In 2012, nearly half a million premature births occurred in the United States. An infant born before 37 weeks gestation is considered premature. Risk factors include: race, smoking, alcohol use, having delivered a previous pre-term infant, carrying multiple infants (twins, triplets), problems with the uterus or cervix, and chronic illnesses such as diabetes, asthma and kidney disease. www.cdc.gov/PrematureBirth

If you don’t already know, post-traumatic stress disorder is also considered a risk factor for premature births. In the largest study ever conducted, researchers at Stanford University Medical Center followed more than 16,000 infants delivered by female veterans. More than 3,000 premature births were delivered by mothers diagnosed with PTSD. Those diagnosed with PTSD in the year prior to delivery were found to be at thirty-five percent greater risk. The researchers factored in other issues, such as race, age, medical conditions, and alcohol and drug use. It’s worth noting that fifty percent of the women studied never went into combat, proving that the link between PTSD and delivering a premature infant is not exclusive to veterans. Civilian women are affected too. www.sciencedaily.com/2014/11/14

But how does PTSD contribute to premature births? Stress. Though the exact mechanism is not completely understood, higher than normal levels of stress hormones are released in those suffering from PTSD symptoms. The immune system then becomes suppressed, increasing the risk for infection, which increases the risk for premature birth. www.marchofdimes.org/pregnancy/stress

The good news: those who do not experience PTSD symptoms in the year before delivery are at the same risk for giving birth to a premature infant as those who do not have PTSD. For those who do suffer symptoms in the year prior to delivery, treatment is available. The Veterans Administration is using the results of the study in the care of pregnant women with PTSD. For pregnant civilians with PTSD, the good news is that you now know you are at risk, and can inform your obstetrician. There are some risk factors you might not be able to control – age and race for instance – but you can gain control over your PTSD. www.sciencedaily.com/2014/11/14

For a list of therapists, go to The National Board of Certified Counselors at: www.nbcc.org/counselorFind

Once a nurse, always a nurse. For those of you who are retired from nursing, or have left nursing because your back, or psyche, can no longer bear the weight of patients, does this phrase sound familiar? Maybe you’ve changed careers – maybe you’re now a lawyer, or a writer. But you’re still a nurse.

You’re a nurse when your mother calls and says, “My leg has a red spot on it and it’s been itching for three days, what do you think it is?” You wonder if she could possibly think that you have superhero vision and can see through the telephone wires into the red spot. You tell her to stop scratching it, to put some cream on it.

You’re a nurse when a good friend asks you if you would mind telling her alcoholic brother that drinking is bad for his liver and he is at risk for liver cancer. You want to tell her that he probably won’t listen to you any more than he’d listen to family, but you know she’s desperate. You want to tell her you don’t have experience with liver disease, that you’re background in nursing is with babies, and they don’t drink, as far as you know. She says she’ll get you her brother’s phone number, but the next time you get together with her, she forgets it. You’re relieved and careful not to ask how her brother is doing.

You’re a nurse when your sister-in-law asks you what to do about her bee sting. “It’s swollen,” she says. You tell her to put ice on it. And when your mother-in-law complains of a headache, you tell her to put ice on her head. “It decreases blood flow to the area, you say, “it should help the throbbing” You’re sister-in-law, who is in the room at the time, asks, “Is ice your answer to everything?” We laugh. But I think she’s on to something. Maybe ice is the answer. Maybe the next time my mother or father, or my husband or stepchildren ask what they should do for a stubbed toe, a twitching eyelid, or a paper cut, I’ll tell them to put ice on it.

Since “you’re the nurse in the family,” you’re assigned as your father’s health care proxy. He has Alzheimer’s and can no longer make decisions for himself. He requires caregivers to help him bathe, dress, and sometimes eat. His doctors call you for consent to admit him to the hospital when he suffers from pneumonia, or diverticulitis, or a blood clot. You are called upon to decide whether or not your father should have surgery to remove a lesion that might or might not be cancerous. You are asked to weigh the risks and benefits of every medical intervention your father faces. Sometimes you wish you never became a nurse.

But you are a nurse –no amount of ice can change that.

Born ten weeks premature, Jesse Cooper suffered a brain hemorrhage, and survived – with cerebral palsy. In 2005, at age seventeen, he died.

During the course of my twenty-year career as a pediatric and neonatal intensive care nurse, I cared for thousands of babies and children, many who had cerebral palsy. I provided the best care possible – heeded their cries, exercised their rigid limbs, and carefully fed them pureed foods so they wouldn’t choke. But it was impossible for me to know what it was like to be a mother of a child with cerebral palsy, or any of the ill children I cared for.

But actress Marianne Leone knows. In her memoir, Jesse, Leone writes with stark prose, sharing with us her “mask of red rage,” and her “fuck-you double slather of red lipstick,” as she, and her actor-husband Chris Cooper, work tirelessly to navigate the hairpin turns of their lives caring for a child with cerebral palsy (185, 189). She lures us along in their trek, from Jesse’s endless days in the neonatal intensive care unit, through their frustrating odyssey in search of physical, occupational, and speech therapists who would treat Jesse with dignity, and their fevered commitment to convince the school system within their community to integrate Jesse into classes with what Leone calls “able-bodied” students. Leone reminds us that “Jessie wasn’t a CP kid first, and a kid second (57).”

Jesse is more than a mere telling of the speed bumps Leone and her family encountered along the way. It is a story of perseverance, and idiosyncratic family coping mechanisms in the face of Sisyphean challenges. It hurtles the reader into a better awareness of what it means to be a quadriplegic, and non-verbal – which does not equate with being an “idiot (31).” Leone’s memoir is a must-read for families, health care professionals, teachers – all of us – who are on a quest to do what is right for our children, whether or not they are disabled.

Jesse speaks to the human condition – in this case, internal conflict – and the human being in us: Even long after the death of her son, Leone admits she’d rather “stay inside and be alone (248).” But she also knows, in order to still feel connected with her son, she must reach out and talk to other mothers with “babies like Jesse (248).”

Jesse himself tugs at the human being in us. His humor, non-judgmental approach to others, and endurance – he was an honor roll student, and windsurfed and wrote poetry – impels us to take a long, hard look at ourselves and ask, “Who am I? Am I aware of what is happening around me? How do I treat others? How do I want to be treated? What meaningful contributions am I making to others? What if I were a quadriplegic and non-verbal?”

In an autobiography Jesse wrote in sixth grade, he says:

“The most important lesson I can teach/is to see people for what they can do/ and not for what they cannot do (82).”

 Associated Press Photo

Though the latest Ebola outbreak is mostly confined to three West African countries, three cases – two of them nurses who cared for a patient from Liberia with the virus – have been confirmed in the United States. That pales in comparison to the number of people who have died from the virus in West Africa – 4,484 as of October 18. With such knowledge, we have little reason to panic. And, with the influenza season at our heels, we have larger concerns to contend with: two hundred thousand people are hospitalized every year from the flu, and between 3,000 and 49,000 people die.
http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html

http://www.cdc.gov/flu/keyfacts.htm

But it makes sense that nurses in the US are vocalizing their concerns about the Ebola virus and lack of adequate personal protective equipment. Among the 18 million health care workers employed in the United States, registered nurses comprise nearly 3 million. Nurses are the primary caregivers of hospitalized patients. http://www.cdc.gov/niosh/topics/healthcare http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-fact-sheet

According to the CDC, the “natural reservoir” of Ebola has yet to be identified, so the process of a human being infected is not known. But researchers believe the “first patient becomes infected through contact from an infected animal.” Ebola is spread through direct contact with body fluids, such as blood, vomit, semen, feces, and breast milk, as well as contaminated needles, and infected mammals – i.e. humans. Insects cannot contract the virus.
http://www.cdc.gov/vhf/ebola/transmission/index.html?s_cid=cs_3923

Since nurses, and other health care workers, are exposed to all kinds of body fluids, they are at the highest risk of getting sick when caring for patients with Ebola. If nurses become ill from the virus, who will care for the millions of patients who are hospitalized every year for various other illnesses? The CDC recommends the following personal protective equipment (PPE): disposable gloves, gowns, goggles, and a face mask in the event body fluids splatter. In cases where there is a large amount of body fluids, double gloving, booties, and leg coverings may be required.
http://www.cdc.gov/vhf/ebola/hcp/patient-management-us-hospitals.html

But is this enough? The typical hospital gown is made of cotton material, easy for fluids to seep through. Perhaps double gowning is a good idea, but what if your hospital unit runs out of gowns?

The nurses who cared for the dying patient in Dallas wore full PPE, including Tyvek suits – heavy-duty outfits that look like space suits – and a face shield and respirator mask. They even wore three pairs of gloves and booties. Yet, they became infected. Because the suits were too large, and exposed the necks of the nurses, the CDC recommended they secure the neck of the gowns with tape.
http://bigstory.ap.org/article/f5d8d9bb2f2a44d59dd10042d3e0e57b/existing-protocols-might-not-be-enough-ebola

National Nurses United, the largest union of registered nurses, has reached out to hospitals, advocating for better PPE, training on how to properly use the equipment, and adequate staffing to appropriately care for Ebola patients.
http://www.nationalnursesunited.org/pages/nursing-practice-patient-advocacy-alert-treatment-of-patients-with-ebola

What is your hospital doing to protect your nurses, and patients?

For more information on the CDC’s most recent guidelines when caring for Ebola patients go to:
http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html

Luis Grenada, a 16th century theologian, would probably not care whether or not newborns feel pain, for he called them “a lower animal in human form.” And during the early 20th century, the ignorance of the times drove researchers to stick newborns with pins, even while they were asleep, to determine whether or not they sensed pain. Their defensive frantic kicking apparently was not adequate proof. More studies were undertaken, more pinpricks. Because the newborns reacted with what one researcher called “diffuse bodily movements accompanied by crying,” she determined that they had “limited sensitivity to pain” (http://www.nocirc.org/symposia/second/chamberlain.html). But did these researchers take into consideration that mothers might have received anesthesia during labor, effecting newborns’ response to painful stimuli?

A 2011 British study concluded that the sensation of pain starts before birth, between 35 and 37 weeks gestation (http://www.livescience.com/15975-babies-feeling-pain.html). Continually sticking newborns with pins merely to prove they  feel pain is unnecessary, and cruel. As a neonatal intensive care nurse, my job, unfortunately, required me to poke babies’ heels for blood samples – I don’t need to share with you the more than unpleasant experiences.

Newborns may experience pain from surgery, and discomfort from the various tubes inserted into their bodies. Male newborns undoubtedly feel pain when circumcised. Dozens of studies, in which researchers have measured cortisol levels in babies, have proven so. They noted that this stress hormone increased as high as four times the levels prior to circumcisions (http://www.circumcision.org/response.htm).

So, if you’re a novice neonatal nurse, or a first time parent, here’s clear evidence that a newborn is experiencing pain:

Crying: At one time, people believed newborn cries were not purposeful sounds, but random noises. But when a newborn cries, I mean wails, his breath cut short, his face turning the color of an eggplant, you know he needs more than his diaper changed. With prolonged crying, newborns may turn cyanotic, or blue, from decreased oxygen levels.

Facial expressions: furrowed eyebrows with eyes squeezed shut. You might also notice their chins quivering.

Body Language: Kicking. Clenched fists. Flailing – arms and legs pulled in then stretched out. Premature babies often become quite and still, or floppy when in pain.

Vital signs: Increased heart rate and blood pressure. Decreased oxygen levels. A change in vital signs are particularly helpful when assessing premature or ill newborns in pain, as they do not have the energy to cry or flail like healthy newborns.

To help determine appropriate intervention, it’s common practice for nurses to score newborns’ discomfort (http://www.vuneo.org/nppainass.htm).

But how do you relieve newborns’ pain? If you’re a neonatal nurse, and the source of pain is evident – the newborn just woke up from abdominal surgery for instance – administration of narcotics might be warranted. Parents might worry that their newborns will become addicted to pain medication, but allowing babies to endure unnecessary pain comes with consequences: difficulty sleeping and eating, and physiological and structural changes in the nervous system. Babies might become hypersensitive to pain during future procedures (http://www.ncbi.nlm.nih.gov/pubmed/12391738). Different from addiction – a psychological issue – babies can become physically dependent on pain medication. To avoid withdrawal symptoms, nurses slowly wean them off medication.

Swaddling, breastfeeding, skin-to-skin contact with parents, sucking on a pacifier, and infant massage can also alleviate newborn discomfort (http://www.parents.com/baby/care/newborn/how-to-massage-baby).

You might think of war veterans when you hear, or see, the words post-traumatic stress disorder – an anxiety disorder recognized after the Vietnam War, when soldiers returned home with symptoms of mental illness. You might also think of victims of tragic accidents, rape victims, or those who have endured any kind of abuse. What about health care workers, such as nurses? We tend to think of nurses as in control, emotionally strong, even in the face of gore and death. Still, nurses often hear others ask them, “How do you do what you do? How do you manage watching people die all the time?” But nurses suffer from PTSD too, also referred to as compassion fatigue, vicarious trauma, or empathic strain. PTSD is an occupational hazard for nurses. Fourteen percent of nurses experience PTSD symptoms – compare that statistic to the 3.5 percent of the general adult population.

Critical care, emergency room, and labor and delivery nurses are particularly at risk for PTSD, as well as those who work on rescue transport teams. For long shifts – twelve, sixteen, hours they witness an unending stream of trauma: shooting and stabbing victims, an attempted suicide victim, the deaths of newborns – the list goes one. Nurses cannot simply walk away from patients who are bleeding or not breathing. Their duty is to be wholly present – physical and emotionally – at patients’ bedsides. And since nurses are perfectionists (I’m a nurse, so I know the feeling), they might view their own PTSD as a sign of weakness. It’s easier for them to see symptoms of PTSD in others, because that’s what nurses are supposed to do – assess patients, then intervene on their behalf. Nurses, unfortunately, don’t take care of themselves.

Treatment is simpler than you might think: stretches and meditation. Researchers at the National Institutes of Health followed 22 nurses with PTSD symptoms. Led by someone trained in exercise science and martial arts, the nurses participated in a twice a week mind-body class that involved stretching, deep breathing, meditation, and balancing techniques. After eight weeks, half of the nurses experienced a 41 percent decrease in symptoms; the other half experienced only a four percent decrease. The exercises were simplified so that the nurses could easily engage in them anywhere at anytime, even during a quick bathroom break.

For more information see The Endocrine Society’s Journal of Endocrinology and Metabolism, Volume 98 Issue 7 – July 1, 2013.

http://nursing.advanceweb.com/Features/Articles/PTSD-in-Nurses.aspx

http://www.uic.edu/orgs/convening/vicariou.htm

http://psychcentral.com/news/2013/05/30/mind-body-techniques-reduce-ptsd-in-nurses/55418.html

http://press.endocrine.org/doi/full/10.1210/jc.2012-3742