The Man in the Iron Lung

or rather the people in the iron lungs…

Spending my afternoon off doing the usual things; as I was folding laundry watching one of my favorite quirky comedies, Bubba Ho-tep, it brought to mind an interesting bit of medical history.. the era of the Iron Lung, or negative pressure ventilator.

There is a brief scene at the beginning of the film, which is set in “Shady Rest Home” in rural Texas..  In this scene at the beginning of the film, one of the nursing home residents, who is a bit of a thief, steals the glasses from another resident, an elderly woman who is imprisoned in an iron lung.

iron lung display at the Sacramento Medical Museum

iron lung display at the Sacramento Medical Museum

This is an interesting footnote to the Iron Lung – the one we don’t often hear about – the fact that several Americans are still encased in this iron maiden of artificial respiration.  According to the most recent statistics available (2004) there were more than thirty people still living in iron lungs in the USA.  (Some sources cite 19 people in Houston alone – in 2009.)

Not everyone needed to use iron lungs for years – in fact, many of the children and young adults stricken with polio recovered after several months, and went on to live normal (ventilator-free) lives.  But for others – the iron lung became a life-long condition.  Here are some of their stories..

“28 years in an iron lung” – interview with Joan Herman – Mark Finley, April 1976, Ministry Magazine

Soon, as these  few elderly patients pass away – the iron lung, the relic of early life support technology will be forgotten into the pages of history; remembered only by history buffs such as myself, in a few scattered photos and the backrooms and storage sheds of obscure museum archives.

The negative pressure ventilator aka ‘tank respirator’ worked exactly as it sounded – patients were placed into the small cylinder, with their chests and lower bodies enclosed as the machine applied negative pressure (think of vacuüm suction) to make the patient’s chest physically rise for inspiration. While iron lungs were invented in the late 1920’s, they became popularly known in the decades following their invention due to Poliomyelitis.

The iron lungs became critical life-saving devices for large numbers of people, especially children (who were more affected) during the polio outbreaks of the forties and fifties, and were one of the most visible images of medical technology / modern medicine of the era.

Martha Mason, one of the most well-known of the modern-day iron-lung reisdents published a memoir entitled, “Breath” of her sixty-year experience in 2003.  It’s a great glimpse into a full and amazingly rich life lived despite these handicaps.

Another Iron Lung resident, Diane Odell made headlines after she died during a power outage, which caused her iron lung to stop working. (This is an on-going problem for people living on life-support apparatus in their homes according to a 2009 article.)

Related stories:

Bangor man living with effects of Polio still  in Iron Lung.

Polio: The Iron Lung

University of Virginia on-line Iron Lung Exhibit

We are all welcome here” – fictionalized biography of Pat Raming.

The Sessions: Life in an iron lung – movie about man in Iron Lung.  Click here to read an interview with the actor.

Mark O’Brien – the real life behind the man in the sessions.

Interview with British man from 2004, BBC living in an iron lung.

Life in an iron lung – Paul Berry

Not even an iron lung” – Laurel Nisbet, who became a preacher in Jehovah’s Witness religion

Iron lung in Dallas – Star-News article, 1976

The Emerson Respirator – article brief from Anesthesiology, April 2009

A practical mechanical respirator, 1929: the ‘iron’ lung.   Meyer, J. (1990).  Annals of thoracic surgery.

Reading periscope for iron lung patients

An improvised iron lung – 1956 letter to the British Medical Journal

Negative pressure ventilation in the treatment of acute respiratory failure: an old noninvasive technique reconsidered. – 1996 article on potential modern applications for the iron lung.

Iron lung versus conventional mechanical ventilation in acute exacerbation of COPD. – a 2004 article comparing use of iron lung (negative pressure ventilation) with more invasive positive pressure mechanical ventilation.

More about Martha Mason:

Documentary on YouTube

Book review of Breath – at the Washington Post

“Martha in Lattimore”

Locums life – the traveling NP

Best of both worlds

It looks like sometimes I can have the best of both worlds; spending time with my patients (and hopefully helping to improve their lives/ restore wellness) while having the opportunity to travel, to interview and observe surgeons from around the world.  It’s been a difficult balance because it’s hard to find nurse practitioner positions that allow the sort of flexibility I need to continue my other (pursuits?)

Nurse Practitioner/ Medical Writer?

I love being a nurse practitioner but I also see myself as a writer so it’s hard to relegate my journalistic endeavors to the little corner known as ‘hobby’.   In fact, I feel that my travels are an essential counterbalance to my daily practice in nursing and cardiothoracic surgery.  My travels, particularly into cardiothoracic surgery in other locations – give me grounding and perspective.  Otherwise, without continuous effort – things can become too routine, too “by rote”.  While it’s critical to stay-up-to-date in medicine; it’s also crucial to continue to think about what we are doing – to get away from the ‘cookbook medicine’ of algorithms and protocols every so often.

Is it all about the protocol?

Protocols and algorithms based on ‘evidence-based practice’ are highly useful but they aren’t the only consideration when it comes to patient care.  Patients are individuals – and care needs to be individualized to each person’s situation and needs – which is where protocols often fail.

So it’s also helpful to see other variations in practice.  Sometimes the ways that other people/ hospitals/ groups practice isn’t just different; it’s better.  Maybe it’s not better for every situation, and maybe it shouldn’t replace the current standardized protocols at your hospital – but it might fit the needs of some of your individual patients.

But you have to be more that open and receptive to the idea of variations in practice – you have to be aware of different practices.   While conferences, lectures and publications may present and discuss different practices, the best way to learn about and see different practices – is to go there.  

But how/ when can a working nurse practitioner find the time to see different practices?

Locum tenums

Both, now I have found a way to see and experience this on both a national and international level.  I’ve begun practicing as a locum tenums (or temporary) nurse practitioner at different facilities in the United States.   I work for a few (or several) months at different hospitals and practices across the USA – giving me a spectrum of care within a basic framework of American medicine; from rural or small-town surgery programs to big-city/ metropolitan or academic settings.

In between assignments – with careful planning and budgeting, I can continue my international travels.. So far it seems ideal..

fwy bw

Coming to a city near you..

Nurse Practitioners around the world: 27th AANP conference

I wanted to post some more information and links for people like myself, who are interested in a more global view of the profession.

On Saturday, several speakers discussed the state of advanced practice nursing and the role of the Nurse Practitioner in different countries.  All of the speakers were members of the International Council of Nurses, an organization created to help develop advanced practice nursing roles around the world.

Unfortunately, as is often the case at these conferences – there was no Latin American representation (even though there are several strong doctoral programs and advanced nursing in several Latin American countries – if not the actual NP role, per se.)  But that’s my bias, since I have a strong interest in both my profession and Latin America. (Be careful, Professor, given the opportunity – I just might not leave.. But alas!  No NPs in Mexico yet..)

Of course, none of the European NPs (outside of the UK) were present either, so if you want to be more involved with these nurses you have to attend the ICN or other Region – Specific* conferences.

The actual speakers were interesting and engaging and included speakers from the UK, Singapore, Canada and Australia.  (I was taking notes as fast as I could, so I didn’t manage to get complete titles for everyone, and I apologize).


Madrean Schober at the Alice Lee Center for Nursing Studies presented information about nurse practitioners in Singapore.  As the role is quite new, she is a visiting fellow who is helping the National University of Singapore develop and implement this role.

In Singapore, the advanced practice nurse is a legally protected title, meaning that people have to meet rigorous standards to use the title, with penalties enacted for people who appropriate the title wrongfully.  This is similar to the USA but an important distinction that doesn’t apply in many countries.

The title and role of the APN is a hybrid of what we traditionally think of as both the NP and CNS (clinical nurse specialist) roles.

The first training programs were started in 2003 – and now consists of a 24 month program, with over 150 graduates so far.  The majority of graduates function in in-patient (or hospital-based) roles with the majority in intensive care units and mental health facilities.

In contrast to many countries, the push for the development of the APN role wasn’t due to an acute need, it was a deliberate effort to try to retain Singapore nurses and prevent a ‘brain drain’ as nurses from Singapore look for opportunities in other countries.

Advanced Practice Nursing in Singapore

Singapore Nursing Board

* Since the AANP is fairly region specific to the United States.

South Africa

Nelouise Geyer, CEO of the Nursing Education Association talked about the state of nursing in South Africa which is currently undergoing several changes in the classification of different levels of nursing.  There is no formally recognized NP role at present but there are advanced practice nurses such as midwives, clinicians in primary care and wound care specialists.

I found the new proposals for nursing classifications to be somewhat confusing and overly complicated as an outsider, but she was presenting a lot of information in a very short time.


Christine Buckley from Ontario presented information about Canada.  I find the situation in Canada to be quite encouraging despite having the usual growing pains with licensure requirements being fairly inconsistent across the provinces.  Despite being one of the newest countries to add nurse practitioners to the health care provider team – Canada has come on strong – with over 3400 NPs in just a few short years. (There were only 1129 in 2006).  Nurses in Canada have initiated a very successful (and catchy) slogan to encourage public interest in nurse practitioners, called “It’s about time!”

It’s about time!

Of course, they stress the use of NPs in primary care, but as the use of NPs grows in Canada – hopefully they will start to highlight some of the great things we do in specialty care too..  (They recently recognized a “NP in Anesthesia” role in British Columbia so it’s definitely on the way.)  They have done such an incredible job in just a few years – so kudos to our neighbors up north.  (As a Dalhousie graduate [non-nursing], I am particularly proud.)


I didn’t get the name of the Australian nurse practitioner (couldn’t write that fast!) but she did an excellent job outlining the history and the current state of the NP in Australia.  In a country of 22.3 million people, there are currently 740 nurse practitioners.  Unfortunately, only 71% (436) of these NPs are able to find work as a nurse practitioner due to a multitude of issues.

However, in the last few years, the NPs in Australia have been able to achieve national registration and well as reimbursement for their services.  (Prior to 2010, patients had to pay out-of-pocket to see an NP.)

United Kingdom

Jenny Ashton talked about the roles of the NPs in the United Kingdom, and explained that due to a lack of formal registration, there is no accurate count of the numbers of NPs currently practicing there.  While there is little consistency across the UK in general, she stated that both Wales, and Scotland have a more formalized process.

While there remain multiple barriers for NPs practicing in the UK, one of the biggest obstacles has already been overcome: NPs in the UK have full prescribing rights – which is something that not even all states in the USA have.

Unfortunately, from her presentation (and this is my interpretation) it sounds like one of their biggest obstacles is the Nursing Council itself which seems uninterested in examining (and resolving) the issues around standardizing educational requirements, formal title protection and registration and other policy issues.  Luckily, it sounds like the medical colleges are more than interested in playing a role in the continued development of APNs.  (Of course, that can be a double-edged sword as well.)

Hopefully, we’ll hear more news about our other nursing colleagues around the world soon – and maybe I’ll be able to attend one of the ICN conferences in the future (and be able to report from there.)

Future of NPs

In my mind, one of the biggest obstacles to the implementation and utilization of the nurse practitioner in other countries is lack of understanding of the role.  In many places, this is due to the perception that NPs can only function in a primary care role.  (This is extremely limiting in countries where there is no shortage or even an overflow of primary care physicians.)  In my [very limited] experience and interactions with surgeons in both the USA and abroad – this obstacle is quickly diminished as surgeons see the utility of having someone trained to handle all the ‘medicine’ aspects of surgical patients, so they can spend more time operating, and not worrying about managing co-morbidities or post-operative care.  This perception has been validated by several of the papers we’ve seen (and talked about before) from Germany, Japan and other nations where the surgeons themselves are trying to import the NP position to their home countries after working with NPs during their fellowships or other training in the United States.

References / Additional Information

The ICN / Nurse Practitioner & Advanced Practice Nurse Network – This organization is for the promotion and support of the development of the APN/ NP role internationally.  The above link takes you to the membership information page.  Membership is free.

The ICN website also contains information on the development of the NP role in other countries (Thailand, for example), a global definition of the NP role, and information about other nursing conferences worldwide. I recommend a look at the FAQ page which explains that the NP role exists (or is in development) in over 70 countries.

This is a link to the definition of the NP role in Spanish for all my friends/ colleagues and everyone else I’ve met who wonders what my job really is (for when my own explanations have them questioning my Spanish language abilities)..

27th AANP conference highlights: Poster Presentation

As many of my readers here at Cartagena Surgery and my sister sites know – I came to the National Conference to present a poster on “Use of Social Media to Promote Specialty Practice.”

presenting my poster at the 27th AANP conference

The poster is about how the thoracic surgery website brings together thoracic surgery professionals (surgeons, NPs, PAs, Respiratory therapists) from around the world and how it connects patients with credible but easily understandable information.

While I was there – I got the chance to meet some of the other presenters.

Tulay Cakiner-Egilmez, ANP is an ophthalmology nurse practitioner at the Boston Veteran’s Administration.  She was presenting a poster talking about performing eye exams and screening for glaucoma and other eye conditions.   My poster was next to hers, so we were able to talk in-between visitors. She’s been a nurse practitioner for three years, but has worked in the field of ophthalmology for over 25 years so she has a lot of great experience!

Tulay Cakiner-Egilmez, ANP

Debbie Kantor, MSN, ARNP and Lt. Sherrin Whiteman, MA from Hero, Inc. had a great presentation so I wanted to be sure to mention them since they may be a good resource for our readers.   They were talking about “Health Education to Reduce Obesity” and their mobile patient / community health education program.

Sherrin Whiteman, MA and Debbie Kantor, ARNP, MSN of Mobile Hero provide health education to reduce obesity

They run a pretty cool program with a nurse practitioner, a fitness instructor and other health educators who travel around to different communities to provide people with information about fitness, exercise, diet and healthy eating to prevent/ reduce obesity and promote wellness.

Brenda Reed, DNP, FNP-BC, RN presents information of genetic screening and referrals for Ovarian and Breast Cancer

Dr. Brenda Reed, DNP, FNP-BC, RN is an absolutely delightful nurse practitioner who is on the nursing faculty at Texas Christian University (Harris College of Nursing and Health Sciences) presented a wonderful poster on the genetic screening for breast and ovarian cancers.  Not only was the poster visually stunning, but she presented a lot of great information.  I really enjoyed talking to her.  (I’m not sure if they give awards at the end of the conference for ‘best poster presentation’ but my bet is on Dr. Reed.)

I ran into one of my favorite professors from Vanderbilt. Dr. Joan King, PhD, ACNP-BC, RN (almost literally – I was a bit lost in thought at the time).  She was (and is) the director of the acute care nurse practitioner program.  She was lecturing at the conference, and surprisingly, remembered me immediately.  (It’s been more years than I care to admit and the Vanderbilt School of Nursing is a large school so I was very flattered that she recognized me.)

Lastly, I was thrilled to meet Dave Mittman, PA.  He’s the founder of Clinician 1 which is an online website/ community for nurse practitioners and physician assistants.  He’s really down to earth and charming in person, and didn’t seem to mind taking a few moments to talk to me.

with Dave Mittman, PA and founder of Clinician 1

27th AANP conference highlights: International

Orlando, Florida –

AANP President, Angela Golden addresses a packed house

The new AANP president, Angela Golden was here to cut the ribbon and officially open the conference.

at the ‘Spanish for Nurse Practitioners” course

Away from Mexicali this week for the 27th annual American Academy of Nurse Practitioners (AANP) National Conference.  It’s been a fun couple of days; meeting and talking with nurse practitioners from several different countries and talking about issues in nursing.

The Nurse Practitioner  – International

Wedsnesday, I sat in on an international NP meeting with NPs from Canada, the UK, and New Zealand.  There was also a NP who is working in India, trying to promote advanced practiced nursing.  There are several more sessions on the role and status of NPs in other countries – so I will be updating this section over the next few days.

NPs are pretty new to the scene in all of these countries –

the UK recognized its first fifteen NPs in 1991, and continues to struggle with role recognition and role protection there.  The moderator of the meeting, who is one of the original British NPs explained that there is no restriction or requirements for a nurse to call themselves an NP,  whether they have qualified as an NP or not.

New Zealand first recognized NPs in 2003, and currently boasts 103 formally recognized nurse practitioners.  Currently, New Zealand has no established nurse practitioner specific master’s program or clinically based requirements, so that will be one of their growing pains..

Canada – is the newest of the bunch – but appears to leading the way – with Family nurse practitioners and a new acute care nurse practitioner program.   Unfortunately, much like the United States – each individual province has different licensure requirements (which are time-consuming and expensive).  Unlike the USA, despite a huge need for NPs – there are few jobs available due to the relative lack of private employment opportunities.  (The majority of positions are government-funded.)

(There are NPs in other parts of Europe, but none of their representatives were present.)

Introducing Trish Hutton, CRNFA

Today we are talking to one of my colleagues – Ms. Trisha Hutton.

Ms. Trisha Hutton, CRNFA

Ms. Trisha Hutton, CRNFA, ACNP (student)

Trisha is a certified registered nurse first assistant (CRNFA) .   She performs procedures in the operating room such as endovascular saphenous vein harvesting (EVH) for bypass surgery, and assists in other aspects of surgery, such as suturing, retraction and tissue dissection.

  Years in the operating room:   16

  Years working in cardiac surgery:  8

We’re talking to Ms. Hutton today about her current career and her developing role as an acute care nurse practitioner in cardiothoracic surgery.   Ms. Hutton is currently pursuing her master’s degree for certification in acute care, and will be part of a small but growing sub-specialty of acute care nurse practitioners in surgical practices.

As we’ve discussed during past posts; in the midst of a primary care crisis, advanced practice nurses such as nurse practitioners have moved to the forefront of the health care arena.  While NPs have worked (successfully) in this role since the creation of the specialty in the late 1960’s – the efforts of NPs in this (and other) roles are just now being recognized.

However, for nurses like Trisha Hutton, the increasing recognition (by surgeons) of the utility of nurse practitioners IN and OUT of the operating room is equally important.  So it’s important that nurses like Ms. Hutton receive the exposure to the public that may not always be aware of their role behind the scenes in caring for patients undergoing surgery.

What prompted you to return to school to become a nurse practitioner?

 “I felt like something was missing.  It was like chapters were missing from a book,” Ms. Hutton states, explaining that while she loves her current role, assisting and caring for patients in surgery – she wants to expand her role to encompass the care of patients outside of the operating room; from admission to discharge.

Ms. Hutton (pictured on the right) in the operating room

What drew you to cardiothoracic surgery, specifically?

I have always been interested in vascular surgery, and had been trained by and a vascular surgeon (Dr. Mark Donnelly) who I have worked closely with for many years.  When Flagstaff Medical Center started talking about beginning a heart program, I was immediately interested, and Donnelly encouraged me to be involved in it.  Also, because of our elevation (7000 ft), there was controversy about the success of our program, and that challenge excited me.

How do you see your role evolving after graduation?

To have the ability to continue my care to patients outside of the operating room.  I am looking forward to the opportunity to meet patients pre-operatively, participate in their diagnosis, operate on them, then continue their care through discharge.

Where do you see yourself in five years?

I hope to continue practicing within the CT and vascular specialty, and be comfortable within my expanded role.

Who are your role models?

I began as nurse in the operating room 16 years ago, and was instantly attracted to the vascular specialty.  I developed a relationship with a surgeon named Mark Donnelly, a very respected and talented General/Vascular surgeon.  When I decided to become a RNFA, he supported me, acted as my preceptor, and taught me how to operate.  As mentioned earlier, when word of a heart program started, he encouraged me to join the heart team.  That was a bitter-sweet decision for me….learning CT surgery has been a fantastic choice for me and has opened many doors, but it meant leaving a surgeon that I truly enjoyed operating and spending my day with.  He has been such an important role model for me and “life” coach (advice ranging from career to parenting!!), and I still miss working with him. More recently, our current heart surgeon Dr. Steve Peterson has been an important role model to me.  I joined cardiac surgery with good assisting skills, but he has pushed and challenged me even more.  He continues to test me daily, teaching me the finesse of cardiac surgery.  Without him I would not be  successful within this specialty, and I would never have considered continuing my education.  He has given me endless opportunities, pushed me to grow, and I am very grateful for him.

How do you see the nurse practitioner role in comparison to other peri-operative roles?  Do you think NPs provide any unique perspectives or contributions to surgical care?

NP’s absolutely offer unique contributions to surgical care!  Especially if they have had perioperative experience prior to becoming an advanced practice nurse.  I believe continuity of care is an important factor in delivering high quality care to our patients, and if the NP can follow her patient into the operating room, that continuity of care can be achieved.  They see and experience first hand what occurs during surgery, which can aid in their post op management.

For instance, if closing an aorta post AVR and the aortic tissue is particularly fragile, the NP will know that post op blood pressure management will be even  more critical. If a different practitioner had been operating, that concern may not be communicated adequately.  The surgeon who practices with a NP First Assistant can feel at ease knowing that both HIS needs and the patients’ needs will be met.  The NP who is familiar with the patient will know just what the surgeon will want in the operating room, will have appropriate equipment, supplies, support staff etc available, therefore making the patients’ surgical experience smooth and uneventful. A first assistant that does not have that relationship with the surgeon or patient (ie family practice MD or TechFA) cannot offer that unique service.

Nurse Practitioners in the operating room?  Current issues and controversies

While this seems like a natural and normal progression for many nurses and nurse practitioners within the field – it isn’t as obvious to people outside the profession.  Many people including human resources personnel, staffing companies and the surgeons themselves have pre-conceived notions that exclude nurse practitioners, even those with extensive operating room (peri-operative) experience from assisting in the operating room.  That role is often exclusively assigned to Physician Assistants, often to the detriment of our profession, our nursing colleagues and the patients.

In fact, in this recent statement and study on the role of surgical assistants (2011) only mentions nurses as assistants as a side note.  It fails to recognize the different levels of qualifications (ie. a certified registered nurse first assistant (RNFA) versus a surgical technician (with weeks to months of formalized training).

Now, with the adverse economy, and changes in medicare regulations, nurse practitioners face even more competition for the operating room; the disenfranchised primary care physician.  In several of the facilities where I have worked in the past; more and more of these physicians were taking an active role in assisting in surgery.  These doctors, often primary care doctors ‘moonlight’ in the operating room as a way to augment their salaries.  Conversely, while these physicians had the least amount of surgical training, they were afforded the most reimbursement for their intra-operative role.    This array of peri-operative assistants has led to a wide range of skill sets in this patient care role with little research or comparison of effectiveness of these positions.

Ideally, the best ‘surgical assistants*’ would be patient care roles that encompassed the entire patient surgical experience from pre-operative evaluation to patient discharge, which is the spectrum of both nurse practitioners and physician assistants.  But only nurse practitioners can bring a holistic, patient-centered approach to this

* The ‘surgical assistant’ title like surgical technician/ technologist has also been designated to another career entirely, with similar focus.  However, in this post, we are using the term generically to refer to any individual (NP, RNFA, PA , MD or technician) who acts as an assistant to the surgeon intra-operatively, and performs procedures under the supervision of the attending surgeon.

References/  Literature surrounding nurse practitioners in the Operating Room

Hodson D. M. (1998).  The evolving role of advanced practice nurses in surgery.  AORN J. 1998 May;67(5):998-1009. Erratum in: AORN J 1998 Jun;67(6):1102

Pear, S. M., & Williamson, T. H. (2009).  The RN first assistant: An expert resource for surgical site infection prevention.  AORN, 89(6); 1093 – 1097.  No free full text available.
Schroeder JL. (2008).  Acute care nurse practitioner: an advanced practice role for RN first assistants.  AORN J. 2008 Jun;87(6):1205-15.
Wadas T. M. (2008).  Expanding the scope of acute care nurse practitioners with a registered nurse first assist specialty.  AACN Adv Crit Care. 2008 Jul-Sep;19(3):261-3.

Wadlund D. L.  (2001).  Graduate education: the perioperative nurse practitioner.  Semin Perioper Nurs. 2001 Apr;10(2):77-9

Zarnitz P, Malone E.  (2006).    Surgical nurse practitioners as registered nurse first assists: the role, historical perspectives, and educational training.  Mil Med. 2006 Sep;171(9):875-8.   No free full text available.
More about the Registered Nurse First Assistant (RNFA) role from the Association of peri-Operative Nurses (AORN).

National conference in Cancun

No school-related posts this week as I attend the National Conference for Pulmonologists & Thoracic Surgeons.  Don’t worry – that doesn’t mean I’m slacking off, it just means it’s all a bit condensed as I try to absorb volumes of information in just a few days..  (I’ll be back in Mexicali at Monday – eager and ready to pick up where I left off.. Hope the doctor is in full “Professor” mode.)

Attended some great lectures this morning including a talk regarding the evaluation of patient quality of life as a whole package (health, culture, socio-economic status, etc) as part of health and wellness promotion and treatment for patients with chronic respiratory disease.  (Sounds like a great nursing lecture, doesn’t it?  But you’d be wrong – it was presented by a physician, Dra. Sarai Toral Freyre, which just goes to show that all of the holistic practices that nursing has promoted over the last hundred years are starting to catch on.)  That’s always encouraging – too often ‘the body as a machine’ has predominated medicine over the years – which I think is such a limited view that misses much of the individuality involved when treating people, particularly people with serious or chronic illness.

Met some nice people; a nurse and a respiratory therapist who have been sharing their experiences from different corners of Mexico – also enjoyed a great lecture by Dr. Luis Torre Bouscoulet.  He is giving a two day lecture for certification in spirometry (and I would have liked to stay for the entire thing but I knew I could never pass the exam in Spanish.)  But I enjoyed his historical overview of spirometry.

Mexicali Project update

As you all know, thoracic surgery is my life, and my love.  But it has been a while since I’ve hit the road and done some serious writing.  A year ago, I was researching and writing my second book, living ‘on location’ in Bogota, Colombia – and I miss it!

I miss the life of a traveling writer; meeting new people, and learning (learning, learning, learning!) new things, and writing about all of it; the highs, the lows, the things that are mundane in everyday life but somehow become new and interesting when you are doing it somewhere else..  Why is riding the bus in your hometown boring and frustrating, but that same bus in Madrid, Bogota or London becomes a mini-adventure in itself?  (It’s not just the second story in London that makes it fun.)

But at the same time, it is always so difficult for me to be away from my patients, thoracic surgery and nursing –  all the things that I do so much better than my mediocre writing.

Now I have a chance to do both.  It’s a dream come true, even if like most dreams – the nitty-gritty details don’t always stand out; no salary (yet again), but I am thrilled with the opportunity nonetheless.   I’ll be studying as a student at the elbow of a young, energetic and up- and-coming thoracic surgeon.  In him – I’ve met my match (and then some!)  He has the energy and the passion for thoracics that brings joy to long days, and hours on your feet..  But he is also a talented surgeon, who is excited about teaching – and that pleases me to no end.

Right now, my family is preparing to move; boxing up our lives, and getting ready to immerse ourselves into my newest endeavor – and I am taking all of my readers with me.  It will be a change from the usual posts, but one I hope that everyone will enjoy.

Nurse Practitioners and Medscape

A couple of new articles over at Medscape highlight the role of Nurse Practitioners (and Physician’s Assistants) in patient care.

The Role of Nps and PAs with MDs in today’s care

A study from Loyola showed that surgical NPs reduced emergency room visits  : here’s a link to the article abstract by Robles et al. (2011).

Reducing cardiovascular risk with NPs: the Coach trial

And yet again, Nurse Practitioners trump physicians in patient satisfaction surveys.

This is just a sampling of the articles featured over at Medscape’s NP perspective.

From the free-text files: a selection of articles showing the growing use of Nurse Practitioners around the world

Nurse practitioners improve quality of care in chronic kidney disease: two-year results of a randomised study.  – a study from the Netherlands

A Parallel Thrombolysis Protocol with Nurse Practitioners As Coordinators Minimized Door-to-Needle Time for Acute Ischemic Stroke.  A taiwanese study showing the impact of nurse practitioners in reducing door-to-needle time in acute coronary syndromes.

Helping patients attain and maintain asthma control: reviewing the role of the nurse practitioner.

Type 2 diabetes, cardiovascular disease and the utilisation of primary care in urban and regional settings.  An Austrailian study discussing the impact of NPs in rural care.

The TAVI Registry, journey to the UK and other news

London Bridge, at night.

Just returned from a quick trip to London, UK to interview a couple of fantastic thoracic surgeons. (You can read the interview here.)

In the meantime, a midst multiple conflicting reports regarding the use and safety of TAVI (percutaneous aortic valve replacement) the ACC and STS have finally come together to create a TAVI registry, similar to the PCI and cardiac surgery registries.  The new registry will be used to track TAVI procedures and outcomes.  Hopefully, by gathering information in a standardized fashion and collecting data on patient outcomes, we can finally answer the essential question surrounding TAVI: Is It Safe?

As someone who is intimately involved in the STS database – I can assure readers that if STS is involved, data collection will be extensive, cumbersome and overly complicated.  (The adult cardiac surgery data collection form is fourteen pages long.)  However, the database will allow doctors to identify whether complications are device related/ procedure related or operator related.  (For example, are post-procedural strokes caused by the valve (device related) itself, or by the person (operator related) inserting it?  It will also track 30 day mortality – and the causes of mortality.  (ie. Was the death coincidental versus bleeding/ stroke/ kidney failure, etc?)  The registry will also track one year outcomes – but unfortunately – the essential question  – Is it Safe long-term?  will remain unanswered.

In Big Pharma news – I had the good fortune to meet (and talk to at length) one of the inside investigators* for GlaxoSmithKline.  He was a delightful and charming interview – and it was a fascinating inside look at the future of pharmacology, pharmacy, drug development and marketing.

As readers know – I have vilified and railed against pharmaceutical companies in the past (and most likely – will continue to do so) but it was an excellent opportunity to see the other side of a blighted industry.  [Here at Cartagena Surgery – I may have unabashedly strong opinions, but I do try to be fair.]

As an investigator for a pharmaceutical company, his position is somewhat akin to George Clooney’s character in the recent film ‘Up in the Air’.  He investigates company employees as well as independent contractors who represent the company for moral, ethical and criminal violations.   In the wake of several serious recent ethical and criminal investigations into the pharmaceutical industry in recent years – companies such as GSK take this duty extremely seriously.  As part of this effort – they hired people like the man I am interviewing today.  Mr. X is surprisingly charming, amiable, and witty.  Somehow as a ‘trigger man’ for a big company, and former NYC police officer, the gentleness, and the compassion emanating from him is unexpected.   He tells me that he has received thank you letters from people who were ‘separated from the company’ on his say-so – and I am not surprised.

We talk about public and health care providers perceptions of the pharmaceutical industry, and trends of the past.  We discuss the previous ‘bribe and gift’ atmosphere of the past – and he gently calls me out for my Pfizer bag from a long-ago conference.  [Ironically, I’ve railed against this bag in the past – it’s from a conference I attended as a student, but hypocrite that I am – have neglected to throw it out.  In my own weak defense – I will say that I never again have accepted or received ‘sponsored’ gifts or items.]  But he’s right – and I accept my scolding, hopefully with the grace it was given.

He talks about one of the new projects that GSK is implementing – and I immediately sit up and take notice.  Phasing out the ‘hootie girls’ as we call the often scantily clad, inappropriately dressed, invariable young, attractive (and always! well-endowed) pharmaceutical representatives that cold call doctors offices with girlish laughs, lots of legs and sample supplies of costly drugs.   No, I will not be sad to see the end of the ‘hootie girls’.

Replacing the hootie girls will be nurse educators.  Instead of pushing costly brand name drugs – they will be restricted from mentioning brand specific medications.. But educate they will.  Hopefully these educators will serve as a resource for healthcare providers – to assist us and inform us without trying influence us.  In many ways – it sounds like GSK may be moving in the direction that we need to go.. Afterall – with millions of millions of people needing treatment (and the vast amount of disease out there)  just obtaining and supplying these patients with the medications they need is a phenomenal effort – and companies can still make a HUGE profit on volume alone.    (And I am not against making a profit – it supports drug research etc..)

But the idea of being able to use the vast amount of information collected from these companies and their volumes of research without rancor, or hardcore skepticism – is encouraging.  If we can build bridges and trust – we can ultimately better serve our patients.. Of course, nothing this big ever goes off without a hitch, and Rome wasn’t build in a day – but it’s a start.. 

It’s a hopeful view from an unlikely source at the end of a very long day that started in one country and ends in another..

* I didn’t get a chance to ask his permission to  write about our meeting – so in fairness, I have omitted his name.

The doctor can’t see you now..

On the other side of the equation (from the doctor won’t see you now)- is the on-going physician shortage, which will impact millions of Americans just as the aging baby boomer generation places increased demands on our strained health care system..  Rural areas will be the hardest hit (and already have the hardest time attracting physicians and other care providers).

In this article by Beverly Miller, [re-posted below] the author suggests solutions to the blooming crisis.

 I would like to add my own.  In her article, Ms. Miller gives short shift to nurse practitioners and physician assistants filling the gap.  This is unfortunate as multiple studies have shown that NPs and PAs provide an excellent level of care, and patient satisfaction – and have served as the mainstay of primary care in many rural and inner-city communities since the late 1970’s.  Nurse practitioners and physician assistants are currently hampered by several federal and state legislative issues which limit compensation and billing by nonphysician providers.  Several attempts at open and earnest dialogs among legislators, nurse practitioners and physicians have been hampered by physician attitudes.  A new report from the Institute of Medicine on the future of nursing emphasises the need to utilize nurse practitioners in this role (as we discussed here) but without further community and public support – much of the utility of NPs will fail to be realized**.

But as this author (Dr. Richard Cooper) points out – there just aren’t enough NPs, PAs and MDs combined to fill the projected shortfalls.  (So we shouldn’t argue amongst ourselves – there are plenty of patients to go around.)

PBS special on Nurse Practitioners a look at NPs in primary care.

To support your local NPs – take legislative action!  Right now, NPs are lobbying to be able to order home health and hospice for our patients as part of the ‘Medical Home’ bill.

How to handle the physician shortage  – Beverly Miller

The primary goal of health care reform deals with providing health coverage for all Americans. Policymakers tell us that it will pay for itself, but with the influx of an estimated 40 to 50 million people who were previously uninsured and the baby boomer generation now becoming eligible for Medicare (some say at a rate of eight per second), who do these policymakers believe is going to take care of these patients?
The problem is one of basic economics: supply is simply not keeping pace with demand.
The physician shortage in the U.S. is not a new problem caused solely by health care reform. Twenty-two states and 17 medical specialty societies are already reporting shortages today, long before the 2014 influx under the provisions of the Patient Protection and Affordable Care Act. Aging and population growth have created a greater demand for physicians than ever before.
Family practice, internal medicine, and geriatric specialists will be the gatekeepers under the reformed system. These specialties require more knowledge in a broader spectrum of diseases than other specialty physicians, yet are paid less for these services. For those doctors choosing family practice, internal medicine or geriatrics as a career, it is often a social decision.
A large number of physicians, mirroring the rest of the population, are reaching retirement age. The American Medical Association (AMA) has reported that in 2017, more than 24,000 physicians will turn 63. The number of retiring physicians could be even higher if the economy rebounds and many who delayed retirement for financial reasons decide to retire.
For the fifth year in a row, family practice and internal medicine have topped the Merritt Hawkin’s recruiting and retention survey.
It has been noted that new physicians are:

– opting for higher paying specialties since student loan debt often exceeds $150,000 – opting to practice at hospitals and health care systems where better technologies are available – desiring more flexible scheduling for family time and social activities – desiring to live in high-population areas  leaving vast areas of the U.S. underserved.

Also, the availability of residency slots is not keeping pace with the demand for new physicians and often residency slots for family medicine and internal medicine often go unfilled. A cap on Medicare-funded residency programs by the Balanced Budget Act of 1997 has not kept pace with needs. Also, there has been less availability of graduate medical education (GME) funding through state Medicaid programs
The Patient Protection and Affordable Care Act does include a provision for redistribution of residency positions by the Health and Human Services (HHS) secretary if residency positions have been unfilled for three Medicare cost reporting periods. The slots, which appear to number approximately 600, will be redistributed giving preference to hospitals located in states with a low resident physician to population ratio; or with a large population living in primary care health professional shortage areas, rural hospitals, and urban hospitals with accredited rural training tracks.
Need is driving the demand for primary care physicians. Groups and hospitals are rushing to form Accountable Care Organizations, patient-centered medical homes and other employment models, all of which are centered around the foundation of primary care.
As we moved to a managed care delivery system, the overriding belief was that good primary care promotes better outcomes and prolongs life. In many respects, it was a success since preventive care was added to coverage and patients began to think in terms of quality rather than quantity of care.
Moving to the next stage, most believe that it must better connect consumers to the health care system and that it must use information technology to better manage costs and patients.
Demand for services will continue to increase as the economy rebounds, resulting in more covered workers, and the baby boomer generation continues to attain Medicare coverage. And if the provisions of the legislation stay on track, there will be even more demand in 2014.
What do we do?
Varying solutions are being discussed.
Nationally, medical school enrollments have been flat over the past 20 years. Policymakers are calling for a significant increase in new physicians, recommending increases in medical school enrollments and increases in GME positions.
Signing bonuses, relocation expense reimbursement and medical education allowances remain standard in most physician recruitment incentive packages. Higher base salaries and productivity bonuses are slowly becoming the norm for family practice and internal medicine.
The 2009 stimulus package and health reform law have designated nearly $300 million for the National Health Service Corps to offer medical loans repayment to new physicians who practice in underserved areas.
Increase in reimbursements for family practice and internal medicine services are necessary to entice physicians to specialize in these areas.
Nurse practitioners and physician assistants can fill some of the void, along with non-U.S. trained physicians becoming eligible to practice in the U.S.
Shorten the training time for primary care physicians from an average of ten years to a more targeted education taking five to eight years by eliminating undergraduate majors and moving straight to medical curriculum and clinical training.
Expand the role of telemedicine as technology becomes more widely adopted by healthcare providers and patients.
There are no certain answers to the problem, but physicians have always been flexible and innovative. In conjunction with other players in the system, physicians themselves will be the ones with the right ideas and solutions. [unfortunately, physicians have also used their strength and influence to prevent alternative solutions in the past – cartagena surgery].

Beverly A. Miller, CPA, CAPPM , is Manager of Physician Services with Hayflich & Steinberg, CPA’s, PLLC and the current president of the National CPA Health Care Advisors Association. She has been heavily involved in practice startups, as well as aiding existing practices with billing issues, accounting issues, staff modeling and selection, project analysis, financial management, compliance issues, and tax planning. Beverly can be reached at (304) 697-5700.

Hayflich & Steinberg, CPA’s, PLLC is also a proud member of the National CPA Health Care Advisors Association (HCAA). HCAA is a nationwide network of CPA firms devoted to serving the health care industry. Members provide proactive solutions to the accounting needs of physicians and physician groups. For more information contact the HCAA at

** As mentioned previously on this site, Nurse Practitioners work in a variety of specialty medicine and surgery practices. As an acute care nurse practitioner in specialty surgery practice – I work directly with a surgeon (versus a NP in primary care practice.)

Celebrating National Nurse Practitioners Week

In honor of the profession that has brought me so much career and personal satisfaction – I am posting several links about Nurse Practitioners, and National Nurse Practitioner week.

This evening, I had the privilege of speaking with Dr. Angela Golden, DNP.  Dr. Golden is a family nurse practitioner here in Flagstaff, an Associate Professor at the Northern Arizona University (NAU) School of Nursing as well as the president-elect of the American Academy of Nurse Practitioners (AANP).  She’s a fascinating lady, and she was talking about the Institute of Medicine’s  recent statement of the Future of Nursing – and what it means for Nurse Practitioners and the future of health care in the United States.

But, as you know – national borders have never hampered my vision, and I am happy to say that nurse practitioners are growing (and thriving!) in Canada, New Zealand, the United Kingdom and other countries around the world.  We’ve talked about the efforts of surgeons in Japan and other countries in establishing the NP role..

New Zealand poster

This local (Arizona) organization has a nice explanation about nurse practitioners and the services many of us provide.

New Jersey ( blog talking about the contributions NPs have made to health care.

NP Fact sheet – AANP information about NPs

NP & PAs – timelines of the Nurse Practitioner profession

US congress recognizes NPs

Nurse Practitioner week article – Amarillo, TX

AANP statement

Meta-analysis of NP care

More about NPs, MDs and Midwives

Just a small selection this evening – I hope you’ve enjoyed.

MDs, NPs, CNS and midwives

A new study has been published online (on advance of print) looking at medical outcomes among physicians, nurse practitioners, clinical nurse specialists and nurse midwives.

Advance Practice Outcomes 1990 – 2008 : A Systemic Review discusses the role of advanced practice nurses in improving access to healthcare, and improving the quality of healthcare in the United States.

What is an Acute Care NP? a review of the literature surrounding the role, function and patient satisfaction

One of the questions I field frequently in both practice and here at Cartagena surgery is – What is an acute care nurse practitioner (ACNP)?  This is usually bracketed by statements such as, “I didn’t know NPs could work in surgery.  I thought you only worked in [primary care] clinics.”  Sometimes it’s patients asking the questions – sometimes it’s the surgeons themselves.

This is usually followed by questions or statement about whether ACNPs belong in this role, and if we function at a ‘satisfactory level’ in acute care settings such as intensive care units, emergency departments and specialty surgery practices.

The answer lies in the research, and the overwhelming majority of the literature states that we do, in fact, function very well, in our role to augment  (not replace) physician services.  We do so well, in fact, that the most recent literature is primarily focused on surgeons in other countries and their efforts to import the NP models to their countries (Japan, the UK specifically) over the last few years.

But I don’t expect readers to take my word for it.  Hopefully by now, you’ve all become informed consumers – so I’ve posted some references with links below.  In many cases the entire article was not available [without subscription] so in those cases, particularly long articles – I’ve posted a link to the abstract.  In some cases, there is no abstract available on-line so I’ve included the citation.

Unfortunately many of the larger studies on patient satisfaction are based in the primary care setting, so I have omitted them.

Since I’ve gotten quite a bit of interest on this topic from medical providers, other nurses and readers – I’ve added a section for literature relating to nurse practitioners, which I will try to update periodically, since it is too large of a project for a single post.

Nurse Practitioners in Surgical Specialties/ Acute Care Settings: Review of the available literature

1. The role, productivity, and patient satisfaction of surgical nurse practitioners compared to medical surgeons at VA outpatient clinics.  Palmquist, D. (2010).  Graduate dissertation at Tui University.  This is actually a head to head comparison of NPs to MDs which showed greater productivity by MDs (saw more patients) but greater patient satisfaction with care by NPs. [abstract only].  This isn’t surprising in that surgeons have an enormous amount of responsibilities and demands placed on their time.

2. Patient satisfaction with a nurse practitioner in a university emergency service. Rhyee, K & Dermyer, A. (1995). Annals of Emergency Medicine, Volume 26, Issue 2 , Pages 130-132, August 1995.    Study showed no difference between patient satisfaction with care by either MD or NP. Notably, the primary author was a physician [abstract only].

3. Acute care pediatric nurse practitioner: a vital role in pediatric cardiothoracic surgeryOkuhara CA, Faire PM, Pike NA.  J Pediatr Nurs. 2011 Apr;26(2):137-42  [abstract only].  These NPs are actually dually certified in most cases – in pediatrics and acute care.

4.  The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs.  Cowan MJ, Shapiro M, Hays RD, Afifi A, Vazirani S, Ward CR, Ettner SL.  J Nurs Adm. 2006 Feb;36(2):79-85.  Reduced length of stay, reduced patient costs, and hospital costs on teams with nurse practitioners.

5. The evolving role of the acute care nurse practitioner in critical care.  Howie-Esquivel J, Fontaine DK.  Curr Opin Crit Care. 2006 Dec;12(6):609-13. A nice article that talks about how the NP role is expanding internationally to copy American health care models.

6. The advanced practice nurse in an acute care setting. The nurse practitioner in adult cardiac surgery care.  Callahan M.  Nurs Clin North Am. 1996 Sep;31(3):487-93.  [abstract only].  This article was actually written by researchers at my alma mater, Vanderbilt.

7.  Outcomes of tube thoracostomies performed by advanced practice providers vs trauma surgeons.  Bevis LC, Berg-Copas GM, Thomas BW, Vasquez DG, Wetta-Hall R, Brake D, Lucas E, Toumeh K, Harrison P.  Am J Crit Care. 2008 Jul;17(4):357-63. [full text article].  This is a nice study that actually compares NP/ MDs performing invasive procedures – in this case, chest tube placement.

8. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners.  Russell D, VorderBruegge M, Burns SM.  Am J Crit Care. 2002 Jul;11(4):353-62. [full text article].  This article is one of a series of articles published by researchers at UVA which led the changes in the University of Virginia policy – (the results were so compelling that UVA)  to advocate for exclusive use of nurse practitioners in all acute care areas.  It showed shorter length of stays, less infections for patients care for by NPs versus residents.

Several Japanese researchers are looking at the role of nurse practitioners, as mentioned above.

1.  Nurse practitioners in surgical services in the United States.  Okano A.  Nippon Geka Gakkai Zasshi. 2011 May;112(3):207-10. Japanese.  No abstract available.

2.  Considering the feasibility of introducing nurse practitioners into Japanese thoracic services.  Komatsu T, Coutler L, Henteleff H, Johnston M, Bethune D. Ann Thorac Cardiovasc Surg. 2010 Aug;16(4):303-4  [full text article].  An interesting article, written by Canadians, who have just started to recognize NPs in the acute care/ surgical settings.The comments from the surgeons at the Canadian facility are quite interesting as well.   I wouldn’t mind helping the thoracic surgeons in Japan get used to ACNPs..  🙂

3.   [Surgeons’ hope: expanding the professional role of co-medical staff and introducing the nurse practitioner/physician assistant and team approach to the healthcare system].  [Article in Japanese]  Maehara T, Nishida H, Watanabe T, Tominaga R, Tabayashi K. Nippon Geka Gakkai Zasshi. 2010  Jul;111(4):209-15.

Summary: The healthcare system surrounding surgeons is collapsing due to Japan’s policy of limiting health expenditure,market fundamentalism, shortage of healthcare providers, unfavorable working environment for surgeons, increasing risk of malpractice suits, and decreasing number of those who desire to pursue the surgery specialty. In the USA,
nonphysician and mid-level clinicians such as nurse practitioners (NPs) and physician assistants (PAs) have been working since the 1960s, and the team approach to medicine which benefits patients is functioning well. One strategy to avoid the collapse of the Japanese surgical healthcare system is introducing the NP/PA system. The division of labor in medicine can provide high-quality, safe healthcare and increase the confidence of the public by contributing to: reduced postoperative complications; increased patient satisfaction; decreased
length of postoperative hospital stay: and economic benefits. We have requested that the Ministry of Health, Labor and Welfare establish a Japanese NP/PA system to care for patients more efficiently perioperatively. The ministry has decided to launch a trial profession called “tokutei (specifically qualified) nurse” in February 2010. These nurses will be trained and
educated at the Master’s degree level and allowed to practice several predetermined skill sets under physician supervision. We hope that all healthcare providers will assist in transforming the tokutei nurse system into a Japanese NP/PA system.

Note: This is also ground-breaking, as other countries have been slow to implement nurse practitioners in any areas of their medical care system.  The fact that this is a surgical setting is  even more encouraging. These researchers have also published research on the introduction of NPs in other surgical specialties.

NPs and Residents: a delicate balancing act

In fact, nurse practitioners are the reason that recent changes (July 2011) in surgical/ medicine residency hours are even possible. Without the services that NPs provide, it would be impossible for large teaching institutions to implement the new mandated resident hour restrictions.

Even before the newest restrictions – nurse practitioners have been called to take up the slack (when resident hours were previously reduced both here and in Canada.)  However, it was these restrictions that gave us our greatest opportunities for larger acceptance in the acute care specialties.  (Nurse practitioners have worked in acute care since our inception but were not widely known in this acute care role.)  Fortunately, the data shows that not only have NPs made up for the lack of residents, we’ve actually improved the level of care and patient satisfaction [in comparison to care given by residents].

More information of resident hour restrictions

Next time – I’ll include several more articles, including some more looking at my own specialty – cardiothoracic surgery.