Feeling Burnt Out? The Adrenal Fatigue Link

stressAdrenal fatigue has gained increased attention as more of us recognize burning our candle at both ends is not all that good for our health. It was previously understood that the feeling of burnout was more a psychological issue, typically related to work and almost entirely a mental health issue. Pharmaceuticals were prescribed. Some were helped, yet most, only temporarily. More recently, experts have started recognizing that exhaustion of physical or emotional strength and loss of motivation is typically the result of prolonged stress and frustration, and while also related to work and life circumstances, its effects are both mental and physical. The exciting news, experts are increasingly recognizing remedies which offer improvement of symptoms in a matter of days to months, without the need for long-term pharmaceutical dependence.

We’re spending so much more time at work. Downtime is still up-time because we continue to check our email, tweets, texts, and Facebook. There is no rest. Personal lives are overwhelmed by on-going work, and as a midwife, I can certainly relate. Drawing boundaries can be exceptionally challenging and ultimately, damaging to our adrenals, particularly when we interrupt our sleep.

Burnt-Out Symptoms

Physical

  • Chronic pain
  • Fibromyalgia
  • Headaches
  • Joint pain
  • Inflammation
  • Muscle spasms
  • GI issues
  • Sexual dysfunction
  • Fatigue
  • Burn-Out
  • Light headed or dizziness

Emotional

  • Anxiety
  • Stress
  • Feeling overwhelmed
  • Burn-Out
  • OCD
  • Fatigue
  • PTSD

Clinicians are recognizing patterns as well. For example, teens, especially girls with adrenal fatigue, often complain of GI upset, headaches, and fatigue. Men often complain of sexual dysfunction, while women tend to complain of pain and fatigue. A significant proportion of our population are being treated for anxiety, stress, OCD, pain or fatigue. Many times these physical and emotional complaints don’t appear to have one root cause. It’s imperative that primary practitioners ask about such symptoms, and screen for them. Our practice offers the Edinburgh screening at each well woman visit, as well as each trimester in pregnancy and at each postpartum visit. If we were primary providers for men, we would offer the same for our postpartum fathers as one in ten have some sort of perinatal mood disorder.stress causes disease

Screening

Additional questions the clinician may consider asking or you can ask yourself, include:

  • Do you feel numb, unable to feel joy
  • Have you lost your drive
  • Does everything and everyone irritate you
  • Do you feel that nothing is worth the effort at home
  • Do you feel that nothing is worth the effort at work
  • Do you have multiple aches and pains
  • Restless, feeling keyed-up or being on edge
  • Easily tired
  • Having problems concentrating
  • Irritability
  • Muscle tension
  • Trouble falling asleep, staying asleep, or general poor sleep
  • Do you have anxiety
  • Does your anxiety interfere with your life
  • Do you feel depressed
  • Have you thought of hurting yourself or other as a solution to your problems

These questions may seem common, but they are specifically designed to pull out both emotional and physical concerns. If five or more questions are flagged, evidence suggests cortisol levels are low indicating need for further assessment. Certainly chiropractic and nutritional care can be exceptionally helpful.

How Does Burn-Out Occur?

Adrenal fatigue is related to chronic stress, whether emotional or physical. This stress can be positive or negative, whether getting married, graduating and moving to physically training for a triathlon or birthing a child to experiencing a traumatic event. The body is simply fatigued and has little reserve for further endurance.

Interesting Studies

Lupien, Maheu, Fiocco, & Schramek (2007) discovered the presence of high cortisol levels seem to lock in bad memories. This is important for those that suffer post-traumatic stress disorder. Sexual abuse is a common abuse, for example, and the trauma increases cortisol levels, which subsequently keeps the memory fresh, replaying in one’s mind, and ultimately leads to post-traumatic stress disorder (PTSD).

Another interesting finding is related to DHEA, which is the hormone that responds to acute psychosocial stresses and essentially flushes the body of its negative response. DHEA attempts to create balance after a stressful event. Lennartsson, Theorell, Kushnir, Bergquist, & Jonsdottir (2013) discovered that those with PTSD most often have lower levels of DHEA; therefore, they are unable to find psychological balance after a traumatizing event. Their brains never get washed clean from these emotional traumas.

Scientists are discovering that there are biochemical reasons for why people suffer anxiety, depression, OCD and PTSD. They recognize the link and can treat it effectively.

Tanriverdi, De Bellis, Ulutabanca, Bizzarro, Sinisi, Bellastella, Paglionico, Mora, Selcuklu, Unluhizarci, Casanueva & Kelestimur (2013) investigated pituitary function after traumatic brain injury are discovered long term hormone deficiencies which plays a role in post-traumatic stress after such events. Researchers have also correlated a desensitization following childbirth to cortisol and the feedback mechanism following stressful events, leading to perinatal mood disorders.

PANDAS is the abbreviation for a new pediatric autoimmune disease, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Steptococcal Infections. This term describes a subset of children who have obsessive compulsive disorder (OCD) or a tic disorder such as Tourette Syndrome, whose symptoms worsen subsequent to a strep infection. These children often experience a dramatic onset of symptoms. The theory is that the infection depletes their reserves and their neurotransmitters need evaluated.

 

Adrenal Function

The adrenal cortex which surrounds the adrenal medulla, releases glucocorticoids such cortisol, mineralocorticoids such as aldosterone, and sex hormones such as testosterone. The adrenal medulla then releases, epinephrine and norepinephrine. The adrenals are responsible for the fight or flight response. Those who face stressful events, particularly chronic adrenal glandsstress continue in this fight or flight response and drain their reserve of DHEA to ‘wash themselves clean’ of the stress response. Signs and symptoms then present (see above), and clients state, “I just don’t feel myself.” A clear sign is sharing multiple complaints, physical and emotional, although most can identify that they are genuinely burnt out.

Triggers

We’ve talked about chronic and acute stress, whether emotional or physical, and certainly trauma can create adrenal fatigue, but less appreciated is the genetic relationships. Introverts are quite vulnerable, because the theory is that the entire reason they are an introvert is because they have an over stimulated nervous system. Introverts seek solitude in effort to decrease their stimulation. Extroverts are not typically over stimulated, and aren’t as likely to have PTSD or burn out. Abnormal neurotransmitters or hormone imbalances are generally the root cause. Personally, I’ve noticed as I’ve become older, I have become more and more of an introvert. Based on this theory, my transition makes perfect sense. As a child of a single mother who was rarely home and simply failed to connect with me as a child, I earnestly sought out relationships and connection with others, feeling very energized within groups of people. As a midwife, in a service role with many demands at all times of the day and night, every single day of the week, I find myself secluding myself outside of work needs.

Those of us who have mastered the lifestyle of a procrastinator can also relate. We sort of thrive off the cortisol release generously extended when we wait until the last minute to complete a project, but if these demands have any consistency, good results will not continue. Our bodies simply can not tolerate continued stress. One of my favorite nurses also struggles with this reality, in that she takes on new assignments with great eagerness and excels, but only for a while. Eventually she crashes and burns, because that cortisol high doesn’t sustain her and her reserve runs dry. Many of us know that person that over promises and under-delivers. They have great intentions, but can’t seem to follow through. How many of you end up sick on vacation, or on every school break? You ramp your body up and up in preparation, and then crash and burn the moment you have opportunity to relax.

I use to thrive under stress and always did very well. Now I can’t handle anything!

You have worn yourself out. Your body can no longer tolerate the stress. There is no more reserve. This is adrenal fatigue.

Hypothalamus-Pituitary-Adrenal Axis

The biochemical pathways of stress are quite complex. In easy terms, each of us have hormones that respond to stress. We also have hormones that come in to restore us to a healthy balance. During acute stress, we’ll find high levels of these neurotransmitters, but eventually our reserves will run low of those which try to restore. Important as well, our body can become desensitized to the increased fluctuation. Not only does our nervous system begin to become somewhat numb to hormonal response, but we also begin to decrease our overall response to stress. End stage adrenal fatigue is evident when each of the neurotransmitters are depleted and, the client shares a plethora of signs and symptoms, typically visiting multiple practitioners in hopes of finding a solution.

Physical Exam and Diagnostic Testing

Certainly the clinician should provide a full head-to-toe exam to rule out obvious pathologies, including obtaining any pertinent laboratory tests. Orthostatic hypotension should also be evaluated, as well as orthostatic muscle testing. Positive findings in either of these tests can be quite indicative of adrenal fatigue. Pupils of someone with adrenal fatigue may be larger with a slower response. Ligament laxity test is another good test for determining the presence of adrenal fatigue.

Physical Exam for Stress and Anxiety

The Maslach Burnout Inventory (MBI) is a screening tool is currently viewed as the gold standard for measuring burnout. Correlation between results of this test and increased cortisol levels is significant. Diagnostic tests which follow the Maslach Burnout Inventory test are easy to obtain, can be performed in the privacy of the client’s home, and can identify concerns within both the endocrine and nervous system. Not only are the adrenals assessed, but also the HPA axis: neurotransmitters, cortisol and DHEA specifically.

Clients suffering from anxiety, depression, fibromyalgia, chronic pain, insomnia, fatigue, ADHD, low libido, post-traumatic stress, obsessive compulsive disorder, burn-out or the common, “I just don’t feel right” syndrome can benefit from this testing. Treatment then can be determined specific to individual findings, whether that is in nutritional support, herbal remedies, essential oils, or on rare occasion, pharmaceuticals.

Why try Alternative Treatments?

The goal of all complementary medicine modalities is to balance the body. Rather than target the body with pharmaceuticals, identify the actual cause and nudge the body to fix itself. Nutritional supplements such as those designed by NeuroScience, which our practice frequently utilizes in these cases, are not addicting. They heal the body rather than mask the symptoms. Treatment regimens can be personalized through an in-depth review of the client’s symptomology, physical exam and diagnostic tests. We aren’t guessing as clinicians must do with pharmaceuticals. Medications are too specific, addressing a single neurotransmitter, rather than the entire HPA axis.

If you relate, call our office and make an appointment. We would be happy to help you find optimal health once again.

Zodkoy. (2013). Misdiagnosed: The Adrenal Fatigue Link. Retrieved from http://www.youtube.com/watch?v=qJcDavuW044&feature=c4-overview&list=UUGojT7RyTyiLuwu_KEBjMqw

FacebookTwitterGoogle+Pinterest 

Current Status of Indiana Statutes specific to CNMs

We are frequently asked if we are going to open a birth center, especially after opening our beautiful new midwifery clinic in Indianapolis. I will admit that while touring the center, we certainly were tempted and recognize that there is a need for a birth center in the Indianapolis area, but the current statute makes that temptation last no longer than a few fleeting moments.

108 East 9th Street, Indianapolis IN 46204

108 East 9th Street, Indianapolis IN 46204

Currently Indiana is home to only three licensed birth centers: the Auburn Birthing Center, LLC, the Goshen Birth Center, Inc, and the New Eden Care Center, Inc in Topeka. Statute requires that each center have a “staffing physician” which oversees the care provided by the nurse-midwife. In fact, this physician is responsible for “determining, implementing, and monitoring policies governing the center’s operation,” and holds “responsibility for the direction of all medical, nursing and health-related services to patients.” This oversight by physicians is referenced to those outlined in IC 25-23-1-19.4, yet the two are not congruent.

Indiana Code 25-23-1-19.4 does not require “oversight” but rather collaboration, which are not one in the same. Collaboration is a team effort with equal partners, not one supervising the other. Collaboration between a physician or physician group and nurse-midwives within the birthing center could occur without any active role by the physicians in the specific activities of the birth center. Nurse-midwives are highly-educated clinicians, well integrated into the healthcare infrastructure, capable of determining when medical care is indicated and referring appropriately. Obstetricians, experts in pathology and surgical intervention, are best utilized within the hospital environment and still remain readily available for consultation, collaboration, or assuming care in a transport scenario. Their expertise does not typically extend to the management or administration of low-risk maternity services where nurse-midwives excel. Shall we evaluate the state of maternity outcomes today as primarily managed by physicians?

The Indiana Nurse Practice Act defines the practice of nurse-midwifery as “the practice of nursing and the extension of that practice, including well-woman gynecological healthcare, family planning, and care to the normal and expanding family throughout pregnancy, labor, delivery, and post-delivery” (2011, p 82).  The competent practice of nurse-midwifery is further defined as “an independent and interdependent member of the health care team” with a scope that includes making “independent decisions, commensurate with the autonomy, authority, and responsibility of the practice of nurse-midwifery” (2011, p 84). The Indiana State Board of Nursing recognizes that nurse-midwives can “recognize the limits of individual knowledge and experience, and consult with or refer clients to other health care providers as appropriate” (2011, p 84). Why then does the birth center statute require supervision?

Indiana Code 25-23-1-19.4 requires nurse-midwives “operate in collaboration with a licensed practitioner as evidenced by a practice agreement, or by privileges granted by the governing board of a hospital licensed in the state of Indiana with the advice of the medical staff of the hospital that sets forth the manner in which an advanced practice nurse and a licensed practitioner will cooperate, coordinate, and consult with each other in the provision of health care to their patients” (Indiana State Government, 2013). The Nurse Practice Act was crafted by the State Board of Nursing in effort to further detail this statute, and determined that the practice of nurse-midwifery in itself does not require a written collaboration, although certainly collaboration is an integral component of such practice, but does require written collaboration to practice in order to prescribe legend drugs. It is at this point that the details of such collaboration can be quite restrictive, and unfortunately the nurse-midwife is at the mercy of the physician willing to sign the collaboration.

This prescription authority policy, in addition to the birth center bill, needs amended in Indiana. The National Council for the State Board of Nursing (NCSBN) has identified independent practice and independent prescribing as a major elements for improving health care outcomes. State boards of nursing are charged with aligning statutes within each state to the Consensus Model, with an intended implementation target of 2015. Indiana ranks among the worst in the country for its current implementation of the Consensus Model (NCSBN, 2013).

The Institute of Medicine (IOM) published, The Future of Nursing: Leading Change, Advancing Healthrecommending the removal of barriers that prevent nurses from practicing their full scope. The IOM supports the practice model discussed above by the NCSBN, and specifically charges the Federal Trade Commission and the Antitrust Division of the Department of Justice to “review existing and proposed state regulations concerning advanced practice registered nurses to identify those that have anticompetitive effects without contributing to the health and safety of the public” (p 2).

Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States. ~ Institute of Medicine

Indiana Medicare and Medicaid does not recognize the advance practice nurse and cover such services as physicians are covered for the same services. Indiana does not require third-party payers that participate in fee-for-service payment arrangements to provide direct reimbursement to advanced practice registered nurses who are practicing within their scope of practice under state law. In fact, they can refuse to cover any care performed by a nurse-midwife or any care provided within a birth center or within the home. Nurse-midwives are not protected from being discriminated against by physician colleagues or medical boards when requesting hospital privileges, although this collaboration is required for the practice of nurse-midwifery in the state of Indiana.

The Gift of Remembrance for Grieving Parents

The loss of a precious child is an experience no loving parent should have to face. It is so important to nourish support systems which may help bring peace to grieving families in times of need.

GriefNow I Lay Me Down to Sleep is a non profit organization devoted to providing grieving families enduring the loss of a child with professional portraits to help them remember the beauty of their precious time together. Through this organization, photographers receive training and education so that they are able to create heirloom quality portraits for families to treasure. Over 11,000 photographers work with NILMDTS and the photographs are taken and reproduced free of charge.   The organization is present in all 50 states and in 40 countries worldwide. NILMDTS is sponsored by professional photography guilds, but also continues to exists thanks to generous donations. The professionals who volunteer with NILMDTS understand photography within the hospital environment. They require little space. Training through the organization prepares photographers for the sensitive situations they encounter.

NILMDTS was founded in 2005 by Sandy Puc’ and Cheryl Haggard, after Cheryl’s son Maddux Achilles Haggard was born with a condition which prevented him from breathing, swallowing, or moving on his own. Faced with this tragedy, the Haggard family watched their child suffer for several days before making the difficult decision to remove artificial life support. Sandy visited the family, and took pictures of Maddux cradled in his parents’ arms both before and after the tubes and wires which sustained him were removed. These beautiful remembrances of their eternal connection to their child inspired Cheryl and Sandy to bring this gift to parents suffering pregnancy loss, stillbirth, or who are caring for newborns at risk of dying.

If you are interested in learning more about Now I Lay Me Down To Sleep, whether they offer a service your family or friends may need, or you are interested in becoming involved as a donor or a photographer, visit their website.  Their mission is worthy of support and admiration.

 

 

Thanksgiving Safety Tips

Thanksgiving is a time to stop the chaotic routine, settle in with family, and take the time to give thanks for the abundance of blessings each of us often take for granted. This particular holiday is not one we typically associate with any particular risk, as we do with the Fourth of July celebrations for example, but surprisingly there are a few precautions each family should be aware.

Emergency room physicians share that family football games bring in a number of head injuries each year. I applaud the active contribution beyond the sedentary recliner viewing, but scrapes, bruises, and concussions do occur each year. Emergency room physicians warn that groups should consider wearing helmets, particularly when kids and adults are playing together (Scudder & Glatter, 2013).

Auto accidents are another concern, with 500 deaths reported each year and more than 43,000 emergency room visits. Don’t let yourself become distracted while driving. Put down the smartphone, tablets and other multimedia agents. Consider that everyone else probably has their face in their smartphone so you need to be hyper-vigilant due to their lack of concern.

It is no surprise that over-eating occurs on Thanksgiving, but were you aware that this can cause chest pain severe enough in some family members to require an emergency room visit? Heartburn can be significant and while some simply need to be educated in understanding the difference between heartburn and genuine chest pain, some are sincerely putting themselves at risk for having a myocardial infarction because of their indulgence. Experts have named this phenomenon, “Holiday Heart Syndrome,” which is caused by the combination of consuming alcohol and overeating. More specifically this is generally related to binge drinking and binge eating which can cause an otherwise healthy person to have an arrhythmia, most typically atrial fibrillation. Of course those with a known cardiac disease are also at risk. Hydration via intravenous fluids is typically the remedy, although medications are sometimes required to control the heart rate (Scudder & Glatter, 2013).

More and more people are consuming stimulants such as “raging bull” or “speedbull” which may be utilized on Thanksgiving to counter the sleepy effect caused by the large turkey dinner. Synthetic cannabinoids, such as spice, K2, and bath salts are also experimented by new members of the family during these holidays, which have very serious side effects including arrhythmias, stroke, and intracranial bleeding. Electronic cigarettes are also being utilized by more consumers, especially teenagers, who are presenting to the emergency room with agitation and extreme anxiety alongside an elevated heart rate due to the inhalation of large amounts of nicotine (Scudder & Glatter, 2013).

Thanksgiving

Sadly, Thanksgiving is not a holiday welcomed or even pleasant for all. I have great compassion for the diabetic for example that isn’t at liberty to indulge in sampling each of the desserts brought for enjoyment. However, many are affected by the stress of the holiday including anxiety caused by family arguments. Panic attacks bring people to the emergency room, sometimes with symptoms similar to a heart attack. Fistfights and facial trauma are another reason people end up in the emergency room on Thanksgiving, particularly if alcohol is involved.

Geriatric clients also frequent the emergency room more frequently on the holidays, sadly because they are more likely to have visitors that recognize their declining health. Most often the family is simply not aware of the progression of their chronic disease and see the matter as more acute, while at other times, the elderly family member may have an acute need that needs to be identified and treated (Scutter & Glatter, 2013).

Thanksgiving is among the most favorite of all holidays enjoyed by US citizens, but the heightened energy created in the midst of an otherwise chaotic life can create a perfect storm.

Scudder, L & Glatter, R. (2013). How safe is Thanksgiving? Medscape Family Medicine.

Fertility Awareness: TwoDay Method

The TwoDay Method is my favorite approach to fertility awareness and one I teach most all my clients.

Many of my clients are familiar with the Billings ovulation method and the symptothermal method (and their variants), all of which a great deal of research has supported with 95% to 98% effectiveness. Their use poses no harm to either the woman or an developing baby if that were to occur. Despite their safety and efficacy, very few women utilize these methods because of the time and effort required.

The Standard Days Method and the TwoDay Method are two newer fertility awareness-based methods developed by researchers at the Georgetown University Institute for Reproductive Health. They are effective, easy for women and couples to use, and easy for clinicians to offer (Germano & Jennings, 2006). Fertility awareness-based methods are based on observation of fertile and infertile periods of the menstrual cycle. Certainly we are aware of the dominant sign of the cycle, the menses, but changes in cervical secretions, changes in basal body temperatures and a change in the position and feel of the cervix also occur. Fertility awareness-based methods usually rely on the identification of more than one of these symptoms; hence, the difficulty in their use and in the increased time required for health care providers to effectively teach these methods (Germano & Jennings, 2006).

The ovulation method otherwise known as the Billings method, requires the character of the cervical mucous be monitored as well as the sensation of wetness. Dryness and a sticky mucus correlates with infertile days, while wetness or slippery mucus correlates with fertile days. The symptothermal methods requires the woman to monitor her cervical secretions, record her basal body temperature daily, and monitor other bodily changes during the cycle, such as breast tenderness, mittelschmerz, increase in libido, and mood changes. Commercially available fertility monitoring devices are sometimes used in conjunction with these assessments to further validate fertility (Germano & Jennings, 2006).

The Standard Days Method

The Standard Days method is based on the understanding of the menstrual cycle as well as the life span of the sperm and ovum. Women whose cycle ranges between 26 and 32 days would be appropriate candidates, which would include about 80% of women. Using this method, women would need to understand that they are fertile between days 8 and 19 of their cycle. No monitoring of their temperature, cervical secretions, or other bodily symptoms are necessary with the Standard Days Method.

Researchers have discovered a 4% probability of pregnancy if intercourse occurs 5 days before ovulation. The probability increases to 15% if intercourse occurs 4 days before ovulation, and increases to between 25% and 28% if intercourse occurs 1 to 2 days before ovulation. After ovulation, there is an 8% to 10% probability of pregnancy if intercourse occurs within 24 hours. Fertility then decreases, and there is no probability of pregnancy by the day after ovulation (Germano & Jennings, 2006).

These probabilities are determined based on the limited viability of sperm (not more than 5 days) and to the very limited life span of the ovum after ovulation (less than 24 hours). Together, this offers a fertility life span of no more than 6 days each cycle. Of course these days are figured around the mid-cycle period when 95% of ovulations have occurred. Computer analysis of the two probabilities – the probability of pregnancy on different cycle days related to ovulation, and the probability of the timing of ovulation – provides a fertility probability only during days 8 through 19, and intercourse during all other days can be enjoyed without concern for pregnancy. The efficacy, with correct use, is 95.2% with only five of 100 becoming pregnant in the first year of use (Germano & Jennings, 2006).

1.1279316024.fertility-cycle-beadsCycleBeads are a color-coded string of beads that assist women in tracking their cycle days, recognizing their fertile days. Again, these women must have some level of confidence that their cycles usually come about a month apart and when they expect them. This method can be started immediately; however, if breastfeeding, cycles will need to be re-established first. Cycle lengths should be monitored for regularity and barriers methods should be utilized during fertile days (Germano & Jennings, 2006).

The TwoDay Method

This method maximizes on the cervical changes that occur with the menstrual cycle and therefore, doesn’t limit itself to women with regular cycles. The other beauty in this method is that it doesn’t require analyzing the characteristics of the secretions, such as amount, color, consistency, slipperiness, stretchability, or viscosity. Women simply need to ask themselves, “Did I notice any secretions today?” and “Did I notice any secretions yesterday?” If yes to either question, then she may be fertile. Researchers determined the theoretical efficacy of the TwoDay Method as at least as high as that of the Standard Days method.

Nurse-midwifery takes a holistic approach to the care of women and gynecologic care is a large part of that service. Education and counseling in these options empower women to take charge of their own fertility without the need for pharmaceuticals which might invite risk to their health, in spite of their enormous benefit.

Have you utilized either of these methods? Do you have a preference?

References

Germano, E. & Jennings, V. (2006). New approaches to fertility awareness-based methods: incorporating the Standard Days and TwoDay methods into practice. Journal of Midwifery & Women’s Health, 51(6), 471-477.

Prescriptive Authority for Indiana Nurse-Midwives

One of the greatest barriers to the practice of nurse-midwifery in the state of Indiana is the requirement of a written collaborative agreement to prescribe legend drugs. This collaboration is not specific to the practice of midwifery. In fact, a physician of any speciality can sign such requirement so this isn’t about true collaboration, but rather an attempt to restrict the trade of midwifery.

PillsDr. Kathryn Osborne states in her (2011) article published with the Journal of Midwifery & Women’s Health, “The ability of midwives to dispense, administer, or in any way furnish medications for their patients is central to the provision of health care to women but has long been fraught with controversy and challenges” (p 543). The history of midwifery provides tales of midwives burnt at the stake because those in authority feared their power, especially because many mastered the therapeutic use of herbs and oils. Arguments point towards feminist inequality, religious corruption, or social class structuring but no matter the cause, the practice of midwifery has always been oppressed and continues to be today.

The profession was introduced to our country in the 1920′s by Mary Breckinridge, the mother of the Frontier Nursing Service, of which I am a proud alumni. Nurse-midwives, since the onset, have been more than birth attendants but also primary care providers. Osborne points out in her article that with the integration of the Patient Protection and Affordable Care Act (ACA), more primary care providers will be needed to meet the need of the growing insured population making it “crucial for clinicians and policymakers to remain aware of regulatory requirements for all health care providers and to move forward with modification of current laws that pose barriers to practice and limit patient’s access to primary care providers” (2011, p 543).

Certified nurse-midwives have been granted authority to write prescriptions in all fifty states and the District of Columbia, yet that regulation varies greatly from state to state. Ideally, advance practice nurses would have independent privileges to prescribe pharmaceutical medications and the rules and regulations would be consistent across the nation. However, in reality most states present rules and regulations that further create barriers to prescription privileges such as requirements for the number of hours in clinical practice, continuing education, quality assurance, notification of the regulatory board regarding a change in consulting physician, and recertification/certificate maintenance (Osborne, 2011).

Certified nurse-midwives provide primary care for women, “including the provision of all essential elements of primary care and case management: evaluation, assessment, treatment, and referral as necessary. Prescribing medications in an essential component of the treatment of patients” (Osborne, 2011, p 554). Limiting the ability of the advance practice nurse to prescribe is nothing less than limiting access of necessary care to consumers and a restriction of trade for our profession (Osborne, 2011).

References

Indiana State Board of Nursing. (2011). Retrieved from http://www.in.gov/pla/nursing.htm

Osborne, K. (2011). Regulation of prescriptive authority for certified nurse-midwives and certified midwives: a national overview. Journal of Midwifery & Women’s Health, 56(6), 543-556.

 

Electronic Health Records: Mobile Midwife EHR

Midwives have traditionally documented notes regarding their clients care in fairly unstructured handwritten documents. Their clients may have additional charts of healthcare information stored in the area hospital, their community clinic and within the physician’s office. Access to each was a challenge and certainly was never complete, and then abstracting information and comparing it whether for management of care or for quality assurance was slow and difficult, limiting efforts to optimize care. Technology now exists to transition these charts to an electronic format. In fact, President Obama signed the American Recovery and Reinvestment Act (ARRA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act into law in 2009 providing the Department of Health and Human Services (HHS) the authority to establish programs for improving healthcare quality, safety, and efficacy through digital health systems.

“Healthcare professionals need to know more today to perform their daily jobs than at any previous point in history,” (Hebda & Czar, 2013, p 4, para 3). Authors continue, “Advancements in knowledge, skills, interventions, and drugs are growing at an exponential rate. This makes it impossible for any one individual to keep up with all the knowledge needed to practice nursing or any of the other healthcare disciplines without making use of available resources and continuing education. Unfortunately there is a failure on the part of the present healthcare delivery system to consistently translate new knowledge into practice and apply new technologies safely, appropriately, and expediently,” (Hebda & Czar, 2013, p 4, para 3). Healthcare is plagued by a twenty year gap before evidence translates into practice changes. Information technology offers the advantage of bringing necessary knowledge to the nurse in the midst of client care. The profession was once about performing clinical tasks. Then it became more about how to critically think. Now we are charged with the need to critically synthesis evidence-based medicine. EHR

Information Technology Safeguards

EHRs offer tremendous benefit to the patient population including improved access to information, error reduction and improved communication, decreased redundancy of data entry, convenience, decreased time spent in medication administration and documentation, increased time for client care, facilitation of data collection for research, improved quality of documentation, improved compliance with regulatory requirements, improved record security, improved quality of care and patient satisfaction, decreased administrative costs for location and maintenance of client’s records, offering the creation of a lifetime clinical record and cost-savings. While most believe the benefit outweighs any risk, some fear its threats to privacy and private healthcare information (Hebda & Czar, 2013).

Other benefits to EHRs include decision making tools, alerts, and reminders notifying the clinician of possible concerns or omissions. For example, if the nurse-midwife orders Codeine for the breastfeeding client, an alert will notify the clinician of the contraindication and ask for clarification. EHRs should have access to reference databases so practitioners can research best strategies for patient care management. Another example would be an EHR reminding the clinician that a TSH is due to be drawn on the pregnant client with hypothyroidism.

Mobile Midwife

Our practice has recently made the transition from paper to EHR. This is our second transition into the digital health records enterprise. Our first system was designed for primary care with a strong billing component, Office Ally, but did not offer documentation for intrapartum care management. It ultimately proved to be too time consuming, particularly after we transitioned to a cash only practice. Paper documentation once again proved to be more efficient and thorough.

Mobile Midwife EHR, our second trial at EHR, is the premier electronic charting and patient health records software for the iPad. It allows midwives to hand their iPad to the client so they can independently complete their entire health history and sign all documents and consent forms. Then the midwife uses the iPad to review client’s history, adding any additional information gained from their one-on-one consultation, record prenatal visits, labor flow, postpartum and newborn visits. Creator, Michael Daly, has recently implemented primary care components for both the female and male clients. Most unique, is that Mobile Midwife does not require internet connection so traveling midwives can continue to document, then later syncing with other users when a link to the internet is again obtained (Daly, 2013).

How does Mobile Midwife Measure Up?practitioner using ipad

Mobile Midwife EHR is cutting-edge for homebirth midwives – phenomenal, in fact. However, there is room for considerable growth. Michael Daly has an incredible vision and the tenacity to bring it to fruition. Current subscribers have bought into this promise of growth and thus far, have been far from disappointed. The climb however, is steep.

EHRs should ensure access to the right information at the right time to the people who need it. Practitioners require access to clinical practice guidelines, standards of practice, policy and procedure manuals, research findings, drug databases, and information on community resources (Hebda & Czar, 2013). Remember the days of searching the nurse’s desk for the PDR and how many were actually equipped with Hale’s, Medications and Mother’s Milk? These are days of the past.

One aspect of the ARRA necessitates mandated reporting requirements structured to provide information critical for the improvement of patient care delivery. Incentives were established through EHR programs, with financial reward for meeting meaningful use requirements. Reform efforts focused on the integration of hospital programs with physician’s offices, improvements in care management, widespread use of digital healthcare records, and improved third-party payer relationships.

The push for patient safety is driven by the World Health Organization and the Joint Commission. After their identification of specific problems within the healthcare system, solutions for improvement can be established within EHR programs. For example, it was determined that patients would benefit from increased incidence in hand-washing by their healthcare providers. EHR programs were then installed with pop-up reminders. One study in which healthcare providers were video-taped to assess whether the pop-up reminder increased hand-washing practices, demonstrated a positive effect. Medication accuracy, patient identification, and verifying correct procedure and body site have been additional solutions that have been addressed via EHRs. An EHR system therefore, should allow for implementation of strategies for improving health outcomes. Does the EHR program allow for medication reconciliation, for example?

The Patient Safety and Quality Improvement Act of 2005 initiated the creation of patient safety organizations that collect, aggregate, and analyze confidential information reported by healthcare providers. Information is shared about adverse events for learning purposes, allowing institutions to compare their error rates with the statewide rate and produce safety alerts that help organizations to act proactively. Prior to EHRs, there was no ability for wide scale learning from incidences and failures within other organizations and practices (Hebda & Czar, 2013). Birth center practices, as well as home birth-based practices, could establish similar databases that would exponentially improve healthcare outcomes.

EHRs should assist with the process of positive patient identification. Identification errors for procedures should be reduced, as well as errors during medication administration, laboratory testing, bedside glucose checks and blood transfusions, and the administration of intravenous fluids. While the birth center and home birth-based midwife has limited risk in falsely identifying the proper client during the intrapartum or postpartum period, clinic days can be busy and pose the risk of confusing allergies, medications, necessary labs or management plans among clientele. Some programs utilize barcodes. Others have implemented RFID technology. No single technology has proven to be superior (Hebda & Czar, 2013).

E-prescribing, yet another safety feature, is less about the convenience of communicating a prescription need to the local pharmacist, and more about doing so accurately and effectively. IT applications are available for assessing risk management. They may provide clinical alerts specific to the client’s medical history or assist in clinical decision making via collection of data from external sources. E-prescribing eliminates the inability to read the notoriously illegible physician’s handwriting, increasing the incidence of getting the right drug into the right client’s hands.

Does the EHR system allow for computerized provider/prescriber order entry? Does it allow for standard protocols or custom creation as appropriate? Are alerts for critical lab values and prompts when certain tests are due incorporated into the program? Are prescribers warned about potential problems with dosages, drug interactions, allergies, and contraindications such as pregnancy, herbs or other health conditions (Hebda & Czar, 2013)?

Decision-making software is a bit hard to conceive for many of us, but this application can analyze data and present information in a fashion that assists the practitioner in making clinical decisions for the individual client. Lab values, standards of care, and other patient-specific information can be identified while the system reaches into the digital scientific database for knowledge that extends beyond the practitioner’s expertise. Decision-support software is part of the meaningful use criteria which would allow providers to qualify for financial incentives.

Mobile Midwife EHR would benefit from a nurse consultant and an IT to assist in implementation of its projected growth and certain IT support. Midwives require immediate access to support staff at all hours of the day and night, seven days a week. This is potentially our greatest anxiety. Will we get the help we need, when we need it? Michael Daly, creator of Mobile Midwife EHR, has proven to be a trustworthy and professional man, a brilliant visionary, and one that we’re trusting to carry us through into the IT healthcare age.

Public Policy: Understanding the Ropes

The term “policy” is an overarching term used to define both an entity and a process. It is used to refer to goals, programs and proposals. Organizations use this term to outline their “standing decisions.” Just as those policies reflect on the values of the organization, governmental policies reflect on the beliefs of our administration and provide direction for the policy and mission of our individual governmental organizations (Milstead, 2004). The Indiana State Board of Nursing is a governmental organization which regulates the practice of nursing, which all advance practice nurses are subject. In Indiana, lay midwives are regulated by the board of Medicine.

The purpose of public policy is to direct problems to government and secure government’s response (Milstead, 2004). This process is complex and a single policy can affect all arms of the government. Legislatures work to protect the public through regulation of nursing practice and publish opinions on what constitutes safe practice (Milstead, 2004). Regulations define which people can do what functions. For example, Indiana currently has a regulation that prevents nurse-midwives from ordering physical therapy. This order could come from a nurse-practitioner, a chiropractor or a physician, but nurse-midwives were over-looked in creation of this statute. Lay midwives have regulation that prevents them from initiating intravenous fluids.

Laws are types of policy entities. They define action that reflect the will of society or at least a segment of society. Laws may be international, federal, state, regional or local. While the legislative branch of the government controls lawmaking, it is the role of judges to interpret and enforce the law. Many laws are deliberately written quite broad, leaving opportunity for judicial interpretation. The courts may also determine how the laws should be applied, or whether they are unconstitutional (Milstead, 2004).

One point that I had to learn was that although regulations are included in discussion of the law, they are in fact different. Government agencies formulate regulations that achieve the intent of the statute, a sort of interpretation for example. The statute always supersedes the terms of the regulation. Our Indiana State Nursing Act has some inconsistencies between the statute and the regulation that nurses, particularly advance practice nurses, should make themselves aware.

When most people talk about politics or the ambiguities and frustrations within this infrastructure, they are reflecting on the complexity of the various entities. Members of Congress, Congressional staff, special interest groups and their lobbyists, the Executive branch, constituents and the media are all important players. Currently this includes more than 535 members of Congress, 100 Senators, and 35 representatives. The political party with the majority of seats holds considerable influence ranging from setting the legislative agenda to sharing all the congressional committees. The identification of problems and possible solutions emanate from the political ideology of the party in control. Currently the House is Republican controlled but Democrats have majority in the Senate; hence, why nothing gets done! Indiana remains a loyal Republican state, and because of this, our state’s beliefs and priorities are expressed within that framework.

Experts in public policy warn that while it is important to be familiar with the positions policy makers take on various issues, it is equally important to look for cues as to why they have taken or whether they are likely to take certain positions. Identifying these personal characteristics that extend beyond political party affiliations helps determine how malleable an individual may be in the future.

Congressional Staff

Personal Office Staff
Members of Congress employ a number of professional staff within their offices. For example, there is typically a chief or administrative assistant that is responsible for overseeing the press, political and public relations, directly personnel and office management, and maintaining the oversight of the legislative operations. There are also legislative directors responsible for day-to-day legislative work, which have more policy expertise, and there are assistants who work on specific legislation. Every member of Congress has a legislative assistant who is responsible for health policy.

Committee Staff
In addition to personal staff, there are hundreds of experienced professional staff responsible for supporting the work of the congressional committees.

Special Interest Groups and their Lobbyists are those individuals who have organized themselves around a common interest and who seek to influence public policy. Penny is currently a board member on both the Indiana Affiliate branch of the American College of Nurse-Midwives and the Coalition for Advance Practice Nurses of Indiana, and a member of the legislative team for the Indiana State Nursing Association. CAPNI has hired a lobbyist to represent their views, and ISNA currently has two very active lobbyists. In addition to meetings, mailings, conversations with legislative assistants and other strategies, lobbyists will argue their efforts as necessary with grassroots campaigns to bring additional pressure to a member of congress.

The Executive Branch
The nurse should be mindful that considerable interaction occurs between the legislative and the executive branch. The Head of the National Institute for Nursing Research for example, appears before both the House and Senate Appropriations subcommittees for Labor, Health and Human Services and Education and related agencies. The testimony presented highlights major nursing initiatives and activities.

Constituents
While lobbyists and special interest groups seem to hold the power in Congress, it is the voters that send people to the Congress. Voters send them and can replace them. Vote! Share your views with your legislative leaders. They do listen. Penny has received contact from legislative leaders for example, after a client attended a town meeting and shared her homebirth experience, requesting more support for nurse-midwives.

The Media
The Congress and media can utilize each other to push their agendas for legislation and regulation, as well as program implementation and program evaluation (Milio, 1989).

Understanding Government Policy

Four steps must occur for decisions to translate into government policy. The agenda must be identified and brought to the attention of the government, and through legislation and regulation, the government will respond. Implementation of the program will occur in effort to achieve the goals of the statute and program evaluation will appraise the program’s performance. An entirely new orchestra of players will be established at each stage. The reality is that these relationships are made within a framework of power and influence, negotiation and bargaining.

Nurses are the largest group of health care professionals in the country, yet we aren’t the most effective in defending our position or in articulating our view in the political arena. Are you a member of the American Nurses Association? Their position statements can be found here. Are you a member of ISNA and your professional organization groups?

In the 1990′s health care was in the midst of a political reform. Priorities were being determined and public policy was being made, and while nurses were included in the discussion, our impact did not result in substantial change. Nurses are in a position to provide expert counsel for legislative leaders and other players in policy making. Nurses should be involved in providing feedback to ensure that old problems are being addressed and new problems are being identified, as well as appropriate solutions being considered. We are the healthcare work force and need to become more active in all levels of policy. We are responsible for using our collective force to influence the health, welfare and protection of the public and health care professionals.

How a Bill Becomes a Law

To learn further about how a bill becomes a law here.

Milstead, J. A. (2004). Health Policy and Politics: A Nurse’s Guide. ISBN-10: 0763731587
Osborne, K. Power-Point Presentation. November 13th, 2013.

Broth & Brown Rice

heart bellyNausea is among the most common of all pregnancy discomforts, particularly during the first trimester. While not the healthiest of foods, broth can offer new mommas significant relief during these challenging weeks. Its bland taste and ability to be swallowed easily certainly makes it a pregnant mother’s favorite, but it is great for anyone with an uneasy stomach, children included. Broth offers sodium and potassium which are helpful for maintaining proper fluid balance.

Choose a low-sodium brand and other healthy features, like organic or MSG-free. Broths may be chicken, beef or fish. Chicken broth offers niacin, riboflavin, selenium, and protein and beef offers protein, riboflavin, and niacin. Broth from fish contains niacin, protein, and some omega fatty acids. None are superior to the other, but if your stomach allows, try all three. Variety and moderation are always best. chicken soup

Niacin and riboflavin play an important role in energy metabolism. They can help your body utilize fats, carbohydrates, and proteins to make energy needed for growth and health. Add some brown rice if your stomach allows or maybe some peeled, minced fresh gingerroot, which is also relieving for a nauseous stomach.

Johnny Bowden Ph.D., C.N.S. recommends adding shiitake mushrooms and chopped chives or sliced green onions (scallions) to the basic broth, rice and ginger. Cubed tofu or chicken will make it even more satisfying. Try it vice versa: cook your rice in broth or simmer your meats in broth and make a gravy.

Brown rice is also packed with minerals such as niacin, magnesium, manganese, phosphorus, and selenium. Niacin is needed for energy production which all pregnant mothers can benefit from and vitamin B6 is especially important for relieving pregnancy nausea. Brown rice is also a good source of fiber which helps to regulate blood sugar and maintain the feeling of satiation.

brown riceKeep in mind that brown rice cooks longer than white rice and requires a bit more water. If trying brown rice without the broth, toss in some raisins or cranberries for added sweetness.

Kicharee

Michael Tierra (1998) recommends kicharee as part of a therapeutic diet. It is easily digested, wholesome, light, warm and mostly liquid which is perfect for acute illnesses. Add steamed vegetables and soupy grains if desired, or miso. Kicharee is made by mixing one-half cup cooked mung beans or lentils with one-half cup steamed brown rice and sauteing in sesame oil or clarified butter (ghee) for five minutes with a pinch of cumin seed, one-third teaspoon turmeric and one teaspoon ground coriander. Then add four cups of water and simmer for twenty to thirty-five minutes. Tierra suggests topping the recipe with a small dollop of yogurt. This recipe has blood purifying properties, an important herbal principle for optimizing health.

Ayurvedic Cooking

Ayurvedic Cooking – WARMTH TV – How to make Kicharee

Ghee, mentioned above, is a clarified butter. It is useful in cooking and makes an excellent base for herbal salves and oils.

Have you enjoyed kicharee? Share your experience with us!

Food for Thought

Food for Thought

"It is much more important to know what sort of patient has a disease than what sort of disease a patient has." Sir William Osler

Food for Thought

Happiness is underrated and critically important to health. Seriously! Unfortunately, many people just have no idea how to be happy. Aviva Romm

Food for Thought

Physicians simply do not have time to be what patients want them to be: open-minded, knowledgeable teachers and caregivers who can hear and understand their needs. Snyderman and Weil

Food for Thought #1

They say that time changes things. But you actually have to change them yourselves. Andy Warhol

Food for Thought

To think is easy. To act is hard. But the hardest thing in the world is to act in accordance with your thinking. Johann Wolfgang von Goether

Food for Thought

"Birth isn’t about avoiding one set of realities in favor of another. It’s about embracing all facets of birth--contradictory, messy, or unpleasant as some might be--as vital to the whole." Rixa Freeze PhD

Food for Thought

Why I appreciate being a certified nurse-midwife, as opposed to choosing another route for midwifery: I feel learning the science is vital so the art of midwifery is safe and effective. Dr. Penny Lane, nurse-midwife

Food for Thought

When the debate is lost, slander becomes the tool of the loser. Socrates

Food for Thought

To accomplish great things, we must not only act but also dream; not only plan, but also believe. Anatole France

Food for Thought

"Science and uncertainty are inseparable companions. Beware of those who are very certain about things. There are no absolute truths in biological sciences - only hypotheses... 'We need to train medical students and residents more in the art of uncertainty and less in the spirit that everything can be known or that it even needs to be known.'" Grimes (1986)

Food for Thought

American physicians are rewarded for doing things to patients, not for keeping them well. Grimes, 1986

Food for Thought

The false idol of technology. "Having a widget screwed into one's scalp has become an American birthright." Grimes, 1986

Food for Thought

"Between 1985 and 1987, a hospital instituted a successful program to reduce its cesarean rate. The rate fell from 18% to 12%, losing the hospital $1 million in revenues - no small sum in those days." Goer & Romano, 2012, p 37

Food for Thought

"Obstetricians are much more likely to perform a cesarean when they wrongly believe the baby weighs 4000 g or more based on sonographic estimates than when the baby actually weighs this much but the obstetrician did not suspect it." Goer & Romaro, 2012, p 35

Food for Thought

"If you play God, you will be blamed for natural disasters." Marsden Wagner (2006)

Food for Thought

An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you know and what you don't. Anatole France

Food for Thought #3

"Birth is not only about making babies. Birth also is about making mothers - strong, competent, capable mothers, who trust themselves and know their inner strength."

Barbara Katz Rothman PhD (1996)

Food for Thought #4

Believe there is always, always, always a way.

When you have exhausted all possibilities, remember this: you haven't. THOMAS EDISON

Food for Thought #5

"All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident." Arthur Schopenhauer

Food for Thought #2

Yet you brought me safely from my mother’s womb and led me to trust you at my mother’s breast.

Psalm 22:9