"

Jadin stood up, keeping one hand on her abdomen.

"Come on back.” The technician guided her through several hallways that all looked the same.  “We'll get some vital signs and then set you up in an exam room."

"Don't worry," she reassured, noting the look of apprehension on Jadin's face. "Your nurse practitioner does these all the time. You'll be fine."

Jadin steadied herself and imaged a cosmic symbol in her mind's eye.

Into The Exam Room

The technician ushered her into an exam room which to Jadin felt like the proverbial lion's den. Medical instruments and cups filled with liquid were lined up on a tray like obedient tin soldiers. A large machine on rollers dominated the room.

A sinking feeling crept into the pit of her stomach as she contemplated that they were, indeed, going to take biopsies of her cervix.

The technician handed her a starched, green sheet to drape over herself during the procedure. "I'll step out while you change. Clothes off from the waist down, socks can stay on. Your nurse practitioner will be here in a minute. We'll take good care of you."

Jadin slipped off her clothes and patterned a spiral as she sat down on the edge of the exam table tucking the stiff sheet around her waist. She silently repeated words of encouragement to herself. 

"I can do this. I can get through this."

 

If We Break It, We'll Fix It

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Incidental Findings

"You need a biopsy, Tara," the pulmonologist advised as he fiddled with his mouse to bring up the CT scan on his computer.

"Yes, a biopsy" he repeated, focusing on the flat screen. "The nodule in your lung has gotten bigger in the last three months." Clicking on the mouse, he enlarged one area of the black and white image. "See," he pointed to the offending nodule, "the ground glass aspect has a solid component in it now, measuring 5 by 7 millimeters."

An abdominal CT scan that itself was normal, turned up an incidental finding of pulmonary nodules. Incidental findings. Things you weren't looking for, but found nonetheless, and now required that you follow up.

They both stared at the follow-up scan that showed "significant interval growth" in just three short months. Localized to the right middle lobe of the lung.

Just A Biopsy

A lung biopsy.

A long needle pushed through your chest wall to gather tissue from deep inside. Not a simple venous puncture.

The overshadowing and unspoken fear? Lung cancer.

The frustrating part? She was a lifetime non-smoker.

Risks of the procedure?

"Well, the usual," he intoned. "Infection, but that's unlikely." Right. Any time something punctures your skin and digs into your body, you have a risk of infection.

"And a collapsed lung," then he quickly added, "but that really is unlikely. You're strong and healthy, Tara. It's not like you have COPD."

Tara wasn't feeling terribly strong or healthy at the moment. Her gaze fell on the lump of her black purse sitting on the floor beside her. She really needed to replace that. She had promised herself she would buy one that wasn't black, now that she was free to have any color that tickled her fancy.

With retirement finally reached a month ago, she dreamed of a new purse that wasn't "regulation." She hadn't gotten around to that yet.

We'll Fix The Complications

And in the unlikely chance it happened? A collapsed lung? What then? She pictured herself positioned on the CT scan machine, lying on her side in the midst of the biopsy, suddenly unable to breathe.

"Don't worry, we'll fix that," he stated as a matter of fact. "We'll insert a chest tube and admit you to the ICU to give your lung time to reinflate."

Tara had to smile to herself. Medicine is so linear and mechanical. If we break it, we'll fix it and if we break it again, we'll fix that too. Because that's what we do in medicine. We fix things.

For all the frustrations with reductionism in medicine, there are wonderful aspects. Broken bones that could handicap us for life are carefully mended with the use of ultrasounds. High blood pressures that could slam our hearts to a crashing halt are coaxed down to reasonable levels with pills.

Medicine puts us back together, extends our lives, makes us prettier.

Medicine also finds incidental things, especially with the myriad scans, x-rays and ultrasounds that we order. 

Sometimes, that's a blessing. We find something, we take care of it right away. 

Other times, it's nothing and off we run on a wild goose chase.

It was possible it was only inflammation. That's what her radiology report said, "inflammation versus malignancy." 

It's Your Move

She would need to hold space in her meditations for this one.

Tara was clear that her meditation didn't guarantee a rosy outcome. Still, the inner support comforted her. It was hard to explain. Unlike medicine, the richness of the support accessed was not linear or mechanical.

She supposed she could choose to do nothing and let nature take its course, whatever that may be. Cancer or not. Maybe this was the end of the ride. How do you know when it's time to say goodbye?

Taking a deep breath, she looked down and placed one hand in her heart for clarity with her choice. When she looked up, their eyes locked, and she nodded consent to the biopsy.

For some reason, not any particular one she could identify, today was not the day to do nothing. 

"We'll find out what those cells are up to," he nodded back for emphasis.

"Alright," Tara whispered when she added a final pen stroke to her signature on the consent form, "Let's do this."

 

Laughter Is Part Of The Healing Process

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Laughter In The Healing Process

This clever video of a dog "talking" about getting a new kitten makes me smile. I must confess, having watched it over and over, it never fails to brighten up my day.

Medical Screening Exams

As a Women's Health Nurse Practitioner, I often perform screening exams for women. This important part of my patient care includes lab work, mammograms, and pap smears of the cervix. One type of patient I care for routinely – women with abnormal pap smears.

Dealing With Abnormal Results

If a patient has an abnormal pap smear result, the cervix is further evaluated with a microscope procedure called a colposcopy. If the results are mild, we then have a waiting period of 12 months before we test again for the HPV virus (human papillomavirus).

We need that time to allow the immune system to rise up and "clear" the virus. The immune system must recognize the virus is there and then push it back behind a "gate."  Once that takes place, it is no longer detected on the cervix. If the virus isn’t there, it can't make changes to the cervix.

What Can I Do To Treat HPV?

Invariably a patient asks what she can do to treat HPV.

Is there a pill, some kind of drug she can take?

There are no medications for HPV. Instead, we help our immune system to be strong so it can suppress the virus. I always tell my patients about healthy eating, good exercise, adequate rest, no smoking, decrease stress and... laughter.

Take Some Laughter, Call Me In The Morning

Medical research shows that laughter and humor can boost the immune system and promote healing.  Laughter is considered to be a "natural medicine" that lifts our spirits and helps reduce stress and discomfort. The Cancer Treatment Centers of America integrate Laughter Therapy into their care of patients.

 

Healing Laughter

Laughter Therapy, combined with a healthy diet, exercise and adequate sleep, are all part of a healthy lifestyle.

May laughter bubble forth in your healing.