Paul Nelson reporting
PROVO -- Their job is to help the sick, but one woman says nurses at a Utah County hospital mistreated her mother by taping over her mouth.
The alleged abuse happened over the weekend at Utah Valley Regional Medical Center in Provo. Wednesday afternoon, KSL learned the nurses involved in the investigation have been fired.
Brittany Bilson, who made the claim, said her mother Penny Artalejo goes to various hospitals several times a year because of a medical condition. She's even been to Utah Valley Regional Medical Center before and had no problems. But she says the treatment her mother got this weekend was inhumane.
An accident more than six years ago left her with chronic neck pain. She often gets nauseous, too, and can't keep her pain medication down. Bilson said the pain leads to anxiety, and her mother will start shaking and moaning.
"When she can't keep her pain medication down, this is a typical thing that happens," Bilson said.
Brittany Bilson says her mother had her mouth partially taped up by two nurses at Utah Valley Regional Medical Center On Saturday night, Artalejo took 20 painkillers. Her daughter called 911 and Artalejo was taken to the emergency room at Utah Valley Regional Medical Center. She was admitted into the adult ICU for further care.
While in the ICU, "(my mother) was still chattering, shaking and moaning," Bilson said.
She said the nurses put their hands over Artalejo's mouth and told her to shut up. The alleged abuse got worse from there.
Bilson alleges that they then took wide hospital tape and covered her face from the top of her nose to the bottom of her chin, and put thinner tape from cheekbone to cheekbone, and more across her jawline.
She claims the nurses knew what they were doing was wrong.
"They were saying to each other that they need to make sure that she can breathe with the tape and if they got caught, they were so going to get fired for this," Bilson said.
The nurses left the tape on her mother for five to 10 minutes, according to her account. Artalejo, who has difficulty talking when she's shaking and moaning, was nevertheless still alert the whole time and she told another daughter what happened.
"It's not right. It's inhumane," Bilson said. "We put our loved one's lives in their hands. I left the hospital, basically thinking she's fine from here, and just more bad happened."
A spokeswoman for Utah Valley Regional Medical Center declined an interview but released a statement that says the hospital is "fully committed to providing our patients with compassionate care. These are allegations that go against our core values and poor treatment of any patient would not be acceptable."
This afternoon, the hospital finished its investigation and, as a result, two nurses, a male and female, were fired. Bilson says that was the right thing to do.
"I don't think we should give them an opportunity to do this to anyone else."
The hospital spokeswoman says she can't provide any information about the nurses or the case, but she says this was an isolated incident.
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Woman's breast implant disappears during Pilates
Woman's breast implant disappears during Pilates
By Melissa Dahl
There's really no other way to put this: During a Pilates stretching exercise, a 59-year-old woman said her body "swallowed" one of her breast implants. Sounds like something we just made up, but the woman's case is the subject of an unbelievable report, just published online in the latest New England Journal of Medicine.
The woman was a breast cancer survivor who'd had a double mastectomy, and afterward had gotten breast implants. During a Pilates routine, she was doing a Valsalva maneuver, a breathing technique in which a person takes a deep breath and holds it while bearing down. (In other words, you're going through the motions of exhaling forcibly, but without letting any air escaping through the mouth or nose.)
Doing a Valsalva maneuver increases pressure inside your chest cavity. In this lady's case, enough pressure built to essentially send her right implant through the thin tissue between her ribs and into the space in between the lungs. This left her more perplexed than anything -- where did it go?! Fortunately (and incredibly), she said upon arriving in the the emergency department of the Johns Hopkins Hospital in Baltimore that she wasn't experiencing any chest pain or shortness of breath.
"I can picture how this could happen in a freak occurrence," says Dr. Anthony Youn, a Michigan-based cosmetic surgeon and frequent contributor to msnbc.com, who didn't treat this patient but gave us his professional opinion on what the heck happened here.
Note that Youn called this a "freak occurrence" -- this is not exactly going to happen to your average Pilates lover, as this woman's case had some extra complications. She'd recently undergone a surgery to repair her heart's mitral valve, a procedure that typically involves some separating of the muscles that run between the ribs.
"What likely happened in this instance is that the breast implant was placed under the chest muscle and on top of the ribs, an extremely common practice in breast reconstruction," Youn says. "When the patient Valsalva'd, the pectoralis (chest) muscle likely contracted and pushed the implant through the space between her ribs," which was particularly fragile after the valve surgery.
"The weakened scar tissue was easily torn, and the strength of the pectoralis muscle pushed the implant deep into her chest," Youn explains.
The woman was treated at Johns Hopkins, where surgeons retrieved the implant from within her chest and put it back where it belonged.
By Melissa Dahl
There's really no other way to put this: During a Pilates stretching exercise, a 59-year-old woman said her body "swallowed" one of her breast implants. Sounds like something we just made up, but the woman's case is the subject of an unbelievable report, just published online in the latest New England Journal of Medicine.
The woman was a breast cancer survivor who'd had a double mastectomy, and afterward had gotten breast implants. During a Pilates routine, she was doing a Valsalva maneuver, a breathing technique in which a person takes a deep breath and holds it while bearing down. (In other words, you're going through the motions of exhaling forcibly, but without letting any air escaping through the mouth or nose.)
Doing a Valsalva maneuver increases pressure inside your chest cavity. In this lady's case, enough pressure built to essentially send her right implant through the thin tissue between her ribs and into the space in between the lungs. This left her more perplexed than anything -- where did it go?! Fortunately (and incredibly), she said upon arriving in the the emergency department of the Johns Hopkins Hospital in Baltimore that she wasn't experiencing any chest pain or shortness of breath.
"I can picture how this could happen in a freak occurrence," says Dr. Anthony Youn, a Michigan-based cosmetic surgeon and frequent contributor to msnbc.com, who didn't treat this patient but gave us his professional opinion on what the heck happened here.
Note that Youn called this a "freak occurrence" -- this is not exactly going to happen to your average Pilates lover, as this woman's case had some extra complications. She'd recently undergone a surgery to repair her heart's mitral valve, a procedure that typically involves some separating of the muscles that run between the ribs.
"What likely happened in this instance is that the breast implant was placed under the chest muscle and on top of the ribs, an extremely common practice in breast reconstruction," Youn says. "When the patient Valsalva'd, the pectoralis (chest) muscle likely contracted and pushed the implant through the space between her ribs," which was particularly fragile after the valve surgery.
"The weakened scar tissue was easily torn, and the strength of the pectoralis muscle pushed the implant deep into her chest," Youn explains.
The woman was treated at Johns Hopkins, where surgeons retrieved the implant from within her chest and put it back where it belonged.
MRSA
This article is a CME/CE certified activity. To earn credit for this activity visit:
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CME/CE Released: 03/17/2011; Valid for credit through 03/17/2012
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This activity is intended for infectious disease specialists, emergency medicine clinicians, hospitalists, internists, primary care and family medicine physicians, nurses/advanced practice nurses, and physician assistants.
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The goal of this activity is to address the educational needs related to the evolving epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) and increase clinical competency related to early and accurate identification and differential diagnosis of MRSA infections, treatment options including appropriate antimicrobial utilization, and emerging clinical controversies. In turn, patients will receive optimal care, and patient outcomes will be improved.
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Upon completion of this activity, participants will be able to:
1.Select evidence-based interventions for containing MRSA infections in the community and hospital
2.Identify clinical challenges resulting from the changing epidemiology of MRSA
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[CLOSE WINDOW]Authors and DisclosuresAs organizations accredited by the ACCME, NFID and Medscape, LLC require everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner that could create a conflict of interest.
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Disclosed financial relationships have been reviewed by NFID to resolve any potential conflicts of interest. All faculty and planners have attested that the content of this activity will be based on the best available evidence; will promote quality healthcare, not a specific commercial interest; and will be well balanced and unbiased.
Author(s)Robert A. Weinstein, MD Chairman, Department of Medicine, Cook County Health and Hospitals System; Chief Operating Officer, Ruth M. Rothstein CORE Center, C. Anderson Hedberg, MD, Professor of Internal Medicine, Rush University Medical Center, Chicago, Illinois
Disclosure: Robert A. Weinstein, MD, has disclosed the following relevant financial relationships:
Received grants for clinical research from: US Centers for Disease Control and Prevention
Owns stock, stock options, or bonds from: Merck & Co., Inc.; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; GlaxoSmithKline
Dr. Weinstein does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics not approved by the US Food and Drug Administration (FDA) for use in the United States.
Dr. Weinstein does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.
Editor and Nurse PlannerSusan L. Smith, MN, PhDScientific Director, Medscape LLC
Susan L. Smith, MN, PhD, has disclosed no relevant financial relationships.
CME ReviewerNafeez Zawahir, MDCME Clinical Director, Medscape, LLC
Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.
From Medscape Education Infectious Diseases
Containing the Superbug CME/CE
Robert A. Weinstein, MD
CME/CE Released: 03/17/2011; Valid for credit through 03/17/2012
Download Audio
Editor's note: Staphylococcus aureus is the most commonly isolated human bacterial pathogen and is an important cause of several potentially serious and fatal infections, including bacteremia and sepsis, endocarditis, endovascular infections, foreign-body infections, osteomyelitis, pneumonia, skin and soft-tissue infections (SSTIs), and septic arthritis. The disease burden of methicillin-resistant S aureus (MRSA) (strains that are resistant to all available penicillins and other beta-lactam antimicrobial agents) in the United States has not only increased considerably, but the epidemiology of MRSA has changed. Historically, MRSA infections occurred in individuals considered at risk due to healthcare exposure; primarily patients admitted to inpatient healthcare facilities and/or those who frequented other healthcare environments.[1] Beginning in the mid-1990s, infections caused by new strains of MRSA began to be reported in individuals in the community without risk factors and are responsible for a significant proportion of the increased disease burden of MRSA in the last decade.
Delorme and colleagues conducted a retrospective survey of all staphylococcal infections diagnosed by a single medical center in Northeastern Ohio during 2006 and 2007.[2] The incidence of MRSA increased 77% overall, 58% in outpatients, 43% in hospitalized patients, and 183% in residents of long-term care facilities. Sixty-six percent of individuals diagnosed with MRSA had no risk factors for staphylococcal infection. SSTIs are especially burdensome, especially complicated SSTIs, which by definition are those requiring surgical intervention.[3] SSTIs are caused by a variety of pathogens, including aerobic gram-positive or gram-negative organisms, and in some settings other unique pathogens. Overall, S aureus is the pathogen most frequently isolated from complicated SSTIs. SSTIs in patients in healthcare settings are more likely due to MRSA, methicillin-resistant Staphylococcus epidermidis, vancomycin-resistant Enterococcus, and resistant gram-negative pathogens. Community-acquired or community-associated MRSA (CA-MRSA) is the single most frequent pathogen responsible for SSTIs.[3]
Infection control and prevention are responsibilities of all healthcare workers, whether caring for hospitalized patients or caring for and educating patients on preventive practices in community settings, including the home. MRSA in the community is widespread and therefore anyone is at risk. Nurses in particular, and especially those who practice in community health settings, schools, and correctional facilities, are more likely to provide this education. Because the majority of MRSA infections in the community are SSTIs, this should be the focus of education: to prevent the occurrence and spread of CA-MRSA. Individuals at highest risk for SSTIs are those in close skin-to-skin contact with others (eg, athletes, children in day care centers, and living in crowded conditions such as in dormitories, military barracks, or correctional facilities), with openings in the skin such as cuts or abrasions, likely to be in contact with contaminated items and surfaces, and with poor hygiene. The Centers for Disease Control and Prevention (CDC) provides special information and advice for family caregivers, athletes, coaches and athletic directors, school officials, and others. In particular, downloadable fact sheets for these groups are available at no charge on the CDC's Website. Examples are shown in Figure 1 and Figure 2.
(Download PDF) Figure 1. MRSA fact sheet for athletes, coaches, and athletic directors.
(Download PDF) Figure 2. MRSA fact sheet for early childhood care and education professionals.
Robert A. Weinstein, MD, Chairman of the Department of Medicine for the Cook County Health and Hospitals System, the Chief Operating Officer of the Ruth M. Rothstein CORE Center, and the C. Anderson Hedberg, MD, Professor of Internal Medicine at Rush University Medical Center, in Chicago, Illinois, discusses implications of the changes observed with MRSA over the last 2 decades and selected recommendations from recently published clinical practice guidelines from the Infectious Diseases Society of America (IDSA).[4]
Introduction
The epidemiologic landscape of MRSA has changed dramatically over time. In the 1990s, we saw MRSA infections only in hospitals. At the end of that decade and the beginning of the next, MRSA infections began to emerge in the community in individuals who had not been exposed to the hospital in the past year, did not have any indwelling catheters, were not on hemodialysis therapy, had not had surgery in the past 12 months, and did not have family members who worked in hospitals. In essence, MRSA infections occurring in the community were not due to feral nosocomial strains, and patients infected or colonized by these strains did not acquire them through direct or even indirect healthcare contacts. In light of this lack of connection to hospitals, these newly recognized antibiotic-resistant staphylococci became known as CA-MRSA.
CA-MRSA on the Move
MRSA strains are classified by phenotype and genotype (Table 1). Historically, certain MRSA phenotypes occurred in the community (CA-MRSA) and were distinct from MRSA phenotypes that occurred in hospitals (healthcare-associated MRSA [HA-MRSA]). CA-MRSA has slightly different antibiograms compared with HA-MRSA. CA-MRSA is more likely to be susceptible to nonbeta-lactam antibiotics, specifically trimethoprim-sulfamethoxazole (TMP-SMZ)*, the tetracyclines, and in some cases, clindamycin, whereas nosocomial HA-MRSA is more often broadly resistant with limited susceptibility to nonbeta-lactam antibiotics. From a genotypic perspective, CA-MRSA (vs HA-MRSA) has a slightly different genetic element that encodes for cell wall changes that make the bacteria methicillin resistant.
From an epidemiologic perspective, over the last 5-7 years, the differences between CA-MRSA and HA-MRSA have become blurred. In other words, the incidence of nosocomial infections caused by MRSA isolates phenotypically and genotypically consistent with CA-MRSA strains has increased.[5] Thus, CA-MRSA strains are now considered part of the epidemiologic continuum of HA-MRSA strains.
Table 1. Phenotypic and Genotypic Distinctions Between CA-MRSA and HA-MRSA
MRSA Isolates Phenotypea Genotypeb
CA-MRSA Often susceptible to nonbeta-lactam antibiotics. In addition to susceptibility to vancomycin, often susceptible to TMP-SMZ, doxycycline, minocycline, clindamycin, daptomycin, and linezolid. USA300,cUSA400c are the most common genotypes based on PFGE.
SCCmec type IV is the most common genetic element that encodes methicillin resistance.
HA-MRSA Resistant to more classes of antibiotics than are CA-MRSA. Usually susceptible to at least vancomycin, daptomycin, and linezolid. USA100, USA200, and USA600 are the most common genotypes based on PFGE.
SCCmec type II-III are the most common genetic elements that encode for methicillin resistance.
CA-MRSA = community-associated methicillin-resistant Staphylococcus aureus; HA-MRSA = healthcare-associated methicillin-resistant Staphylococcus aureus; TMP-SMZ = trimethoprim-sulfamethoxazole; PFGE = pulsed-field gel electrophoresis; SCCmec = staphylococcal cassette chromosome mec
a. Based on antimicrobial drug susceptibilities.
b. MRSA clones most closely associated with CA-MRSA and HA-MRSA in the United States.
c. Often contain Panton-Valentine leukocidin genes and are more frequently associated with skin and soft-tissue infections.
Management of SSTIs
The most common CA-MRSA infections are SSTIs[6];I'm going to focus on outpatient treatment of SSTI. In 2008, the New England Journal of Medicine polled its readers about how they would treat a college athlete who presented with a tender 5- by 3-cm area of erythema with an abscess in the center.[6,7] The poll included 11,205 participants from 124 countries. Readers were asked to choose 1 of the following 3 treatment options:
1.Incision and drainage alone with no antimicrobial therapy;
2.Incision and drainage plus antimicrobial therapy active against methicillin-susceptible S aureus (MSSA); the patient had not had a culture taken so it was a clinical scenario, not a known bacteria, that was being treated; or
3.Incision and drainage plus antibacterial therapy that would be active against MRSA, presuming that MRSA would be the most common cause of infection.
The results were interesting (Figure 3).[7] The majority of North American readers (53%) selected option 3, incision and drainage plus antibacterial therapy for MRSA. This probably reflects the fact that in the United States, if a patient goes to an emergency room with an abscess that is incised and drained, a culture of the drainage will be positive for MRSA more than 50% of the time if S aureus is the offending pathogen, even in individuals without exposure to hospitals. In Europe, where MRSA is far less common in the community, the highest percentage (45%) of respondents selected option 1, incision and drainage alone. Option 2, incision and drainage plus antibacterial therapy for MSSA, was selected by 18% of respondents in the United States and 34% of respondents in Europe.
Figure 3. Percentage of North American vs European participants choosing each treatment option for the management of skin and soft-tissue infection in an Internet poll.A discussion of participant feedback regarding their choices is included in the publication.
I&D = incision and drainage; MRSA = methicillin-resistant Staphylococcus aureus; MSSA = methicillin-susceptible Staphylococcus aureus
From Diep BA, et al. Ann Intern Med. 2008;148:249-257.[8]
The IDSA recently published clinical practice guidelines for the treatment of MRSA infections in adults and children with recommendations for several different clinical scenarios in addition to SSTI, including uncomplicated and complicated bacteremia and severe community-associated pneumonia in the hospitalized patient.[4] Vancomycin and daptomycin are the recommended agents for bacteremia and vancomycin, linezolid, and clindamycin are the recommended agents for pneumonia. The new recommendations for management of SSTI are listed in Table 2.
Table 2. Recommendations for Management of Skin and Soft-Tissue Infections
Clinical Presentation Recommended Treatment
Simple cutaneous abscess Incision and drainage (I&D)
Abscess associated with severe disease, rapid progression with cellulitis, systemic comorbidities, difficult-to-drain areas I&D and antibiotic therapy
Purulent cellulitis in outpatient setting Empiric antibiotic therapy for MRSA: most often either clindamycin, TMP-SMZ*, doxycycline, or minocycline, with choice guided by local susceptibility pattern
Nonpurulent cellulitis in outpatient setting Empiric antibiotic therapy for beta-hemolytic Streptococcus: penicillin V or amoxicillin (with the caveat that beta-hemolytic streptococcal resistance to clindamycin is emerging in some communities), or if TMP-SMZ* or a tetracycline (doxycycline or minocycline) is used because of concern about potential CA-MRSA, add a beta-lactam (eg, amoxicillin) with activity against beta-hemolytic Streptococcus.
CA-MRSA = community-associated methicillin-resistant Staphylococcus aureus; MRSA = methicillin-resistant Staphylococcus aureus; TMP-SMZ = trimethoprim/sulfamethoxazole
From Liu C, et al. Clin Infect Dis. 2011;52:1-38.[4]
If, in addition to incision and drainage, you decide to treat MRSA with an antibiotic in the United States, of the options in Table 2, TMP-SMZ* tends to be the most active in vitro. However, in my experience, the agent chosen may depend on the individual providing the treatment. Infectious disease physicians who use a lot of TMP-SMZ* for a variety of infections tend to use TMP-SMZ*, most commonly for treatment of CA-MRSA-related SSTI; dermatologists who typically treat acne with tetracycline are more likely to use doxycycline or minocycline, and emergency medicine physicians tend to use clindamycin because they may not see the patient again and are concerned about covering for a potential group A Streptococcus infection.
In addition to the traditional first-line agents, the newer antimicrobials (telavancin and ceftaroline) also have in vitro activity against MRSA. Telavancin is approved by the US Food and Drug Administration (FDA) for treatment of MRSA-related complicated SSTI, and ceftaroline is FDA approved for treatment of acute bacterial SSTI, including those due to MRSA.
As implied in Table 2, the likelihood of S aureus is higher in an abscess or lesion with draining pus; treatment with TMP-SMZ*, doxycycline, minocycline, or clindamycin if these agents are active against CA-MRSA in your part of the country is a reasonable approach. If the infection is a cellulitis and there is no drainable pus, then a group A streptococcal infection is more likely. TMP-SMZ*, doxycycline, and minocycline are not as active against group A Streptococcus, so you would have to combine one of those agents with amoxicillin, ampicillin, or penicillin, whereas clindamycin may cover both MRSA and group A Streptococcus.
One must keep in mind that the epidemiologic MRSA landscape is ever-changing. For example, a new multidrug-resistant clone of MRSA has been reported in San Francisco and Boston in men who have sex with men.[8] This particular strain is resistant to clindamycin and tetracycline and has increased resistance to mupirocin, a topical agent used for staphylococcal nasal decolonization. If you are treating a soft tissue abscess and suspect MRSA in men who have sex with men in San Francisco or Boston and do not have susceptibility results, you might shy away from clindamycin, doxycycline, and tetracycline, and focus more on TMP-SMZ*.
Managing Recurrent MRSA-Related SSTI
Some individuals have recurrent MRSA-related SSTI and some of these individuals carry MRSA in the nares, the main reservoir of S aureus in the body, and in other body sites. Should these patients be decolonized in an effort to prevent recurrence, and if so when and how?
Recent clinical practice guidelines from the IDSA include recommendations for decolonization of patients with recurrent MRSA infections (Table 3).[4] The level of evidence for all of the recommendations for interventions is C-III, meaning that they have the least data to support them and are mostly based on expert opinion. In the United States, management is most often with nasal decolonization with mupirocin alone or in combination with chlorhexidine bathing, but usually not with oral antibiotics unless repeated MRSA infections occur despite use of a nasal and skin decolonization regimen. In Europe, particularly in The Netherlands where there has been pioneering work in control of MRSA, decolonization management with a combination of all 3 approaches (nasal mupirocin, chlorhexidine bathing, and oral antibiotic) is more likely to be done than in the United States.
Table 3. Recommendations for the Use of Decolonization in the Management of Recurrent Skin and Soft-Tissue Infections
Decolonization may be considered in selected cases if:
•A patient develops a recurrent SSTI despite optimizing wound care and hygiene measures (C-III*)
•Ongoing transmission is occurring among household members or other close contacts despite optimizing wound care and hygiene measures (C-III*)
Decolonization strategies should be offered in conjunction with ongoing reinforcement of hygiene measures and may include the following:
•Nasal decolonization with mupirocin twice daily for 5-10 days (C-III*)
•Nasal decolonization with mupirocin twice daily for 5-10 days and topical body decolonization regimens with a skin antiseptic solution (eg, chlorhexidine) for 5-14 days or dilute bleach baths. (For dilute bleach baths, 1 teaspoon per gallon of water [or one quarter cup per one quarter tub or 13 gallons of water] used for 15 min twice weekly for ~ 3 months can be considered) (C-III)*
Oral antimicrobial therapy is recommended for the treatment of active infection only and is not routinely recommended for decolonization (A-III**). An oral agent in combination with rifampin, if the strain is susceptible, may be considered for decolonization if infections recur despite the above measures (C-III*).
SSTI = skin and soft-tissue infection
*Indicates strength of recommendation and quality of evidence: C = poor evidence to support a recommendation; III = evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
**Indicates strength of recommendation and quality of evidence: A = good evidence to support a recommendation for or against use; III = evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
From Delorme T, et al. Am J Clin Pathol. 2009;132:668-677.[2]
What do you do at the institutional level? At an institutional level there is the issue of preoperative decolonization. In some hospitals, it is policy that patients who are having elective surgery (particularly cardiac surgery or placement of prosthetic devices) be treated with mupirocin for 5 days before surgery for nasal decolonization, particularly if the patient is known to be colonized with MRSA. This is somewhat controversial, but even more controversial is the use of active surveillance to prevent transmission of MRSA within hospitals.
Search and Destroy
The Dutch have eliminated the spread of MRSA by active surveillance or the so-called "search and destroy" approach to outbreak control, which consists of the use of active surveillance cultures for persons at risk, pre-emptive isolation of patients at risk, and strict isolation of known MRSA carriers and the eradication of MRSA carriage.[9] The Dutch culture the nares of patients who are admitted to hospitals if they're from other countries, being transferred from another hospital, or if there is reason to believe that the patient is colonized with MRSA. Through the initiation of contact precautions (gown and gloves before contact with the patient or patient's room environment) in these patients, MRSA has been eliminated from hospitals in The Netherlands and a number of Scandinavian countries.
In the United States, a number of states have adopted this approach and mandated that patients who are admitted from the community to intensive care units (ICUs) or who are admitted to the hospital from nursing homes or other potential high-risk areas undergo nasal screening for MRSA.[10] If positive, they are placed on contact precautions. In my view, whether that mandate will make a difference in terms of the spread of MRSA is controversial. My approach is to focus on device-related infections. For example, CDC published their experience recently and showed that from 2002 (when new central line-associated bloodstream infection [CLABSI] guidelines were introduced) to 2007 there was a marked decrease (46%) in the number of MRSA-related CLABSI in ICUs in hospitals monitored by the CDC, even though the percentage of S aureus that is MRSA has remained the same in those hospitals.[11] My view is that focusing on prevention of device-related infections will give more bang for the buck and prevent not only MRSA but other infections as well.
Back to the Basics: Hygiene
Prevention is also an issue in community settings where people are in close contact. For example, outbreaks of CA-MRSA have been documented among both professional and amateur athletic teams, military recruits, and men who have sex with men, and also in correctional facilities, schools, and newborn nurseries.[5] The major message here is hygiene. Individuals on sports teams should not share equipment unless it's cleaned between uses, and they should not share towels. Aggressive cleaning should be done in schools. Some schools have approached this by closing the school for 1 day or 2 to try to get rid of environmental contamination, but there are no data to support that approach and the benefit of this is unknown. Finally, communication needs to be better between nursing homes and hospitals. As patients move from hospitals to long-term acute care facilities or nursing homes, we need to do a better job of communicating if these patients may be colonized with MRSA and therefore, may need to be placed on contact precautions.
*TMP-SMX is not FDA-approved for the treatment of any staphylococcal infections. However, because 95%-100% of CA-MRSA strains are susceptible in vitro, it has become an important option for the outpatient treatment of SSTI.[2]
Supported independent educational grants from Cubist Pharmaceuticals, Inc.; Astellas Pharma, Inc.; and Pfizer Inc.
This article is a CME/CE certified activity. To earn credit for this activity visit:
http://www.medscape.org/viewarticle/737999
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References
1.David MZ, Daum RS. Community-associated methicillin-resistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic. Clin Microbiol Rev. 2010;23:616-687. Abstract
2.Delorme T, Rose S, Senita J, Callahan C, Nasr P. Epidemiology and susceptibilities of methicillin-resistant Staphylococcus aureus in northeastern Ohio. Am J Clin Pathol. 2009;132:668-677. Abstract
3.May AK, Stafford RE, Bulger EM, et al. Treatment of complicated skin and soft tissue infections. Surgical Infections. 2009;10:467-499. Abstract
4.Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52:1-38. Abstract
5.Maree CL, Daum RS, Boyle-Vavra, Matayoshi K, Miller LG. Community-associated methicillin-resistant Staphylococcus aureus isolates causing healthcare-associated infections. Emerg Infect Dis. 2007;13:236-242. Abstract
6.Chambers HF, Moellering RC Jr, Kamitsuka P. Management of skin and soft-tissue infections. N Engl J Med. 2008;359:1063-1067. Abstract
7.Hammond SP, Baden LR. Management of skin and soft-tissue infection - polling results. N Engl J Med. 2008;359:e20.
8.Diep BA, Chambers HF, Graber CJ, et al. Emergence of multidrug-resistant, community-associated, methicillin-resistant Staphylococcus aureus clone USA300 in men who have sex with men. Ann Intern Med. 2008;148:249-257. Abstract
9.Vos MC, Behrendt MD, Melles DC, et al. 5 years of experience implementing a methicillin-resistant Staphylococcus aureus search and destroy policy at the largest university medical center in the Netherlands. Infect Control Hosp Epidemiol. 2009;30:977-984. Abstract
10.Weber SG, Huang SS, Oriola S, et al. Legislative mandates for the use of active surveillance cultures to screen for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci: Position Statement from the joint SHEA and APIC Task Force. Infect Control Hosp Epidemiol. 2007;28:249-260. Abstract
11.Burton DC, Edwards JR, Horan TC, et al. Methicillin-resistant Staphylococcus aureus central line-associated bloodstream infections in US intensive care units, 1997-2007. JAMA. 2009;301:727-736. Abstract
Sponsored by the National Foundation for Infectious Diseases.
Disclaimer
The material presented here does not necessarily reflect the views of Medscape, LLC, or companies that support educational programming on www.medscape.org. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity.
Medscape Education © 2011 Medscape, LLC
This article is a CME/CE certified activity. To earn credit for this activity visit:
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http://www.medscape.org/viewarticle/737999
CME/CE Released: 03/17/2011; Valid for credit through 03/17/2012
Target Audience
This activity is intended for infectious disease specialists, emergency medicine clinicians, hospitalists, internists, primary care and family medicine physicians, nurses/advanced practice nurses, and physician assistants.
Goal
The goal of this activity is to address the educational needs related to the evolving epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) and increase clinical competency related to early and accurate identification and differential diagnosis of MRSA infections, treatment options including appropriate antimicrobial utilization, and emerging clinical controversies. In turn, patients will receive optimal care, and patient outcomes will be improved.
Learning Objectives
Upon completion of this activity, participants will be able to:
1.Select evidence-based interventions for containing MRSA infections in the community and hospital
2.Identify clinical challenges resulting from the changing epidemiology of MRSA
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[CLOSE WINDOW]Authors and DisclosuresAs organizations accredited by the ACCME, NFID and Medscape, LLC require everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner that could create a conflict of interest.
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Author(s)Robert A. Weinstein, MD Chairman, Department of Medicine, Cook County Health and Hospitals System; Chief Operating Officer, Ruth M. Rothstein CORE Center, C. Anderson Hedberg, MD, Professor of Internal Medicine, Rush University Medical Center, Chicago, Illinois
Disclosure: Robert A. Weinstein, MD, has disclosed the following relevant financial relationships:
Received grants for clinical research from: US Centers for Disease Control and Prevention
Owns stock, stock options, or bonds from: Merck & Co., Inc.; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; GlaxoSmithKline
Dr. Weinstein does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics not approved by the US Food and Drug Administration (FDA) for use in the United States.
Dr. Weinstein does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.
Editor and Nurse PlannerSusan L. Smith, MN, PhDScientific Director, Medscape LLC
Susan L. Smith, MN, PhD, has disclosed no relevant financial relationships.
CME ReviewerNafeez Zawahir, MDCME Clinical Director, Medscape, LLC
Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.
From Medscape Education Infectious Diseases
Containing the Superbug CME/CE
Robert A. Weinstein, MD
CME/CE Released: 03/17/2011; Valid for credit through 03/17/2012
Download Audio
Editor's note: Staphylococcus aureus is the most commonly isolated human bacterial pathogen and is an important cause of several potentially serious and fatal infections, including bacteremia and sepsis, endocarditis, endovascular infections, foreign-body infections, osteomyelitis, pneumonia, skin and soft-tissue infections (SSTIs), and septic arthritis. The disease burden of methicillin-resistant S aureus (MRSA) (strains that are resistant to all available penicillins and other beta-lactam antimicrobial agents) in the United States has not only increased considerably, but the epidemiology of MRSA has changed. Historically, MRSA infections occurred in individuals considered at risk due to healthcare exposure; primarily patients admitted to inpatient healthcare facilities and/or those who frequented other healthcare environments.[1] Beginning in the mid-1990s, infections caused by new strains of MRSA began to be reported in individuals in the community without risk factors and are responsible for a significant proportion of the increased disease burden of MRSA in the last decade.
Delorme and colleagues conducted a retrospective survey of all staphylococcal infections diagnosed by a single medical center in Northeastern Ohio during 2006 and 2007.[2] The incidence of MRSA increased 77% overall, 58% in outpatients, 43% in hospitalized patients, and 183% in residents of long-term care facilities. Sixty-six percent of individuals diagnosed with MRSA had no risk factors for staphylococcal infection. SSTIs are especially burdensome, especially complicated SSTIs, which by definition are those requiring surgical intervention.[3] SSTIs are caused by a variety of pathogens, including aerobic gram-positive or gram-negative organisms, and in some settings other unique pathogens. Overall, S aureus is the pathogen most frequently isolated from complicated SSTIs. SSTIs in patients in healthcare settings are more likely due to MRSA, methicillin-resistant Staphylococcus epidermidis, vancomycin-resistant Enterococcus, and resistant gram-negative pathogens. Community-acquired or community-associated MRSA (CA-MRSA) is the single most frequent pathogen responsible for SSTIs.[3]
Infection control and prevention are responsibilities of all healthcare workers, whether caring for hospitalized patients or caring for and educating patients on preventive practices in community settings, including the home. MRSA in the community is widespread and therefore anyone is at risk. Nurses in particular, and especially those who practice in community health settings, schools, and correctional facilities, are more likely to provide this education. Because the majority of MRSA infections in the community are SSTIs, this should be the focus of education: to prevent the occurrence and spread of CA-MRSA. Individuals at highest risk for SSTIs are those in close skin-to-skin contact with others (eg, athletes, children in day care centers, and living in crowded conditions such as in dormitories, military barracks, or correctional facilities), with openings in the skin such as cuts or abrasions, likely to be in contact with contaminated items and surfaces, and with poor hygiene. The Centers for Disease Control and Prevention (CDC) provides special information and advice for family caregivers, athletes, coaches and athletic directors, school officials, and others. In particular, downloadable fact sheets for these groups are available at no charge on the CDC's Website. Examples are shown in Figure 1 and Figure 2.
(Download PDF) Figure 1. MRSA fact sheet for athletes, coaches, and athletic directors.
(Download PDF) Figure 2. MRSA fact sheet for early childhood care and education professionals.
Robert A. Weinstein, MD, Chairman of the Department of Medicine for the Cook County Health and Hospitals System, the Chief Operating Officer of the Ruth M. Rothstein CORE Center, and the C. Anderson Hedberg, MD, Professor of Internal Medicine at Rush University Medical Center, in Chicago, Illinois, discusses implications of the changes observed with MRSA over the last 2 decades and selected recommendations from recently published clinical practice guidelines from the Infectious Diseases Society of America (IDSA).[4]
Introduction
The epidemiologic landscape of MRSA has changed dramatically over time. In the 1990s, we saw MRSA infections only in hospitals. At the end of that decade and the beginning of the next, MRSA infections began to emerge in the community in individuals who had not been exposed to the hospital in the past year, did not have any indwelling catheters, were not on hemodialysis therapy, had not had surgery in the past 12 months, and did not have family members who worked in hospitals. In essence, MRSA infections occurring in the community were not due to feral nosocomial strains, and patients infected or colonized by these strains did not acquire them through direct or even indirect healthcare contacts. In light of this lack of connection to hospitals, these newly recognized antibiotic-resistant staphylococci became known as CA-MRSA.
CA-MRSA on the Move
MRSA strains are classified by phenotype and genotype (Table 1). Historically, certain MRSA phenotypes occurred in the community (CA-MRSA) and were distinct from MRSA phenotypes that occurred in hospitals (healthcare-associated MRSA [HA-MRSA]). CA-MRSA has slightly different antibiograms compared with HA-MRSA. CA-MRSA is more likely to be susceptible to nonbeta-lactam antibiotics, specifically trimethoprim-sulfamethoxazole (TMP-SMZ)*, the tetracyclines, and in some cases, clindamycin, whereas nosocomial HA-MRSA is more often broadly resistant with limited susceptibility to nonbeta-lactam antibiotics. From a genotypic perspective, CA-MRSA (vs HA-MRSA) has a slightly different genetic element that encodes for cell wall changes that make the bacteria methicillin resistant.
From an epidemiologic perspective, over the last 5-7 years, the differences between CA-MRSA and HA-MRSA have become blurred. In other words, the incidence of nosocomial infections caused by MRSA isolates phenotypically and genotypically consistent with CA-MRSA strains has increased.[5] Thus, CA-MRSA strains are now considered part of the epidemiologic continuum of HA-MRSA strains.
Table 1. Phenotypic and Genotypic Distinctions Between CA-MRSA and HA-MRSA
MRSA Isolates Phenotypea Genotypeb
CA-MRSA Often susceptible to nonbeta-lactam antibiotics. In addition to susceptibility to vancomycin, often susceptible to TMP-SMZ, doxycycline, minocycline, clindamycin, daptomycin, and linezolid. USA300,cUSA400c are the most common genotypes based on PFGE.
SCCmec type IV is the most common genetic element that encodes methicillin resistance.
HA-MRSA Resistant to more classes of antibiotics than are CA-MRSA. Usually susceptible to at least vancomycin, daptomycin, and linezolid. USA100, USA200, and USA600 are the most common genotypes based on PFGE.
SCCmec type II-III are the most common genetic elements that encode for methicillin resistance.
CA-MRSA = community-associated methicillin-resistant Staphylococcus aureus; HA-MRSA = healthcare-associated methicillin-resistant Staphylococcus aureus; TMP-SMZ = trimethoprim-sulfamethoxazole; PFGE = pulsed-field gel electrophoresis; SCCmec = staphylococcal cassette chromosome mec
a. Based on antimicrobial drug susceptibilities.
b. MRSA clones most closely associated with CA-MRSA and HA-MRSA in the United States.
c. Often contain Panton-Valentine leukocidin genes and are more frequently associated with skin and soft-tissue infections.
Management of SSTIs
The most common CA-MRSA infections are SSTIs[6];I'm going to focus on outpatient treatment of SSTI. In 2008, the New England Journal of Medicine polled its readers about how they would treat a college athlete who presented with a tender 5- by 3-cm area of erythema with an abscess in the center.[6,7] The poll included 11,205 participants from 124 countries. Readers were asked to choose 1 of the following 3 treatment options:
1.Incision and drainage alone with no antimicrobial therapy;
2.Incision and drainage plus antimicrobial therapy active against methicillin-susceptible S aureus (MSSA); the patient had not had a culture taken so it was a clinical scenario, not a known bacteria, that was being treated; or
3.Incision and drainage plus antibacterial therapy that would be active against MRSA, presuming that MRSA would be the most common cause of infection.
The results were interesting (Figure 3).[7] The majority of North American readers (53%) selected option 3, incision and drainage plus antibacterial therapy for MRSA. This probably reflects the fact that in the United States, if a patient goes to an emergency room with an abscess that is incised and drained, a culture of the drainage will be positive for MRSA more than 50% of the time if S aureus is the offending pathogen, even in individuals without exposure to hospitals. In Europe, where MRSA is far less common in the community, the highest percentage (45%) of respondents selected option 1, incision and drainage alone. Option 2, incision and drainage plus antibacterial therapy for MSSA, was selected by 18% of respondents in the United States and 34% of respondents in Europe.
Figure 3. Percentage of North American vs European participants choosing each treatment option for the management of skin and soft-tissue infection in an Internet poll.A discussion of participant feedback regarding their choices is included in the publication.
I&D = incision and drainage; MRSA = methicillin-resistant Staphylococcus aureus; MSSA = methicillin-susceptible Staphylococcus aureus
From Diep BA, et al. Ann Intern Med. 2008;148:249-257.[8]
The IDSA recently published clinical practice guidelines for the treatment of MRSA infections in adults and children with recommendations for several different clinical scenarios in addition to SSTI, including uncomplicated and complicated bacteremia and severe community-associated pneumonia in the hospitalized patient.[4] Vancomycin and daptomycin are the recommended agents for bacteremia and vancomycin, linezolid, and clindamycin are the recommended agents for pneumonia. The new recommendations for management of SSTI are listed in Table 2.
Table 2. Recommendations for Management of Skin and Soft-Tissue Infections
Clinical Presentation Recommended Treatment
Simple cutaneous abscess Incision and drainage (I&D)
Abscess associated with severe disease, rapid progression with cellulitis, systemic comorbidities, difficult-to-drain areas I&D and antibiotic therapy
Purulent cellulitis in outpatient setting Empiric antibiotic therapy for MRSA: most often either clindamycin, TMP-SMZ*, doxycycline, or minocycline, with choice guided by local susceptibility pattern
Nonpurulent cellulitis in outpatient setting Empiric antibiotic therapy for beta-hemolytic Streptococcus: penicillin V or amoxicillin (with the caveat that beta-hemolytic streptococcal resistance to clindamycin is emerging in some communities), or if TMP-SMZ* or a tetracycline (doxycycline or minocycline) is used because of concern about potential CA-MRSA, add a beta-lactam (eg, amoxicillin) with activity against beta-hemolytic Streptococcus.
CA-MRSA = community-associated methicillin-resistant Staphylococcus aureus; MRSA = methicillin-resistant Staphylococcus aureus; TMP-SMZ = trimethoprim/sulfamethoxazole
From Liu C, et al. Clin Infect Dis. 2011;52:1-38.[4]
If, in addition to incision and drainage, you decide to treat MRSA with an antibiotic in the United States, of the options in Table 2, TMP-SMZ* tends to be the most active in vitro. However, in my experience, the agent chosen may depend on the individual providing the treatment. Infectious disease physicians who use a lot of TMP-SMZ* for a variety of infections tend to use TMP-SMZ*, most commonly for treatment of CA-MRSA-related SSTI; dermatologists who typically treat acne with tetracycline are more likely to use doxycycline or minocycline, and emergency medicine physicians tend to use clindamycin because they may not see the patient again and are concerned about covering for a potential group A Streptococcus infection.
In addition to the traditional first-line agents, the newer antimicrobials (telavancin and ceftaroline) also have in vitro activity against MRSA. Telavancin is approved by the US Food and Drug Administration (FDA) for treatment of MRSA-related complicated SSTI, and ceftaroline is FDA approved for treatment of acute bacterial SSTI, including those due to MRSA.
As implied in Table 2, the likelihood of S aureus is higher in an abscess or lesion with draining pus; treatment with TMP-SMZ*, doxycycline, minocycline, or clindamycin if these agents are active against CA-MRSA in your part of the country is a reasonable approach. If the infection is a cellulitis and there is no drainable pus, then a group A streptococcal infection is more likely. TMP-SMZ*, doxycycline, and minocycline are not as active against group A Streptococcus, so you would have to combine one of those agents with amoxicillin, ampicillin, or penicillin, whereas clindamycin may cover both MRSA and group A Streptococcus.
One must keep in mind that the epidemiologic MRSA landscape is ever-changing. For example, a new multidrug-resistant clone of MRSA has been reported in San Francisco and Boston in men who have sex with men.[8] This particular strain is resistant to clindamycin and tetracycline and has increased resistance to mupirocin, a topical agent used for staphylococcal nasal decolonization. If you are treating a soft tissue abscess and suspect MRSA in men who have sex with men in San Francisco or Boston and do not have susceptibility results, you might shy away from clindamycin, doxycycline, and tetracycline, and focus more on TMP-SMZ*.
Managing Recurrent MRSA-Related SSTI
Some individuals have recurrent MRSA-related SSTI and some of these individuals carry MRSA in the nares, the main reservoir of S aureus in the body, and in other body sites. Should these patients be decolonized in an effort to prevent recurrence, and if so when and how?
Recent clinical practice guidelines from the IDSA include recommendations for decolonization of patients with recurrent MRSA infections (Table 3).[4] The level of evidence for all of the recommendations for interventions is C-III, meaning that they have the least data to support them and are mostly based on expert opinion. In the United States, management is most often with nasal decolonization with mupirocin alone or in combination with chlorhexidine bathing, but usually not with oral antibiotics unless repeated MRSA infections occur despite use of a nasal and skin decolonization regimen. In Europe, particularly in The Netherlands where there has been pioneering work in control of MRSA, decolonization management with a combination of all 3 approaches (nasal mupirocin, chlorhexidine bathing, and oral antibiotic) is more likely to be done than in the United States.
Table 3. Recommendations for the Use of Decolonization in the Management of Recurrent Skin and Soft-Tissue Infections
Decolonization may be considered in selected cases if:
•A patient develops a recurrent SSTI despite optimizing wound care and hygiene measures (C-III*)
•Ongoing transmission is occurring among household members or other close contacts despite optimizing wound care and hygiene measures (C-III*)
Decolonization strategies should be offered in conjunction with ongoing reinforcement of hygiene measures and may include the following:
•Nasal decolonization with mupirocin twice daily for 5-10 days (C-III*)
•Nasal decolonization with mupirocin twice daily for 5-10 days and topical body decolonization regimens with a skin antiseptic solution (eg, chlorhexidine) for 5-14 days or dilute bleach baths. (For dilute bleach baths, 1 teaspoon per gallon of water [or one quarter cup per one quarter tub or 13 gallons of water] used for 15 min twice weekly for ~ 3 months can be considered) (C-III)*
Oral antimicrobial therapy is recommended for the treatment of active infection only and is not routinely recommended for decolonization (A-III**). An oral agent in combination with rifampin, if the strain is susceptible, may be considered for decolonization if infections recur despite the above measures (C-III*).
SSTI = skin and soft-tissue infection
*Indicates strength of recommendation and quality of evidence: C = poor evidence to support a recommendation; III = evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
**Indicates strength of recommendation and quality of evidence: A = good evidence to support a recommendation for or against use; III = evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
From Delorme T, et al. Am J Clin Pathol. 2009;132:668-677.[2]
What do you do at the institutional level? At an institutional level there is the issue of preoperative decolonization. In some hospitals, it is policy that patients who are having elective surgery (particularly cardiac surgery or placement of prosthetic devices) be treated with mupirocin for 5 days before surgery for nasal decolonization, particularly if the patient is known to be colonized with MRSA. This is somewhat controversial, but even more controversial is the use of active surveillance to prevent transmission of MRSA within hospitals.
Search and Destroy
The Dutch have eliminated the spread of MRSA by active surveillance or the so-called "search and destroy" approach to outbreak control, which consists of the use of active surveillance cultures for persons at risk, pre-emptive isolation of patients at risk, and strict isolation of known MRSA carriers and the eradication of MRSA carriage.[9] The Dutch culture the nares of patients who are admitted to hospitals if they're from other countries, being transferred from another hospital, or if there is reason to believe that the patient is colonized with MRSA. Through the initiation of contact precautions (gown and gloves before contact with the patient or patient's room environment) in these patients, MRSA has been eliminated from hospitals in The Netherlands and a number of Scandinavian countries.
In the United States, a number of states have adopted this approach and mandated that patients who are admitted from the community to intensive care units (ICUs) or who are admitted to the hospital from nursing homes or other potential high-risk areas undergo nasal screening for MRSA.[10] If positive, they are placed on contact precautions. In my view, whether that mandate will make a difference in terms of the spread of MRSA is controversial. My approach is to focus on device-related infections. For example, CDC published their experience recently and showed that from 2002 (when new central line-associated bloodstream infection [CLABSI] guidelines were introduced) to 2007 there was a marked decrease (46%) in the number of MRSA-related CLABSI in ICUs in hospitals monitored by the CDC, even though the percentage of S aureus that is MRSA has remained the same in those hospitals.[11] My view is that focusing on prevention of device-related infections will give more bang for the buck and prevent not only MRSA but other infections as well.
Back to the Basics: Hygiene
Prevention is also an issue in community settings where people are in close contact. For example, outbreaks of CA-MRSA have been documented among both professional and amateur athletic teams, military recruits, and men who have sex with men, and also in correctional facilities, schools, and newborn nurseries.[5] The major message here is hygiene. Individuals on sports teams should not share equipment unless it's cleaned between uses, and they should not share towels. Aggressive cleaning should be done in schools. Some schools have approached this by closing the school for 1 day or 2 to try to get rid of environmental contamination, but there are no data to support that approach and the benefit of this is unknown. Finally, communication needs to be better between nursing homes and hospitals. As patients move from hospitals to long-term acute care facilities or nursing homes, we need to do a better job of communicating if these patients may be colonized with MRSA and therefore, may need to be placed on contact precautions.
*TMP-SMX is not FDA-approved for the treatment of any staphylococcal infections. However, because 95%-100% of CA-MRSA strains are susceptible in vitro, it has become an important option for the outpatient treatment of SSTI.[2]
Supported independent educational grants from Cubist Pharmaceuticals, Inc.; Astellas Pharma, Inc.; and Pfizer Inc.
This article is a CME/CE certified activity. To earn credit for this activity visit:
http://www.medscape.org/viewarticle/737999
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References
1.David MZ, Daum RS. Community-associated methicillin-resistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic. Clin Microbiol Rev. 2010;23:616-687. Abstract
2.Delorme T, Rose S, Senita J, Callahan C, Nasr P. Epidemiology and susceptibilities of methicillin-resistant Staphylococcus aureus in northeastern Ohio. Am J Clin Pathol. 2009;132:668-677. Abstract
3.May AK, Stafford RE, Bulger EM, et al. Treatment of complicated skin and soft tissue infections. Surgical Infections. 2009;10:467-499. Abstract
4.Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52:1-38. Abstract
5.Maree CL, Daum RS, Boyle-Vavra, Matayoshi K, Miller LG. Community-associated methicillin-resistant Staphylococcus aureus isolates causing healthcare-associated infections. Emerg Infect Dis. 2007;13:236-242. Abstract
6.Chambers HF, Moellering RC Jr, Kamitsuka P. Management of skin and soft-tissue infections. N Engl J Med. 2008;359:1063-1067. Abstract
7.Hammond SP, Baden LR. Management of skin and soft-tissue infection - polling results. N Engl J Med. 2008;359:e20.
8.Diep BA, Chambers HF, Graber CJ, et al. Emergence of multidrug-resistant, community-associated, methicillin-resistant Staphylococcus aureus clone USA300 in men who have sex with men. Ann Intern Med. 2008;148:249-257. Abstract
9.Vos MC, Behrendt MD, Melles DC, et al. 5 years of experience implementing a methicillin-resistant Staphylococcus aureus search and destroy policy at the largest university medical center in the Netherlands. Infect Control Hosp Epidemiol. 2009;30:977-984. Abstract
10.Weber SG, Huang SS, Oriola S, et al. Legislative mandates for the use of active surveillance cultures to screen for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci: Position Statement from the joint SHEA and APIC Task Force. Infect Control Hosp Epidemiol. 2007;28:249-260. Abstract
11.Burton DC, Edwards JR, Horan TC, et al. Methicillin-resistant Staphylococcus aureus central line-associated bloodstream infections in US intensive care units, 1997-2007. JAMA. 2009;301:727-736. Abstract
Sponsored by the National Foundation for Infectious Diseases.
Disclaimer
The material presented here does not necessarily reflect the views of Medscape, LLC, or companies that support educational programming on www.medscape.org. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity.
Medscape Education © 2011 Medscape, LLC
This article is a CME/CE certified activity. To earn credit for this activity visit:
http://www.medscape.org/viewarticle/737999
Thursday, December 15, 2011
Saving the Unseen Patient
AJN, American Journal of Nursing:
September 1996 - Volume 96 - Issue 9 - p 80
Reflections
Lindsay, Carol RN BSN CEN
he confusion at the crime scene was evident in the report received by the emergency department. The paramedics initially called the patient critical, then dead, then critical again. With two gunshot wounds to the face, she had an agonal heartbeat, no pulse, and no respiration. When the ambulance arrived at the ED, the paramedics were performing manual chest compressions and using a bag and mask for ventilation. They were unable to intubate her.
"Load her up and bring her in," the ED physician directed. "We'll decide what to do after we evaluate her."
The slender 33-year-old was carried in strapped to a backboard, her dark hair matted with blood, her mauve crushed-velvet shirt torn to shreds. Gold hoop earrings hung on either side of her blood-covered face. On her feet were a pair of blue slippers.
We tried several times to intubate her, but the tube would only go in about halfway. Between attempts, we ventilated her with the bag and mask while continuing chest compressions. Intravenous epinephrine and atropine were administered. Finally, her heart started beating again and her pulse returned.
As I cut off the patient's clothes, a police officer took them and hastily stuffed them in an evidence bag. He filled me in on what had taken place. The woman's boyfriend had called the police and reported an "accidental shooting." When the officers arrived, they heard shots. The boyfriend explained that he was "unloading his gun into the carpet." Though the paramedics hadn't been able to identify any exit wounds, the police believed two of the bullets they found embedded in a wall had passed through the patient. (Figure 1)
No caption available...
Image ToolsI pulled the cricothyroidotomy tray out of the cupboard and blew the dust off the cover. After checking the expiration date, I set the tray on a bedside stand. Turning to face the patient, I heard a strange flatulent noise each time she was bagged. As I slipped my hand under her back, I felt crepitus. The skin on her upper back and neck was filled with free air. I slid my hand across her shoulders toward her neck and my fingers disappeared into a gaping hole.
"I found an exit wound!" I said. My index finger rested on something sharp, which turned out to be the remains of her fourth cervical vertebra. X-rays later showed her entire third and fourth cervical vertebrae were blown away.
I removed her Saint Christopher's necklace and the physician made a deep incision into her cricoid space. The yellow cartilage of her trachea lay deep beneath the edematous tissue of her neck. We tried several different sizes of tubing before we succeeded in inflating her lungs without losing oxygen through the hole in the back of her neck.
With a secure airway in place and oxygen being administered, her pulse became stronger and her blood pressure rebounded. But it was getting harder and harder to compress the bag. A portable X-ray showed what looked like a left-sided pneumothorax. We inserted a chest tube, but it didn't help. We placed a second chest tube in the right lung. Still no improvement.
Finally, withdrawing the endotracheal tube half an inch eased the resistance. I inserted a nasogastric tube with extreme caution-worrying that it would thread into her brain-and then catheterized her bladder.
By now we were wading through paper, boxes, syringes, trach tubes, linen, and blood. All the major trauma trays had been pulled out of the cabinet and strewn on the floor in our haste to find the ones we needed. I was scribbling notes on the backs of wrappers, to be transcribed into the chart later.
An hour after she arrived, the patient was stable. She was ordered transferred to a nearby trauma center. As we put her in the helicopter, I handed a police officer a plastic bag holding her blood-covered earrings and necklace.
"Was she pretty" he asked.
"I don't know," I answered. "I never looked."
The next day I called the trauma center and learned she'd been pronounced brain dead. Her parents had agreed to organ donation, and her heart, liver, lungs, and both kidneys were successfully harvested.
I never learned her name or anything about her. But I do know that our work was a success, because our patient gave five other people the chance she never had-the chance to live.
© Lippincott-Raven Publishers.
September 1996 - Volume 96 - Issue 9 - p 80
Reflections
Lindsay, Carol RN BSN CEN
he confusion at the crime scene was evident in the report received by the emergency department. The paramedics initially called the patient critical, then dead, then critical again. With two gunshot wounds to the face, she had an agonal heartbeat, no pulse, and no respiration. When the ambulance arrived at the ED, the paramedics were performing manual chest compressions and using a bag and mask for ventilation. They were unable to intubate her.
"Load her up and bring her in," the ED physician directed. "We'll decide what to do after we evaluate her."
The slender 33-year-old was carried in strapped to a backboard, her dark hair matted with blood, her mauve crushed-velvet shirt torn to shreds. Gold hoop earrings hung on either side of her blood-covered face. On her feet were a pair of blue slippers.
We tried several times to intubate her, but the tube would only go in about halfway. Between attempts, we ventilated her with the bag and mask while continuing chest compressions. Intravenous epinephrine and atropine were administered. Finally, her heart started beating again and her pulse returned.
As I cut off the patient's clothes, a police officer took them and hastily stuffed them in an evidence bag. He filled me in on what had taken place. The woman's boyfriend had called the police and reported an "accidental shooting." When the officers arrived, they heard shots. The boyfriend explained that he was "unloading his gun into the carpet." Though the paramedics hadn't been able to identify any exit wounds, the police believed two of the bullets they found embedded in a wall had passed through the patient. (Figure 1)
No caption available...
Image ToolsI pulled the cricothyroidotomy tray out of the cupboard and blew the dust off the cover. After checking the expiration date, I set the tray on a bedside stand. Turning to face the patient, I heard a strange flatulent noise each time she was bagged. As I slipped my hand under her back, I felt crepitus. The skin on her upper back and neck was filled with free air. I slid my hand across her shoulders toward her neck and my fingers disappeared into a gaping hole.
"I found an exit wound!" I said. My index finger rested on something sharp, which turned out to be the remains of her fourth cervical vertebra. X-rays later showed her entire third and fourth cervical vertebrae were blown away.
I removed her Saint Christopher's necklace and the physician made a deep incision into her cricoid space. The yellow cartilage of her trachea lay deep beneath the edematous tissue of her neck. We tried several different sizes of tubing before we succeeded in inflating her lungs without losing oxygen through the hole in the back of her neck.
With a secure airway in place and oxygen being administered, her pulse became stronger and her blood pressure rebounded. But it was getting harder and harder to compress the bag. A portable X-ray showed what looked like a left-sided pneumothorax. We inserted a chest tube, but it didn't help. We placed a second chest tube in the right lung. Still no improvement.
Finally, withdrawing the endotracheal tube half an inch eased the resistance. I inserted a nasogastric tube with extreme caution-worrying that it would thread into her brain-and then catheterized her bladder.
By now we were wading through paper, boxes, syringes, trach tubes, linen, and blood. All the major trauma trays had been pulled out of the cabinet and strewn on the floor in our haste to find the ones we needed. I was scribbling notes on the backs of wrappers, to be transcribed into the chart later.
An hour after she arrived, the patient was stable. She was ordered transferred to a nearby trauma center. As we put her in the helicopter, I handed a police officer a plastic bag holding her blood-covered earrings and necklace.
"Was she pretty" he asked.
"I don't know," I answered. "I never looked."
The next day I called the trauma center and learned she'd been pronounced brain dead. Her parents had agreed to organ donation, and her heart, liver, lungs, and both kidneys were successfully harvested.
I never learned her name or anything about her. But I do know that our work was a success, because our patient gave five other people the chance she never had-the chance to live.
© Lippincott-Raven Publishers.
Tuesday, December 13, 2011
Aquatic Therapy Gains Steam
December 2011
Kathleen Kristoff
Public speaking may statistically top the list of “the most common fears,” but a physical therapist working with older adults who have balance issues knows that fear of falling can be stronger than any other worry. Certainly, it’s easy to understand the patients’ concerns; after all, falling can cause injuries leading to complications, additional health problems, and even death.
Fear of Falling
The reasons why aging individuals fall are varied: decreased range of motion, balance, and gait patterns can all be culprits. And so can medical conditions such as arthritis and degenerative joint disease.
Unfortunately, traditional physical and occupational therapies do not work as well as they would if the patient were not terrified of falling. For instance, if a 70-year-old woman with balance issues and a history of falling is expected to complete physical or occupational therapy exercises, she will have to be supported the entire time, lest she fall or stop working because she’s too frightened.
Most likely, she’ll be relegated to performing rehabilitative exercises while sitting or lying down, which will limit her progress. More than likely, the exercises will be passive, static, and short in duration.
Attitude Adjuster
So what is the answer for this type of patient? In the experience of some rehabilitation practitioners, it’s aquatic therapy
Attitude Adjuster
So what is the answer for this type of patient? In the experience of some rehabilitation practitioners, it’s aquatic therapy.
Aquatic therapy isn’t a new concept in rehabilitation, and it’s gaining momentum year after year.
Warm-water environments were prescribed centuries ago to ease ailments like joint pain and, ironically, they’re still prescribed today. But the soothing temperature of the water isn’t the only benefit to investing in a high-end therapy pool with underwater treadmill and variable floor depths.
By far, one of the greatest advantages to offering patients aquatic therapy is the way it changes patients’ attitudes.
Often, when patients realize they are surrounded and buoyed by water, they tend to put forth a better amount of effort than they would during land-based rehabilitation. Thus they wind up physically stronger and more secure.
The innate scientific properties of water are without a doubt a physical or occupational therapist’s best friend when working with patients with balance challenges.
In an aquatic environment, the body is supported up to 90 percent, depending upon the height of the water, which is why a therapy pool with an adjustable floor is best. This relaxes everyone involved, as falling becomes nearly impossible.
Multiple Benefits
Physical or occupational therapy in a pool has a plethora of other benefits as well, including: increased muscle relaxation, decreased muscle spasms, increased ease of joint movement, decreased sensitivity, increased muscle strength and endurance, increased peripheral circulation, decreased pain, improved body awarenessand balance, and improved proximal trunk stability.
Some patients find it so positive that they continue exercising in the pool for pleasure and health long after their therapy has ended.
While aquatic therapy works on a wide variety of patients, it is especially useful on those with limited range of motion, decreased daily living activities, impaired trunk stability, postural abnormalities, decreased strength, decreased balance, impaired mobility, pain, edema, and gait abnormalities.
However, aquatics may not be suitable for those who have had cardiac failure, have open wounds or infectious diseases, are extremely weak (due to system changes), are incontinent, have abnormal blood pressure levels, or have low vital lung capacities.
Reward Is In The Results
There’s little doubt that adopting aquatic therapy as part of a clinic or facility’s offerings leads to more confident patients who are apt to come back for sessions and work hard to achieve success. When an 85-year-old man with a history of falls starts rehabbing using aquatic therapy techniques, he is able to take traditional physical and/or occupational exercises to a whole new level.
This leads to faster healing, a renewed sense of freedom, and better results for him on land. And from a physical or occupational therapist’s point of view, watching the transformation of an adult from fearful to secure is one of the most highly rewarding aspects of the job.
Kathleen Kristoff, OTR/L, CHT, is a director of rehabilitation services at an outpatient rehabilitation center in Ohio. Kristoff has been nationally recognized as an expert in aquatic therapy methodologies and has been asked to speak at many conferences as a result.
Kathleen Kristoff
Public speaking may statistically top the list of “the most common fears,” but a physical therapist working with older adults who have balance issues knows that fear of falling can be stronger than any other worry. Certainly, it’s easy to understand the patients’ concerns; after all, falling can cause injuries leading to complications, additional health problems, and even death.
Fear of Falling
The reasons why aging individuals fall are varied: decreased range of motion, balance, and gait patterns can all be culprits. And so can medical conditions such as arthritis and degenerative joint disease.
Unfortunately, traditional physical and occupational therapies do not work as well as they would if the patient were not terrified of falling. For instance, if a 70-year-old woman with balance issues and a history of falling is expected to complete physical or occupational therapy exercises, she will have to be supported the entire time, lest she fall or stop working because she’s too frightened.
Most likely, she’ll be relegated to performing rehabilitative exercises while sitting or lying down, which will limit her progress. More than likely, the exercises will be passive, static, and short in duration.
Attitude Adjuster
So what is the answer for this type of patient? In the experience of some rehabilitation practitioners, it’s aquatic therapy
Attitude Adjuster
So what is the answer for this type of patient? In the experience of some rehabilitation practitioners, it’s aquatic therapy.
Aquatic therapy isn’t a new concept in rehabilitation, and it’s gaining momentum year after year.
Warm-water environments were prescribed centuries ago to ease ailments like joint pain and, ironically, they’re still prescribed today. But the soothing temperature of the water isn’t the only benefit to investing in a high-end therapy pool with underwater treadmill and variable floor depths.
By far, one of the greatest advantages to offering patients aquatic therapy is the way it changes patients’ attitudes.
Often, when patients realize they are surrounded and buoyed by water, they tend to put forth a better amount of effort than they would during land-based rehabilitation. Thus they wind up physically stronger and more secure.
The innate scientific properties of water are without a doubt a physical or occupational therapist’s best friend when working with patients with balance challenges.
In an aquatic environment, the body is supported up to 90 percent, depending upon the height of the water, which is why a therapy pool with an adjustable floor is best. This relaxes everyone involved, as falling becomes nearly impossible.
Multiple Benefits
Physical or occupational therapy in a pool has a plethora of other benefits as well, including: increased muscle relaxation, decreased muscle spasms, increased ease of joint movement, decreased sensitivity, increased muscle strength and endurance, increased peripheral circulation, decreased pain, improved body awarenessand balance, and improved proximal trunk stability.
Some patients find it so positive that they continue exercising in the pool for pleasure and health long after their therapy has ended.
While aquatic therapy works on a wide variety of patients, it is especially useful on those with limited range of motion, decreased daily living activities, impaired trunk stability, postural abnormalities, decreased strength, decreased balance, impaired mobility, pain, edema, and gait abnormalities.
However, aquatics may not be suitable for those who have had cardiac failure, have open wounds or infectious diseases, are extremely weak (due to system changes), are incontinent, have abnormal blood pressure levels, or have low vital lung capacities.
Reward Is In The Results
There’s little doubt that adopting aquatic therapy as part of a clinic or facility’s offerings leads to more confident patients who are apt to come back for sessions and work hard to achieve success. When an 85-year-old man with a history of falls starts rehabbing using aquatic therapy techniques, he is able to take traditional physical and/or occupational exercises to a whole new level.
This leads to faster healing, a renewed sense of freedom, and better results for him on land. And from a physical or occupational therapist’s point of view, watching the transformation of an adult from fearful to secure is one of the most highly rewarding aspects of the job.
Kathleen Kristoff, OTR/L, CHT, is a director of rehabilitation services at an outpatient rehabilitation center in Ohio. Kristoff has been nationally recognized as an expert in aquatic therapy methodologies and has been asked to speak at many conferences as a result.
States Require More Training For CNAs Than Home Health Aides
States Require More Training For CNAs Than Home Health Aides
12/12/2011
Patrick Connole
Page Content
Only 15 states mandate home health aides to have more training hours than are federally mandated, yet 30 states and the District of Columbia require certified nurse assistants (CNAs) to have more training hours than the federal requirements, according to a recent report by PHI, a direct-care workforce nonprofit.
In 1987, the federal government set a training standard of 75 hours, including a minimum of 16 hours of clinical training, for both home health aides and CNAs who are employed by Medicare-certified nursing homes or home care agencies.
“Our analysis shows that state home health aide training requirements have not kept pace with their nursing home [CNA] training requirements,” said Steve Edelstein, PHI national policy director.
“Although it is clearly time to revisit the federal standards, having states move ahead on their own to upgrade training requirements is a step in the right direction.”
The Institute of Medicine (IOM) in 2008 recommended that the federal minimum training requirement be raised to at least 120 hours for both CNAs and home health aides and that competency in elder care be demonstrated as a criterion for certification.
PHI also discovered in its report that four states meet the IOM-recommended training standard for home health aides; 14 states meet the IOM-recommended training standards for CNAs; and 13 states require more than 16 hours of clinical training for home health aides—the federal minimum training requirement.
Of the states that exceed the federal training standard, nine require home health aides to be CNAs, and four allow CNAs to become home health aides with supplementary training.
PHI also looked into the future in its analysis and predicted that by 2018, home- and community-based direct-care workers are likely to outnumber facility workers by nearly two to one.
To compare the training requirements for home health aides and CNAs in each state, go to http://phinational.org/policy/wp-content/uploads/2011-state-hha-training-requirements.pdf.
12/12/2011
Patrick Connole
Page Content
Only 15 states mandate home health aides to have more training hours than are federally mandated, yet 30 states and the District of Columbia require certified nurse assistants (CNAs) to have more training hours than the federal requirements, according to a recent report by PHI, a direct-care workforce nonprofit.
In 1987, the federal government set a training standard of 75 hours, including a minimum of 16 hours of clinical training, for both home health aides and CNAs who are employed by Medicare-certified nursing homes or home care agencies.
“Our analysis shows that state home health aide training requirements have not kept pace with their nursing home [CNA] training requirements,” said Steve Edelstein, PHI national policy director.
“Although it is clearly time to revisit the federal standards, having states move ahead on their own to upgrade training requirements is a step in the right direction.”
The Institute of Medicine (IOM) in 2008 recommended that the federal minimum training requirement be raised to at least 120 hours for both CNAs and home health aides and that competency in elder care be demonstrated as a criterion for certification.
PHI also discovered in its report that four states meet the IOM-recommended training standard for home health aides; 14 states meet the IOM-recommended training standards for CNAs; and 13 states require more than 16 hours of clinical training for home health aides—the federal minimum training requirement.
Of the states that exceed the federal training standard, nine require home health aides to be CNAs, and four allow CNAs to become home health aides with supplementary training.
PHI also looked into the future in its analysis and predicted that by 2018, home- and community-based direct-care workers are likely to outnumber facility workers by nearly two to one.
To compare the training requirements for home health aides and CNAs in each state, go to http://phinational.org/policy/wp-content/uploads/2011-state-hha-training-requirements.pdf.
Led by the child who simply knew
Led by the child who simply knew
The twin boys were identical in every way but one. Wyatt was a girl to the core, and now lives as one, with the help of a brave, loving family and a path-breaking doctor’s care.
Nicole Maines, 14, her twin brother, Jonas, and their parents have traveled a long, trying road. (Suzanne Kreiter/Globe Staff)
By Bella English
Globe Staff / December 11, 2011
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Sending your articleYour article has been sent. Jonas and Wyatt Maines were born identical twins, but from the start each had a distinct personality.
‘Wyatt
needs hair
accessories, clothes, shoes . . . likes to wear bikinis, high heels,
mini-skirts.’
Jonas was all boy. He loved Spiderman, action figures, pirates, and swords.
Wyatt favored pink tutus and beads. At 4, he insisted on a Barbie birthday cake and had a thing for mermaids. On Halloween, Jonas was Buzz Lightyear. Wyatt wanted to be a princess; his mother compromised on a prince costume.
Once, when Wyatt appeared in a sequin shirt and his mother’s heels, his father said: “You don’t want to wear that.’’
“Yes, I do,’’ Wyatt replied.
“Dad, you might as well face it,’’ Wayne recalls Jonas saying. “You have a son and a daughter.’’
That early declaration marked, as much as any one moment could, the beginning of a journey that few have taken, one the Maineses themselves couldn’t have imagined until it was theirs. The process of remaking a family of identical twin boys into a family with one boy and one girl has been heartbreaking and harrowing and, in the end, inspiring - a lesson in the courage of a child, a child who led them, and in the transformational power of love.
Wayne and Kelly Maines have struggled to know whether they are doing the right things for their children, especially for Wyatt, who now goes by the name Nicole. Was he merely expressing a softer side of his personality, or was he really what he kept saying: a girl in a boy’s body? Was he exhibiting early signs that he might be gay?Was it even possible, at such a young age, to determine what exactly was going on?
Until recently, there was little help for children in such situations.But now a groundbreaking clinic at Children’s Hospital in Boston - one of the few of its kind in the world - helps families deal with the issues, both emotional and medical, that arise from having a transgender child - one who doesn’t identify with the gender he or she was born into.
The Children’s Hospital Gender Management Services Clinic can, using hormone therapies, halt puberty in transgender children, blocking the development of secondary sexual characteristics - a beard, say, or breasts - that can make the eventual transition to the other gender more difficult, painful, and costly.
Founded in 2007 by endocrinologist Norman Spack and urologist David Diamond, the clinic - known as GeMS and modeled on a Dutch program - is the first pediatric academic program in the Western Hemisphere that evaluates and treats pubescent transgenders. A handful of other pediatric centers in the United States are developing similar programs, some started by former staffers at GeMS.
It was in that clinic, under Spack’s care, that Nicole and her family finally began to have hope for her future.
The Maineses decided to tell their story, they say, in order to help fight the deep stigma against transgender youth, and to ease the path for other such children who, without help, often suffer from depression, anxiety, and isolation.
“We told our kids you can’t create change if you don’t get involved,’’ says Wayne, 53, sitting in the living room of their comfortable home in a southern Maine community they do not want identified.
They have good reason for caution. Their journey has included a lawsuit to protect their daughter’s rights, and a battle against bullying and insensitivity that led them to move to a new place and new schools.
It has been a hard road, but nothing that compares with the physical transformation of Wyatt into Nicole.
“I have always known I was a girl,’’ says Nicole, now 14. “I think what I’m aiming for is to undergo surgery to get a physical female body that matches up to my image of myself.’’
Early confusion
When Wyatt and Jonas were born, their father was thrilled. Wayne looked forward to the day when he could hunt deer with his boys in the Maine woods. The family lived in Orono, near the University of Maine campus, where Wayne is the director of safety and environmental management.
They had no preparation for what would come next.
When Wyatt was 4, he asked his mother: “When do I get to be a girl?’’ He told his father that he hated his penis and asked when he could be rid of it. Both father and son cried. When first grade started, Wyatt carried a pink backpack and a Kim Possible lunchbox.
His parents had no idea what was going on. They had barely heard the term “transgender.’’ Baffled, they tried to deflect Wyatt’s girlish impulses by buying him action figures like his brother’s and steering him toward Cub Scouts, soccer, and baseball.
When the boys were 5, Kelly and Wayne threw a “get-to-know-me’’ party for classmates and parents. Wyatt appeared beaming at the top of the stairs in a princess gown, a gift from his grandmother.
Kelly whisked him off and made him put on pants. Though she and Wayne were accustomed to his girly antics, they were afraid of what others might think.
To this day, she feels guilty about it. “I know she was totally confused and felt like she had done something wrong,’’ says Kelly, 50, who works in law enforcement.
“Even when we did all the boy events to see if she would ‘conform,’ she would just put her shirt on her head as hair, strap on some heels and join in,’’ Kelly says. “It wasn’t really a matter of encouraging her to be a boy or a girl. That came about naturally.’’
Kelly and Wayne didn’t look at it as a choice their child was making.
“She really is a girl,’’ Kelly says, “a girl born with a birth defect. That’s how she looks at it.’’
Fear of the unknown
After Wyatt began to openly object to being a boy, his mother started doing research on transgender children. There was little out there; it seemed they would have to find their way largely on their own.
During those early years, while Kelly was doing her research, Wayne was hoping that this was no big deal, that this was a stage Wyatt just had to go through.
“I felt it had nothing to do with how they would grow up,’’ he says.
But as they grew older, his concern grew. “I feared the unknown,’’ he says.
Even the family Christmas card became a challenge. They would write about Jonas’s affinity for sports and Wyatt’s “flair for the dramatic.’’
Their elderly pediatrician, nearing retirement, did not want to discuss the matter with them. Finally, Kelly picked another pediatrician out of the phone book. “I told her how it was, and it turned out that she understood and was very supportive.’’
When the twins were in the first grade, their parents found a therapist for Wyatt, who was starting to act out. In the third grade, before the GeMS Clinic was even open, Kelly heard about Dr. Spack and made an appointment with him.
“He told us everything,’’ Wayne says, recalling that first meeting. “I didn’t understand it all, but I saw the weight lift off Kelly’s shoulders and a smile in Nicole’s eyes. That was it for me. There were tons of challenges for us after that, but I knew my daughter was going to be OK, medically.’’
Elementary school changes
In elementary school, Wyatt told classmates that he was a “girl-boy.’’ In the fourth grade, he grew his hair longer and started talking about a name change. That same year, he drew a self-portrait as a girl, and in a class essay, wrote: “Wyatt needs hair accessories, clothes, shoes . . . likes to wear bikinis, high heels, mini-skirts.’’
Emma Peterson of Orono, a close friend from the elementary years at the Asa Adams School, recalls playing dolls with Nicole’s giant dollhouse, and the two of them putting on makeup. “Before Nikki started growing her hair out, she looked exactly like Jonas,’’ Emma says.
In fourth grade, Wyatt started using “Nicole’’ as a name, and many classmates were calling him “Nikki.’’ The next year, the family went to court and had the name legally changed to Nicole.
To Kelly, it seemed the next logical step. Family discussions merely centered around what the name would be. In the end, Nicole chose it. “I believed in Nicole,’’ her mother says. “She always knew who she was.’’
Wayne was nervous. Could he call his son Nicole? As usual, he relied on his wife’s instincts. “I have to tell you, Kelly’s the leader in our family,’’ he says. “Both she and Nicole are extremely strong-willed, and I went with the flow.’’
At first, though, he couldn’t bring himself to use the new name. An Air Force veteran and former Republican, he realizes now he was grieving the loss of a son. “But once you get past that, I realize I never had a son,’’ he says.
Legal battles
When fifth grade started, Wyatt was gone. Nicole showed up for school, sometimes wearing a dress and sporting shoulder-length hair. She began using the girls’ bathroom. Nikki’s friends didn’t have a problem with the transformation; there were playdates and sleepovers.
“They said, ‘It was about time!’ ’’ Nicole says. She was elected vice president of her class and excelled academically.
But one day a boy called her a “faggot,’’ objected to her using the girls’ bathroom, and reported the matter to his grandfather, who is his legal guardian. The grandfather complained to the Orono School Committee, with the Christian Civic League of Maine backing him. The superintendent of schools then decided Nicole should use a staff bathroom.
“It was like a switch had been turned on, saying it is now OK to question Nicole’s choice to be transgender and it was OK to pursue behavior that was not OK before,’’ Wayne says. “Every day she was reminded that she was different, and the other kids picked up on it.’’
According to a 2009 study by the Gay, Lesbian and Straight Education Network, 90 percent of transgender youth report being verbally harassed and more than half physically harassed. Two-thirds of them said they felt unsafe in school.
To protect her from bullying at school, Nicole was assigned an adult to watch her at all times between classes, following her to the cafeteria, to the bathroom. She found it intrusive and stressful. It made her feel like even more of an outsider.
“Separate but equal does not work,’’ she says.
It was a burden that Jonas shouldered as well. The same boy who in fifth grade objected to her using the girls bathroom made the mistake of saying to Jonas in sixth grade that “freaking gay people’’ shouldn’t be allowed in the school. Jonas jumped on him and a scuffle ensued.
“He’s taken on a lot,’’ Wayne says. “Middle school boys and sexuality, you know . . . boys can get picked on.’’
Nicole and her parents filed a complaint with the Maine Humans Right Commission over her right to use the girls bathroom. The commission found that she had been discriminated against and, along with the Maines family, filed a lawsuit against the Orono School District. The suit is pending in Penobscot County Superior Court, and the Maines family is represented by lawyers from the Gay & Lesbian Advocates & Defenders (GLAD) in Boston and by Jodi Nofsinger, who serves on the Maine ACLU board.
“What Nicole and Jonas both went through in school was unconscionable,’’ says Jennifer Levi, one of the GLAD lawyers on the case. “Their one huge stroke of luck was having Kelly and Wayne as parents.’’
A huge relief
Since that first visit to Spack when Nicole was 9, her parents discussed putting her into the GeMS Clinic when the right time came. They were glad there was time to adjust to the idea. “Baby steps,’’ Kelly calls their path toward treatment.
“I wasn’t always on board,’’ Wayne says. “Kelly and I were not on the same page. My question was, what is this doctor doing? It scared me. I was grieving. I was losing my son.’’
But the more he watched his child struggle, the better he felt about going to Spack. And once he got there, he says, it was a huge relief. “Not only does he know what he’s doing, he’s extremely comforting. He’s got to deal with a ton of dads who are just freaking out, and he made me feel good.’’
Spack’s experience runs deep; before the clinic was established, he had long worked with transgender youth, as well as with adults. “The most striking thing about these kids was the fact that they were just normal young people who had this incredibly unusual and problematic situation,’’ says Spack, 68.
He believes it is crucial to intervene with such children before adolescent changes begin in earnest.
“Most of us look pretty similar until we hit puberty,’’ he says. “I bet I could go to any fourth or fifth-grade class, cut the hair of the boys, put earrings on various kids, change their clothing, and we could send all those kids off to the opposite-gender bathrooms and nobody would say boo.’’
He adds: “We can do wonders if we can get them early.’’
Second-guessing
Not everyone agrees that they should, of course, and Spack has heard the arguments: Man should not interfere with what God has wrought. Early adolescents are too young for such huge decisions, much less life-altering treatment.
Though GeMS treatment is now considered the standard of care by mainstream medical groups, some have their doubts. Dr. Kenneth Zucker, a psychologist and head of the gender-identity service at the Center for Addiction and Mental Health in Toronto, says he worries about putting youngsters on puberty blockers, drugs that suppress the release of testosterone in boys and estrogen in girls.
“One controversy is, how low does one go in starting blockers?’’ Zucker says. “Should you start at 11? At 10? What if someone starts their period at 9?’’ Nicole started on the blockers at age 11.
He also questions the role the parents have played; have they simply followed the child’s lead? “Say a 5-year-old says repeatedly that he wants to be a girl,’’ Zucker says. “The parents deduce this must mean the child is transgender, so they socially transition him to living in the other gender.’’
Spack and others, however, say the issue is a medical one and that early intervention makes sense. “We’re talking about a population that has the highest rate of suicide attempts in the world, and it’s strongly linked to nontreatment, especially if they are rejected within their family for being who they think they are,’’ says Spack, who adds that nearly a quarter of his patients admitted to “serious self-harm’’ before coming to him.
As for the criticisms about “playing God,’’ Spack quotes from the Old Testament: “Leviticus says, ‘If thy neighbor is bleeding by the side of the road, you shall not stand idly by the blood of thy neighbor.’ It’s a mandate. I think these kids have been bleeding.’’
The next step
The clinic, which includes geneticists, social workers, psychiatrists, psychologists, and nurses, has so far treated 95 patients for disorders that range from babies born with ambiguous genitalia to cases where normal sexual development does not occur.
About a third of the patients have undergone puberty suppression.
Each patient must have been in therapy with someone familiar with transgender issues and who writes a letter recommending the treatment. The child’s family also must undergo extensive psychological testing before and during treatment. And the patient must be in the early stage of puberty, before bodily changes are noticeable.
Nicole and Jonas are the first set of identical twins the program has seen, and they have provided critical comparative data, Spack says.
The effects of the blockers - an injection given monthly to prevent the gonads from releasing the unwanted hormones - are reversible; patients can stop taking them and go through puberty as their biological sex. This is critical, Spack says, because a “very significant number of children who exhibit cross-gender behavior’’ before puberty “do not end up being transgender.’’
Since the 1970s, the blockers have been used for the rare condition of precocious puberty, when children as young as 3 can hit puberty. They are kept on the blockers until they are of appropriate age. “The drugs have a great track record; we already know that these kids do fine,’’ says Spack. “There are no ill consequences.’’
It is the next big step - taking sex hormones of the opposite gender - that creates permanent changes, such as breasts and broadened hips, that cannot be hormonally reversed.
“In puberty,’’’ Spack says, “when your body starts making a statement, you either have to accept it or reject it.’’
There is no definitive answer to the question of what causes gender identity disorder, though studies suggest a genetic contribution. “It’s still a very open question,’’ Zucker says. And how could it affect just one of two identical twins? “There can be genetic changes during fetal development that maybe hit one twin but not the other.’’
Changed atmosphere
After the family’s lawsuit against the Orono schools was publicized, the atmosphere in town changed. When they went to the movies, people pointed and whispered. There were fewer party invitations, fewer sleepovers.
In the sixth grade, the twins joined the school’s Outing Club. All year they attended meetings to prepare for the crowning event: a whitewater rafting trip. Wayne went to several meetings, too, so he could serve as a chaperone.
Wayne thought he had a good relationship with the club leader. But then the man informed him that Nicole would not be allowed to sleep in the tent with the girls - the same girls who had slept over her house several times. She and her father could have a separate tent.
A difficult family conversation followed. Jonas and Wayne went on the trip. Nicole stayed home.
After that episode, Kelly and Wayne decided a new start would be good for the family. The summer after the sixth grade, they moved to a larger, more diverse community in southern Maine, and the twins enrolled in public school. Wayne still works at UMaine and stays in Orono during the week, spending weekends with his family.
For two years, in seventh and eighth grade, Nicole went “stealth,’’ as she calls it: passing as a girl. She did not tell anyone that she was biologically male. Though she made friends at school, she never brought them to the house. After that hard last year in Orono, the family was afraid to come out.
This fall the twins entered high school, transferring to a smaller, private school known for open-mindedness. Before they arrived, the school changed its bathrooms to unisex. And before classes started, the family met with members of the school’s Gay Straight Alliance - “so she’d have older kids watching her back,’’ says Wayne. After the meeting, the group changed its name to include transgender; it is now the Gay Straight Transgender Alliance.
“It made me a lot more comfortable,’’ Nicole says. “I thought, this is OK. I can do this.’’
She recently started telling some of her new friends her story. One girl replied: “Does this mean you’re going to start wearing boys’ clothes to school?’’
“No,’’ replied Nicole. “I’m male to female.’’
The girl’s reaction? “She was like, ‘Ohhhhhhhhhhhhhhh.’ ’’
Concerns about safety
The male hormone suppressors have done their job, and the next step is to add female hormones so that Nicole will undergo puberty as a girl and develop as a woman, with breasts and curvy hips. She is due to see Spack in January, and a date may then be set for adding estrogen, which she will take every day for the rest of her life. Though she will have a higher risk of breast cancer than if she were a male, she will have a lower risk of prostate cancer, Spack says. The treatment will leave her infertile.
But before the estrogen is administered, the GeMS clinic will reevaluate Nicole to make sure that she still identifies as a female and wants to continue.
“In my experience, the patients just blossom physically and mentally when they get the hormones of the gender they affirm,’’ Spack says. “It’s quite amazing. I feel good about Nicole and who she is and where she’s going.’’
An endocrinologist in Maine now administers the blockers Nicole needs, but Spack still sees her in Boston every four to six months. The Maines family has grown close to him and others in the clinic. “I love going to see him,’’ says Wayne, who has thanked Spack for “saving my daughter’s life.’’ The Maines family declined to talk about the cost of the treatment but said insurance has covered much of it.
But as well as things are going, the Maines family still worries about Nicole’s safety. Last year Wayne and Nicole attended Transgender Day of Remembrance in Maine, which honors those who have been killed in hate crimes.
Wayne spoke to the crowd, telling them that as much as Nicole is loved at home, her family cannot always protect her.
“I remind her that she needs to always be aware of her surroundings, to stay close to friends and her brother if she feels uncomfortable, and to call me anytime she feels threatened,’’ he said.
Lobbying the Legislature
Last winter, Maine state representative Kenneth Fredette, a Republican from Penobscot County, sponsored a bill that would have repealed protections for transgender people in public restrooms, instead allowing schools and businesses to adopt their own policies. The bill was a response to the Maines’ 2009 lawsuit against the Orono School District.
Last spring Wayne and Nicole roamed the halls of the State House, button-holing legislators and testifying against the bill. “I’d be in more danger if I went into the boys bathroom,’’ Nicole told the lawmakers, who ultimately rejected the bill.
“She knows how to work a room,’’ her father says proudly. “She even convinced a cosponsor to vote the other way.’’
In October, the family was honored for its activism in helping defeat the transgender bathroom bill. The Maineses received the Roger Baldwin Award, named for a founder of the American Civil Liberties Union, from the Maine chapter of the ACLU.
Surrounded by Kelly and the kids, Wayne told the audience that he and his wife have had top-notch guides as they confronted the unknown.
“As a conventional dad, hunter, and former Republican, it took me longer to understand that I never had two sons,’’ he told them. “My children taught me who Nicole is and who she needed to be.’’
Typical teens
In some respects, Jonas has had as tough a time as Nicole. For one thing, there’s the personality difference: Nicole is the dominant twin, talkative and tough, while Jonas is cautious and reserved.
“If this had been Jonas, I would have had to home school him,’’ his mother says.
The twins have always been close. During an interview, Nicole sits next to her brother on the couch and occasionally lays her head on his shoulder. At one point, when Jonas goes silent as the twins talk of their lives, she whispers words of encouragement into his ear.
But the next minute, like typical teenage siblings, they’re teasing and tussling. Jonas displays a faint scar on his arm where Nicole jabbed him with a pencil. Both have black belts in tae kwon do, which they started at age 5.
They often hang out in Jonas’s spacious basement room, where they watch TV and play video games.
“I love having a sister,’’ says Jonas, who acknowledges being protective of her. “We have a very strong relationship.’’
Nicole calls Jonas her closest friend.
“I would say my brother got lucky with me. Because we grew up with only boy neighbors, I developed a liking to shoot-’em-up and military video games,’’ she says. “I could have come out a lot girlier.’’
At 14, Jonas is handsome, Nicole pretty. Jonas is midway through puberty. His shoulders have broadened, his voice has deepened, and there’s a shadow on his upper lip. He’s 5 feet 6 and weighs 115 pounds, with a size 11 shoe.
Nicole is petite: 5 feet 1, 100 pounds. She’s got long, dark hair and she wears girls’ size 14-16. Her closet contains nice shirts and jeans, party dresses, glittery shoes, and a pair of footy pajamas.
“The thought of being a boy makes me cringe,’’ she says. “I just couldn’t do it.’’
Excited, worried about surgery
Nicole’s final step on her journey to womanhood would be gender reassignment surgery. Doctors generally won’t perform it until the age of consent, which is 18. No hospitals in New England perform such surgery, says Spack. The nearest that do are in Montreal and Philadelphia.
Nicole says she’s excited about the idea of surgery, though a bit worried about the results - “and maybe the pain, too.’’
While she’s interested in boys, she has expressed fear that “nobody is ever going to love me.’’
She has gone on weekend retreats sponsored by the Trans Youth Equality Foundation and to summer camp for transgender children, where she developed her first crush on a boy.
Over the years, the family has become close to several adult transsexuals, and Nicole has seen that some have found happy marriages. “She says she does feel better about it,’’ Kelly says, “but still wonders if she ever met a boy who falls for her, and then found out that she was trans, if he would still like her, or say awful things as he skedaddled out the door.’’
Nicole knows there is a long road ahead, but she feels she’s on the right path.
“Obviously my life is not going to be as easy as being gender-conforming, but there are perks like being able to get out there and do things that will benefit the [transgender] community,’’ she says. “I think everything’s going to turn out pretty well for me.’’
For now, at least, life feels more normal to the Maines family.
Wayne recently spoke at GLAD’s Spirit of Justice dinner in Boston and was introduced by Nicole. She kept her composure in her brief remarks and thanked GLAD for giving them a rare chance to “safely speak out.’’
Wayne choked up when thanking the group for its support. He recounted young Wyatt asking him, sadly, “Daddy, why can’t boys wear dresses?’’ Wayne hated to tell his son that society wouldn’t accept that.
But today, when Nicole asks her father what he thinks of a certain dress she’s wearing, his typical response, he told the audience, is: “That dress is too short. Go change your clothes.’’
In conversation later, Wayne tells another story of how things have changed, for good and forever. He and the twins were getting out of the car recently, and he grabbed their hands to walk with them.
Jonas, being a teenage boy, shook his father off, while Nicole was happy to walk hand-in-hand, swinging arms.
“She’ll do that the rest of her life,’’ Wayne says with a wide grin. “It was an epiphany for me.’’
Bella English can be reached at english@globe.com.
The twin boys were identical in every way but one. Wyatt was a girl to the core, and now lives as one, with the help of a brave, loving family and a path-breaking doctor’s care.
Nicole Maines, 14, her twin brother, Jonas, and their parents have traveled a long, trying road. (Suzanne Kreiter/Globe Staff)
By Bella English
Globe Staff / December 11, 2011
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Sending your articleYour article has been sent. Jonas and Wyatt Maines were born identical twins, but from the start each had a distinct personality.
‘Wyatt
needs hair
accessories, clothes, shoes . . . likes to wear bikinis, high heels,
mini-skirts.’
Jonas was all boy. He loved Spiderman, action figures, pirates, and swords.
Wyatt favored pink tutus and beads. At 4, he insisted on a Barbie birthday cake and had a thing for mermaids. On Halloween, Jonas was Buzz Lightyear. Wyatt wanted to be a princess; his mother compromised on a prince costume.
Once, when Wyatt appeared in a sequin shirt and his mother’s heels, his father said: “You don’t want to wear that.’’
“Yes, I do,’’ Wyatt replied.
“Dad, you might as well face it,’’ Wayne recalls Jonas saying. “You have a son and a daughter.’’
That early declaration marked, as much as any one moment could, the beginning of a journey that few have taken, one the Maineses themselves couldn’t have imagined until it was theirs. The process of remaking a family of identical twin boys into a family with one boy and one girl has been heartbreaking and harrowing and, in the end, inspiring - a lesson in the courage of a child, a child who led them, and in the transformational power of love.
Wayne and Kelly Maines have struggled to know whether they are doing the right things for their children, especially for Wyatt, who now goes by the name Nicole. Was he merely expressing a softer side of his personality, or was he really what he kept saying: a girl in a boy’s body? Was he exhibiting early signs that he might be gay?Was it even possible, at such a young age, to determine what exactly was going on?
Until recently, there was little help for children in such situations.But now a groundbreaking clinic at Children’s Hospital in Boston - one of the few of its kind in the world - helps families deal with the issues, both emotional and medical, that arise from having a transgender child - one who doesn’t identify with the gender he or she was born into.
The Children’s Hospital Gender Management Services Clinic can, using hormone therapies, halt puberty in transgender children, blocking the development of secondary sexual characteristics - a beard, say, or breasts - that can make the eventual transition to the other gender more difficult, painful, and costly.
Founded in 2007 by endocrinologist Norman Spack and urologist David Diamond, the clinic - known as GeMS and modeled on a Dutch program - is the first pediatric academic program in the Western Hemisphere that evaluates and treats pubescent transgenders. A handful of other pediatric centers in the United States are developing similar programs, some started by former staffers at GeMS.
It was in that clinic, under Spack’s care, that Nicole and her family finally began to have hope for her future.
The Maineses decided to tell their story, they say, in order to help fight the deep stigma against transgender youth, and to ease the path for other such children who, without help, often suffer from depression, anxiety, and isolation.
“We told our kids you can’t create change if you don’t get involved,’’ says Wayne, 53, sitting in the living room of their comfortable home in a southern Maine community they do not want identified.
They have good reason for caution. Their journey has included a lawsuit to protect their daughter’s rights, and a battle against bullying and insensitivity that led them to move to a new place and new schools.
It has been a hard road, but nothing that compares with the physical transformation of Wyatt into Nicole.
“I have always known I was a girl,’’ says Nicole, now 14. “I think what I’m aiming for is to undergo surgery to get a physical female body that matches up to my image of myself.’’
Early confusion
When Wyatt and Jonas were born, their father was thrilled. Wayne looked forward to the day when he could hunt deer with his boys in the Maine woods. The family lived in Orono, near the University of Maine campus, where Wayne is the director of safety and environmental management.
They had no preparation for what would come next.
When Wyatt was 4, he asked his mother: “When do I get to be a girl?’’ He told his father that he hated his penis and asked when he could be rid of it. Both father and son cried. When first grade started, Wyatt carried a pink backpack and a Kim Possible lunchbox.
His parents had no idea what was going on. They had barely heard the term “transgender.’’ Baffled, they tried to deflect Wyatt’s girlish impulses by buying him action figures like his brother’s and steering him toward Cub Scouts, soccer, and baseball.
When the boys were 5, Kelly and Wayne threw a “get-to-know-me’’ party for classmates and parents. Wyatt appeared beaming at the top of the stairs in a princess gown, a gift from his grandmother.
Kelly whisked him off and made him put on pants. Though she and Wayne were accustomed to his girly antics, they were afraid of what others might think.
To this day, she feels guilty about it. “I know she was totally confused and felt like she had done something wrong,’’ says Kelly, 50, who works in law enforcement.
“Even when we did all the boy events to see if she would ‘conform,’ she would just put her shirt on her head as hair, strap on some heels and join in,’’ Kelly says. “It wasn’t really a matter of encouraging her to be a boy or a girl. That came about naturally.’’
Kelly and Wayne didn’t look at it as a choice their child was making.
“She really is a girl,’’ Kelly says, “a girl born with a birth defect. That’s how she looks at it.’’
Fear of the unknown
After Wyatt began to openly object to being a boy, his mother started doing research on transgender children. There was little out there; it seemed they would have to find their way largely on their own.
During those early years, while Kelly was doing her research, Wayne was hoping that this was no big deal, that this was a stage Wyatt just had to go through.
“I felt it had nothing to do with how they would grow up,’’ he says.
But as they grew older, his concern grew. “I feared the unknown,’’ he says.
Even the family Christmas card became a challenge. They would write about Jonas’s affinity for sports and Wyatt’s “flair for the dramatic.’’
Their elderly pediatrician, nearing retirement, did not want to discuss the matter with them. Finally, Kelly picked another pediatrician out of the phone book. “I told her how it was, and it turned out that she understood and was very supportive.’’
When the twins were in the first grade, their parents found a therapist for Wyatt, who was starting to act out. In the third grade, before the GeMS Clinic was even open, Kelly heard about Dr. Spack and made an appointment with him.
“He told us everything,’’ Wayne says, recalling that first meeting. “I didn’t understand it all, but I saw the weight lift off Kelly’s shoulders and a smile in Nicole’s eyes. That was it for me. There were tons of challenges for us after that, but I knew my daughter was going to be OK, medically.’’
Elementary school changes
In elementary school, Wyatt told classmates that he was a “girl-boy.’’ In the fourth grade, he grew his hair longer and started talking about a name change. That same year, he drew a self-portrait as a girl, and in a class essay, wrote: “Wyatt needs hair accessories, clothes, shoes . . . likes to wear bikinis, high heels, mini-skirts.’’
Emma Peterson of Orono, a close friend from the elementary years at the Asa Adams School, recalls playing dolls with Nicole’s giant dollhouse, and the two of them putting on makeup. “Before Nikki started growing her hair out, she looked exactly like Jonas,’’ Emma says.
In fourth grade, Wyatt started using “Nicole’’ as a name, and many classmates were calling him “Nikki.’’ The next year, the family went to court and had the name legally changed to Nicole.
To Kelly, it seemed the next logical step. Family discussions merely centered around what the name would be. In the end, Nicole chose it. “I believed in Nicole,’’ her mother says. “She always knew who she was.’’
Wayne was nervous. Could he call his son Nicole? As usual, he relied on his wife’s instincts. “I have to tell you, Kelly’s the leader in our family,’’ he says. “Both she and Nicole are extremely strong-willed, and I went with the flow.’’
At first, though, he couldn’t bring himself to use the new name. An Air Force veteran and former Republican, he realizes now he was grieving the loss of a son. “But once you get past that, I realize I never had a son,’’ he says.
Legal battles
When fifth grade started, Wyatt was gone. Nicole showed up for school, sometimes wearing a dress and sporting shoulder-length hair. She began using the girls’ bathroom. Nikki’s friends didn’t have a problem with the transformation; there were playdates and sleepovers.
“They said, ‘It was about time!’ ’’ Nicole says. She was elected vice president of her class and excelled academically.
But one day a boy called her a “faggot,’’ objected to her using the girls’ bathroom, and reported the matter to his grandfather, who is his legal guardian. The grandfather complained to the Orono School Committee, with the Christian Civic League of Maine backing him. The superintendent of schools then decided Nicole should use a staff bathroom.
“It was like a switch had been turned on, saying it is now OK to question Nicole’s choice to be transgender and it was OK to pursue behavior that was not OK before,’’ Wayne says. “Every day she was reminded that she was different, and the other kids picked up on it.’’
According to a 2009 study by the Gay, Lesbian and Straight Education Network, 90 percent of transgender youth report being verbally harassed and more than half physically harassed. Two-thirds of them said they felt unsafe in school.
To protect her from bullying at school, Nicole was assigned an adult to watch her at all times between classes, following her to the cafeteria, to the bathroom. She found it intrusive and stressful. It made her feel like even more of an outsider.
“Separate but equal does not work,’’ she says.
It was a burden that Jonas shouldered as well. The same boy who in fifth grade objected to her using the girls bathroom made the mistake of saying to Jonas in sixth grade that “freaking gay people’’ shouldn’t be allowed in the school. Jonas jumped on him and a scuffle ensued.
“He’s taken on a lot,’’ Wayne says. “Middle school boys and sexuality, you know . . . boys can get picked on.’’
Nicole and her parents filed a complaint with the Maine Humans Right Commission over her right to use the girls bathroom. The commission found that she had been discriminated against and, along with the Maines family, filed a lawsuit against the Orono School District. The suit is pending in Penobscot County Superior Court, and the Maines family is represented by lawyers from the Gay & Lesbian Advocates & Defenders (GLAD) in Boston and by Jodi Nofsinger, who serves on the Maine ACLU board.
“What Nicole and Jonas both went through in school was unconscionable,’’ says Jennifer Levi, one of the GLAD lawyers on the case. “Their one huge stroke of luck was having Kelly and Wayne as parents.’’
A huge relief
Since that first visit to Spack when Nicole was 9, her parents discussed putting her into the GeMS Clinic when the right time came. They were glad there was time to adjust to the idea. “Baby steps,’’ Kelly calls their path toward treatment.
“I wasn’t always on board,’’ Wayne says. “Kelly and I were not on the same page. My question was, what is this doctor doing? It scared me. I was grieving. I was losing my son.’’
But the more he watched his child struggle, the better he felt about going to Spack. And once he got there, he says, it was a huge relief. “Not only does he know what he’s doing, he’s extremely comforting. He’s got to deal with a ton of dads who are just freaking out, and he made me feel good.’’
Spack’s experience runs deep; before the clinic was established, he had long worked with transgender youth, as well as with adults. “The most striking thing about these kids was the fact that they were just normal young people who had this incredibly unusual and problematic situation,’’ says Spack, 68.
He believes it is crucial to intervene with such children before adolescent changes begin in earnest.
“Most of us look pretty similar until we hit puberty,’’ he says. “I bet I could go to any fourth or fifth-grade class, cut the hair of the boys, put earrings on various kids, change their clothing, and we could send all those kids off to the opposite-gender bathrooms and nobody would say boo.’’
He adds: “We can do wonders if we can get them early.’’
Second-guessing
Not everyone agrees that they should, of course, and Spack has heard the arguments: Man should not interfere with what God has wrought. Early adolescents are too young for such huge decisions, much less life-altering treatment.
Though GeMS treatment is now considered the standard of care by mainstream medical groups, some have their doubts. Dr. Kenneth Zucker, a psychologist and head of the gender-identity service at the Center for Addiction and Mental Health in Toronto, says he worries about putting youngsters on puberty blockers, drugs that suppress the release of testosterone in boys and estrogen in girls.
“One controversy is, how low does one go in starting blockers?’’ Zucker says. “Should you start at 11? At 10? What if someone starts their period at 9?’’ Nicole started on the blockers at age 11.
He also questions the role the parents have played; have they simply followed the child’s lead? “Say a 5-year-old says repeatedly that he wants to be a girl,’’ Zucker says. “The parents deduce this must mean the child is transgender, so they socially transition him to living in the other gender.’’
Spack and others, however, say the issue is a medical one and that early intervention makes sense. “We’re talking about a population that has the highest rate of suicide attempts in the world, and it’s strongly linked to nontreatment, especially if they are rejected within their family for being who they think they are,’’ says Spack, who adds that nearly a quarter of his patients admitted to “serious self-harm’’ before coming to him.
As for the criticisms about “playing God,’’ Spack quotes from the Old Testament: “Leviticus says, ‘If thy neighbor is bleeding by the side of the road, you shall not stand idly by the blood of thy neighbor.’ It’s a mandate. I think these kids have been bleeding.’’
The next step
The clinic, which includes geneticists, social workers, psychiatrists, psychologists, and nurses, has so far treated 95 patients for disorders that range from babies born with ambiguous genitalia to cases where normal sexual development does not occur.
About a third of the patients have undergone puberty suppression.
Each patient must have been in therapy with someone familiar with transgender issues and who writes a letter recommending the treatment. The child’s family also must undergo extensive psychological testing before and during treatment. And the patient must be in the early stage of puberty, before bodily changes are noticeable.
Nicole and Jonas are the first set of identical twins the program has seen, and they have provided critical comparative data, Spack says.
The effects of the blockers - an injection given monthly to prevent the gonads from releasing the unwanted hormones - are reversible; patients can stop taking them and go through puberty as their biological sex. This is critical, Spack says, because a “very significant number of children who exhibit cross-gender behavior’’ before puberty “do not end up being transgender.’’
Since the 1970s, the blockers have been used for the rare condition of precocious puberty, when children as young as 3 can hit puberty. They are kept on the blockers until they are of appropriate age. “The drugs have a great track record; we already know that these kids do fine,’’ says Spack. “There are no ill consequences.’’
It is the next big step - taking sex hormones of the opposite gender - that creates permanent changes, such as breasts and broadened hips, that cannot be hormonally reversed.
“In puberty,’’’ Spack says, “when your body starts making a statement, you either have to accept it or reject it.’’
There is no definitive answer to the question of what causes gender identity disorder, though studies suggest a genetic contribution. “It’s still a very open question,’’ Zucker says. And how could it affect just one of two identical twins? “There can be genetic changes during fetal development that maybe hit one twin but not the other.’’
Changed atmosphere
After the family’s lawsuit against the Orono schools was publicized, the atmosphere in town changed. When they went to the movies, people pointed and whispered. There were fewer party invitations, fewer sleepovers.
In the sixth grade, the twins joined the school’s Outing Club. All year they attended meetings to prepare for the crowning event: a whitewater rafting trip. Wayne went to several meetings, too, so he could serve as a chaperone.
Wayne thought he had a good relationship with the club leader. But then the man informed him that Nicole would not be allowed to sleep in the tent with the girls - the same girls who had slept over her house several times. She and her father could have a separate tent.
A difficult family conversation followed. Jonas and Wayne went on the trip. Nicole stayed home.
After that episode, Kelly and Wayne decided a new start would be good for the family. The summer after the sixth grade, they moved to a larger, more diverse community in southern Maine, and the twins enrolled in public school. Wayne still works at UMaine and stays in Orono during the week, spending weekends with his family.
For two years, in seventh and eighth grade, Nicole went “stealth,’’ as she calls it: passing as a girl. She did not tell anyone that she was biologically male. Though she made friends at school, she never brought them to the house. After that hard last year in Orono, the family was afraid to come out.
This fall the twins entered high school, transferring to a smaller, private school known for open-mindedness. Before they arrived, the school changed its bathrooms to unisex. And before classes started, the family met with members of the school’s Gay Straight Alliance - “so she’d have older kids watching her back,’’ says Wayne. After the meeting, the group changed its name to include transgender; it is now the Gay Straight Transgender Alliance.
“It made me a lot more comfortable,’’ Nicole says. “I thought, this is OK. I can do this.’’
She recently started telling some of her new friends her story. One girl replied: “Does this mean you’re going to start wearing boys’ clothes to school?’’
“No,’’ replied Nicole. “I’m male to female.’’
The girl’s reaction? “She was like, ‘Ohhhhhhhhhhhhhhh.’ ’’
Concerns about safety
The male hormone suppressors have done their job, and the next step is to add female hormones so that Nicole will undergo puberty as a girl and develop as a woman, with breasts and curvy hips. She is due to see Spack in January, and a date may then be set for adding estrogen, which she will take every day for the rest of her life. Though she will have a higher risk of breast cancer than if she were a male, she will have a lower risk of prostate cancer, Spack says. The treatment will leave her infertile.
But before the estrogen is administered, the GeMS clinic will reevaluate Nicole to make sure that she still identifies as a female and wants to continue.
“In my experience, the patients just blossom physically and mentally when they get the hormones of the gender they affirm,’’ Spack says. “It’s quite amazing. I feel good about Nicole and who she is and where she’s going.’’
An endocrinologist in Maine now administers the blockers Nicole needs, but Spack still sees her in Boston every four to six months. The Maines family has grown close to him and others in the clinic. “I love going to see him,’’ says Wayne, who has thanked Spack for “saving my daughter’s life.’’ The Maines family declined to talk about the cost of the treatment but said insurance has covered much of it.
But as well as things are going, the Maines family still worries about Nicole’s safety. Last year Wayne and Nicole attended Transgender Day of Remembrance in Maine, which honors those who have been killed in hate crimes.
Wayne spoke to the crowd, telling them that as much as Nicole is loved at home, her family cannot always protect her.
“I remind her that she needs to always be aware of her surroundings, to stay close to friends and her brother if she feels uncomfortable, and to call me anytime she feels threatened,’’ he said.
Lobbying the Legislature
Last winter, Maine state representative Kenneth Fredette, a Republican from Penobscot County, sponsored a bill that would have repealed protections for transgender people in public restrooms, instead allowing schools and businesses to adopt their own policies. The bill was a response to the Maines’ 2009 lawsuit against the Orono School District.
Last spring Wayne and Nicole roamed the halls of the State House, button-holing legislators and testifying against the bill. “I’d be in more danger if I went into the boys bathroom,’’ Nicole told the lawmakers, who ultimately rejected the bill.
“She knows how to work a room,’’ her father says proudly. “She even convinced a cosponsor to vote the other way.’’
In October, the family was honored for its activism in helping defeat the transgender bathroom bill. The Maineses received the Roger Baldwin Award, named for a founder of the American Civil Liberties Union, from the Maine chapter of the ACLU.
Surrounded by Kelly and the kids, Wayne told the audience that he and his wife have had top-notch guides as they confronted the unknown.
“As a conventional dad, hunter, and former Republican, it took me longer to understand that I never had two sons,’’ he told them. “My children taught me who Nicole is and who she needed to be.’’
Typical teens
In some respects, Jonas has had as tough a time as Nicole. For one thing, there’s the personality difference: Nicole is the dominant twin, talkative and tough, while Jonas is cautious and reserved.
“If this had been Jonas, I would have had to home school him,’’ his mother says.
The twins have always been close. During an interview, Nicole sits next to her brother on the couch and occasionally lays her head on his shoulder. At one point, when Jonas goes silent as the twins talk of their lives, she whispers words of encouragement into his ear.
But the next minute, like typical teenage siblings, they’re teasing and tussling. Jonas displays a faint scar on his arm where Nicole jabbed him with a pencil. Both have black belts in tae kwon do, which they started at age 5.
They often hang out in Jonas’s spacious basement room, where they watch TV and play video games.
“I love having a sister,’’ says Jonas, who acknowledges being protective of her. “We have a very strong relationship.’’
Nicole calls Jonas her closest friend.
“I would say my brother got lucky with me. Because we grew up with only boy neighbors, I developed a liking to shoot-’em-up and military video games,’’ she says. “I could have come out a lot girlier.’’
At 14, Jonas is handsome, Nicole pretty. Jonas is midway through puberty. His shoulders have broadened, his voice has deepened, and there’s a shadow on his upper lip. He’s 5 feet 6 and weighs 115 pounds, with a size 11 shoe.
Nicole is petite: 5 feet 1, 100 pounds. She’s got long, dark hair and she wears girls’ size 14-16. Her closet contains nice shirts and jeans, party dresses, glittery shoes, and a pair of footy pajamas.
“The thought of being a boy makes me cringe,’’ she says. “I just couldn’t do it.’’
Excited, worried about surgery
Nicole’s final step on her journey to womanhood would be gender reassignment surgery. Doctors generally won’t perform it until the age of consent, which is 18. No hospitals in New England perform such surgery, says Spack. The nearest that do are in Montreal and Philadelphia.
Nicole says she’s excited about the idea of surgery, though a bit worried about the results - “and maybe the pain, too.’’
While she’s interested in boys, she has expressed fear that “nobody is ever going to love me.’’
She has gone on weekend retreats sponsored by the Trans Youth Equality Foundation and to summer camp for transgender children, where she developed her first crush on a boy.
Over the years, the family has become close to several adult transsexuals, and Nicole has seen that some have found happy marriages. “She says she does feel better about it,’’ Kelly says, “but still wonders if she ever met a boy who falls for her, and then found out that she was trans, if he would still like her, or say awful things as he skedaddled out the door.’’
Nicole knows there is a long road ahead, but she feels she’s on the right path.
“Obviously my life is not going to be as easy as being gender-conforming, but there are perks like being able to get out there and do things that will benefit the [transgender] community,’’ she says. “I think everything’s going to turn out pretty well for me.’’
For now, at least, life feels more normal to the Maines family.
Wayne recently spoke at GLAD’s Spirit of Justice dinner in Boston and was introduced by Nicole. She kept her composure in her brief remarks and thanked GLAD for giving them a rare chance to “safely speak out.’’
Wayne choked up when thanking the group for its support. He recounted young Wyatt asking him, sadly, “Daddy, why can’t boys wear dresses?’’ Wayne hated to tell his son that society wouldn’t accept that.
But today, when Nicole asks her father what he thinks of a certain dress she’s wearing, his typical response, he told the audience, is: “That dress is too short. Go change your clothes.’’
In conversation later, Wayne tells another story of how things have changed, for good and forever. He and the twins were getting out of the car recently, and he grabbed their hands to walk with them.
Jonas, being a teenage boy, shook his father off, while Nicole was happy to walk hand-in-hand, swinging arms.
“She’ll do that the rest of her life,’’ Wayne says with a wide grin. “It was an epiphany for me.’’
Bella English can be reached at english@globe.com.
The Message
AJN, American Journal of Nursing:
September 1997 - Volume 97 - Issue 9 - p 52
Reflections
Lindsay, Carol RN
Her abdomen was rigid. Her skin was so pale it was translucent. As I removed her clothes, I saw her skin was covered with various shades of black, blue, green, and yellow. "How did you get all those bruises?" I asked. "Playing baseball," she whispered. "I like to play baseball."
An unlikely story, I thought, knowing that she had been brought to the ED by ambulance after being hit in the abdomen by her husband. She lay quiet, her eyes closed. She spoke only to respond to direct questions. Her blood pressure was low, her pulse rapid, her veins nonexistent, her breathing labored.
Suddenly, her eyes opened, clear and blue. She observed the room full of physicians and nurses standing over her. "I'm going to die. Tell my kids I love them," she said.
"You're not going to die," I quickly responded. "You're going to get better and then you can tell your kids you love them yourself."
Looking directly at me with desperation she repeated her request. "Tell my kids I love them." Solemnly, I nodded. Her eyes closed.
She did not speak again. Her labored respirations stopped. "Intubate!" the respiratory therapist shouted. "Does she have a pulse?" someone else asked. Hands flew reaching for pulse points. Her pulse was gone. Chest compressions were begun. Drugs were given. "I'm going to crack her chest," the ED physician said, just as the surgeon entered the room. "Let's get her to the OR," he said.
Packs of IV fluids and units of blood flapped against the pole as we raced to the OR. One nurse kneeled on the stretcher performing chest compressions.
We turned our patient over to the OR crew and returned to the ED. There was chaos as the police questioned her husband. "Murderer!" her parents yelled at him. Two little boys sat quietly in a corner, their heads hung low.
We received word from the OR that her heart was beating. They had removed her ruptured spleen. They transfused blood and platelets. Still she bled. She was transferred to intensive care.
Nurses stood over her every second. Blood seeped from her incision and from every IV site. Her nose bled. Blood rolled out of her tear ducts and down her cheeks. For hours she bled. Over 30 units of blood products were transfused. And then her heart stopped.
Leukemia, the lab tech said. Undiagnosed leukemia, the physician said. Probable cause, the police said. Assault with intent, the district attorney said. Murder, her parents said.
To the little boys sitting lost in the corner I said what their mother told me to say. I told them their mother's last words. I said, "Your mother loves you very much."
Cited By:
September 1997 - Volume 97 - Issue 9 - p 52
Reflections
Lindsay, Carol RN
Her abdomen was rigid. Her skin was so pale it was translucent. As I removed her clothes, I saw her skin was covered with various shades of black, blue, green, and yellow. "How did you get all those bruises?" I asked. "Playing baseball," she whispered. "I like to play baseball."
An unlikely story, I thought, knowing that she had been brought to the ED by ambulance after being hit in the abdomen by her husband. She lay quiet, her eyes closed. She spoke only to respond to direct questions. Her blood pressure was low, her pulse rapid, her veins nonexistent, her breathing labored.
Suddenly, her eyes opened, clear and blue. She observed the room full of physicians and nurses standing over her. "I'm going to die. Tell my kids I love them," she said.
"You're not going to die," I quickly responded. "You're going to get better and then you can tell your kids you love them yourself."
Looking directly at me with desperation she repeated her request. "Tell my kids I love them." Solemnly, I nodded. Her eyes closed.
She did not speak again. Her labored respirations stopped. "Intubate!" the respiratory therapist shouted. "Does she have a pulse?" someone else asked. Hands flew reaching for pulse points. Her pulse was gone. Chest compressions were begun. Drugs were given. "I'm going to crack her chest," the ED physician said, just as the surgeon entered the room. "Let's get her to the OR," he said.
Packs of IV fluids and units of blood flapped against the pole as we raced to the OR. One nurse kneeled on the stretcher performing chest compressions.
We turned our patient over to the OR crew and returned to the ED. There was chaos as the police questioned her husband. "Murderer!" her parents yelled at him. Two little boys sat quietly in a corner, their heads hung low.
We received word from the OR that her heart was beating. They had removed her ruptured spleen. They transfused blood and platelets. Still she bled. She was transferred to intensive care.
Nurses stood over her every second. Blood seeped from her incision and from every IV site. Her nose bled. Blood rolled out of her tear ducts and down her cheeks. For hours she bled. Over 30 units of blood products were transfused. And then her heart stopped.
Leukemia, the lab tech said. Undiagnosed leukemia, the physician said. Probable cause, the police said. Assault with intent, the district attorney said. Murder, her parents said.
To the little boys sitting lost in the corner I said what their mother told me to say. I told them their mother's last words. I said, "Your mother loves you very much."
Cited By:
Sunday, December 11, 2011
60 years later, Utah couple in their 80s tie knot
The Associated Press
Published: December 11, 2011 03:19PM
Updated: December 11, 2011 06:54PM
St. George • Sixty years after meeting as teenagers, a St. George couple in their 80s have tied the knot.
The Spectrum of St. George reports Bill Koncar and Barbara Burt were married Oct. 29 after both of their spouses had died and they reunited at a high school reunion.
Although both attended West High School in Salt Lake City about the same time, they never met at school.
It wasn’t until after Bill’s graduation that his sister suggested he take her friend Barbara out for a date and brought her by the house. But he declined because he was interested in someone else.
After his wife of 52 years died in 2009, Bill finally gave Barbara a call. He says love blossomed after they attended the high school reunion together.
Published: December 11, 2011 03:19PM
Updated: December 11, 2011 06:54PM
St. George • Sixty years after meeting as teenagers, a St. George couple in their 80s have tied the knot.
The Spectrum of St. George reports Bill Koncar and Barbara Burt were married Oct. 29 after both of their spouses had died and they reunited at a high school reunion.
Although both attended West High School in Salt Lake City about the same time, they never met at school.
It wasn’t until after Bill’s graduation that his sister suggested he take her friend Barbara out for a date and brought her by the house. But he declined because he was interested in someone else.
After his wife of 52 years died in 2009, Bill finally gave Barbara a call. He says love blossomed after they attended the high school reunion together.
A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers.
Moore Z ; Cowman S ; Conroy RM
Faculty of Nursing & Midwifery, Royal College of Surgeons in Ireland. zmoore@rcsi.ie
UNLABELLED: BACKGROUNDL: Pressure ulcers are common, costly and impact negatively on individuals. Pressure is the prime cause, and immobility is the factor that exposes individuals to pressure. International guidelines advocate repositioning; however, there is confusion surrounding the best method and frequency required.
DESIGN: A pragmatic, multi-centre, open label, prospective, cluster-randomised controlled trial was conducted to compare the incidence of pressure ulcers among older persons nursed using two different repositioning regimens.
METHOD: Ethical approval was received. Study sites (n=12) were allocated to study arm using cluster randomisation. The experimental group (n=99) were repositioned three hourly at night, using the 30° tilt; the control group (n=114) received routine prevention (six-hourly repositioning, using 90° lateral rotation). Data analysis was by intention to treat; follow-up was for four weeks.
RESULTS: All participants (n=213) were Irish and white, among them 77% were women and 65% aged 80 years or older. Three patients (3%) in the experimental group and 13 patients (11%) in the control group developed a pressure ulcer (p=0·035; 95% CI 0·031-0·038; ICC=0·001). All pressure ulcers were grade 1 (44%) or grade 2 (56%). Mobility and activity were the highest predictors of pressure ulcer development (?=-0·246, 95% CI=-0·319 to -0·066; p=0·003); (?=0·227, 95% CI=0·041-0·246; p = 0·006).
CONCLUSION: Repositioning older persons at risk of pressure ulcers every three hours at night, using the 30° tilt, reduces the incidence of pressure ulcers compared with usual care. The study supports the recommendations of the 2009 international pressure ulcer prevention guidelines.
RELEVANCE TO CLINICAL PRACTICE: An effective method of pressure ulcer prevention has been identified; in the light of the problem of pressures ulcers, current prevention strategies should be reviewed. It is important to implement appropriate prevention strategies, of which repositioning is one.
PreMedline Identifier:21702861
Faculty of Nursing & Midwifery, Royal College of Surgeons in Ireland. zmoore@rcsi.ie
UNLABELLED: BACKGROUNDL: Pressure ulcers are common, costly and impact negatively on individuals. Pressure is the prime cause, and immobility is the factor that exposes individuals to pressure. International guidelines advocate repositioning; however, there is confusion surrounding the best method and frequency required.
DESIGN: A pragmatic, multi-centre, open label, prospective, cluster-randomised controlled trial was conducted to compare the incidence of pressure ulcers among older persons nursed using two different repositioning regimens.
METHOD: Ethical approval was received. Study sites (n=12) were allocated to study arm using cluster randomisation. The experimental group (n=99) were repositioned three hourly at night, using the 30° tilt; the control group (n=114) received routine prevention (six-hourly repositioning, using 90° lateral rotation). Data analysis was by intention to treat; follow-up was for four weeks.
RESULTS: All participants (n=213) were Irish and white, among them 77% were women and 65% aged 80 years or older. Three patients (3%) in the experimental group and 13 patients (11%) in the control group developed a pressure ulcer (p=0·035; 95% CI 0·031-0·038; ICC=0·001). All pressure ulcers were grade 1 (44%) or grade 2 (56%). Mobility and activity were the highest predictors of pressure ulcer development (?=-0·246, 95% CI=-0·319 to -0·066; p=0·003); (?=0·227, 95% CI=0·041-0·246; p = 0·006).
CONCLUSION: Repositioning older persons at risk of pressure ulcers every three hours at night, using the 30° tilt, reduces the incidence of pressure ulcers compared with usual care. The study supports the recommendations of the 2009 international pressure ulcer prevention guidelines.
RELEVANCE TO CLINICAL PRACTICE: An effective method of pressure ulcer prevention has been identified; in the light of the problem of pressures ulcers, current prevention strategies should be reviewed. It is important to implement appropriate prevention strategies, of which repositioning is one.
PreMedline Identifier:21702861
Surge in Young Nurses Buoys Hopes of Easing Shortage
Are the new nurses going to stay in nursing? That my friends is the question. Carol
December 9, 2011 - With the number of young people entering the nursing profession surging, the current group of 23-26 year olds has the potential to become the largest cohort of nurses ever observed, according to a new study, surpassing the legions of baby boomers who became nurses and, possibly, easing the nursing shortage.
“Whereas maybe five years ago it seemed there was no way to avoid a large shortage, now with this response, it creates a pathway where it is possible that the retirement of the baby boomers could be counteracted by this big influx of new people into the profession, if this trend keeps going,” said lead author David I. Auerbach, MS, Ph.D., a health economist at RAND Health in Boston, who adds that he was surprised by the findings.
“No one seemed to think this was possible,” Auerbach said. “For 15 years, we’ve been in the doldrums and a whole generation not seeing this as an attractive profession. It was hard to anticipate what would turn this around. When we saw the first inklings of this in the data, we didn’t believe it.”
Peter I. Buerhaus, Ph.D., RN, said the country needed the surge of younger people to increase the supply of nurses.Co-author Peter I. Buerhaus, Ph.D., RN, the Valere Potter Professor of Nursing and Director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University in Nashville, Tenn., said he was surprised by the size of the trend. Smaller samples had provided hints of an easing, but a larger sample was needed. The current study uses federal data from the American Community Survey and gave the team the power to prove the trend is real, he said.
Aggressive efforts to make nursing a more attractive career choice have helped spur a 62 percent increase in the number of nurses aged 23-26 years entering the field between 2002 and 2009, from 102,000 to 165,000 full-time equivalent RNs, reported the authors in a Health Affairs article.
Because of an influx of people choosing nursing as a second career or coming into it later in life, Auerbach predicted even more nurses from those birth years studied will eventually become nurses and surpass the number of baby boomers who joined the profession.
“It looks like a world turned upside down,” Auerbach said. “It’s pretty neat.”
Although the authors do not know definitively what is driving the increase in nurses joining the workforce, Auerbach attributes much of it to the poor economy.
“Most evidence is pointing the fact that [nursing] is a stable, reliable career,” Auerbach said.
Buerhaus also cited the economy and said society saw that health care tends to weather recessions better than some other industries. He also credited the Johnson & Johnson Campaign for Nursing’s Future with helping create a more positive image of the profession; support from funders, such as the Robert Wood Johnson Foundation and the Gordon and Betty Moore Foundation; and federal expansions of nursing education funding.
Rather than declining as previously projected, the authors expect the registered nurse workforce to increase at roughly the same rate as the population through 2030.
“If new entry keeps growing at 2 percent per year, it looks like that would keep the workforce growing at a steady rate and could eliminate a shortage, but you don’t know what will happen to need in the future,” Auerbach said.
Buerhaus added, “It’s one thing to get people to go into nursing, and it’s another to get them employed.”
A slow job recovery has clogged the labor market, with fewer positions for new nurses opening up, which he said could deter people from entering the profession. He added that the long-term projection reported in the study does not mean the nursing shortage is over.
“While it is unbelievably terrific that we suddenly have this surge of young people coming into the profession, which we started to see over the past four or six years, the impact on growing the supply won’t occur for a while down the stream.”
Shortages continue to exist in some areas. The Florida Hospital Association reported in December 2011 that more than three-quarters of Florida hospitals are facing a nursing shortage, with a 6.5 percent RN vacancy rate, compared to a 4.6 percent vacancy rate in 2009.
In addition, the need for nurses is expected to increase. Many of the 900,000 RNs older than 50 years of age will retire during the next decade and will need to be replaced. In addition, the profession must grow the supply, with an aging population and people with chronic conditions needing more health care and the potential influx of 32 million newly insured patients as a result of health-reform legislation.
“There’s a lot of demand looking forward,” Buerhaus said. “This is the first evidence that shows we will grow the supply, if we maintain these trends.”
December 9, 2011 - With the number of young people entering the nursing profession surging, the current group of 23-26 year olds has the potential to become the largest cohort of nurses ever observed, according to a new study, surpassing the legions of baby boomers who became nurses and, possibly, easing the nursing shortage.
“Whereas maybe five years ago it seemed there was no way to avoid a large shortage, now with this response, it creates a pathway where it is possible that the retirement of the baby boomers could be counteracted by this big influx of new people into the profession, if this trend keeps going,” said lead author David I. Auerbach, MS, Ph.D., a health economist at RAND Health in Boston, who adds that he was surprised by the findings.
“No one seemed to think this was possible,” Auerbach said. “For 15 years, we’ve been in the doldrums and a whole generation not seeing this as an attractive profession. It was hard to anticipate what would turn this around. When we saw the first inklings of this in the data, we didn’t believe it.”
Peter I. Buerhaus, Ph.D., RN, said the country needed the surge of younger people to increase the supply of nurses.Co-author Peter I. Buerhaus, Ph.D., RN, the Valere Potter Professor of Nursing and Director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University in Nashville, Tenn., said he was surprised by the size of the trend. Smaller samples had provided hints of an easing, but a larger sample was needed. The current study uses federal data from the American Community Survey and gave the team the power to prove the trend is real, he said.
Aggressive efforts to make nursing a more attractive career choice have helped spur a 62 percent increase in the number of nurses aged 23-26 years entering the field between 2002 and 2009, from 102,000 to 165,000 full-time equivalent RNs, reported the authors in a Health Affairs article.
Because of an influx of people choosing nursing as a second career or coming into it later in life, Auerbach predicted even more nurses from those birth years studied will eventually become nurses and surpass the number of baby boomers who joined the profession.
“It looks like a world turned upside down,” Auerbach said. “It’s pretty neat.”
Although the authors do not know definitively what is driving the increase in nurses joining the workforce, Auerbach attributes much of it to the poor economy.
“Most evidence is pointing the fact that [nursing] is a stable, reliable career,” Auerbach said.
Buerhaus also cited the economy and said society saw that health care tends to weather recessions better than some other industries. He also credited the Johnson & Johnson Campaign for Nursing’s Future with helping create a more positive image of the profession; support from funders, such as the Robert Wood Johnson Foundation and the Gordon and Betty Moore Foundation; and federal expansions of nursing education funding.
Rather than declining as previously projected, the authors expect the registered nurse workforce to increase at roughly the same rate as the population through 2030.
“If new entry keeps growing at 2 percent per year, it looks like that would keep the workforce growing at a steady rate and could eliminate a shortage, but you don’t know what will happen to need in the future,” Auerbach said.
Buerhaus added, “It’s one thing to get people to go into nursing, and it’s another to get them employed.”
A slow job recovery has clogged the labor market, with fewer positions for new nurses opening up, which he said could deter people from entering the profession. He added that the long-term projection reported in the study does not mean the nursing shortage is over.
“While it is unbelievably terrific that we suddenly have this surge of young people coming into the profession, which we started to see over the past four or six years, the impact on growing the supply won’t occur for a while down the stream.”
Shortages continue to exist in some areas. The Florida Hospital Association reported in December 2011 that more than three-quarters of Florida hospitals are facing a nursing shortage, with a 6.5 percent RN vacancy rate, compared to a 4.6 percent vacancy rate in 2009.
In addition, the need for nurses is expected to increase. Many of the 900,000 RNs older than 50 years of age will retire during the next decade and will need to be replaced. In addition, the profession must grow the supply, with an aging population and people with chronic conditions needing more health care and the potential influx of 32 million newly insured patients as a result of health-reform legislation.
“There’s a lot of demand looking forward,” Buerhaus said. “This is the first evidence that shows we will grow the supply, if we maintain these trends.”
Friday, December 9, 2011
CNA training
I know I already covered all this but just some reminders on what not to do.
These are of course all things you can/will lose your certification for.
Remember: Be nice and wash your hands!
These are acts that can cost them their job, license, and even call for legal action. Here some legal ethics a CNA must keep in mind:
Abuse of patient
It can be infliction of physical injury. However, mere verbal threat can pass for abuse. Not only physical but bringing mental harm to a patient is against legal ethics. This is something CNAs should guard against even though some patients can be abusive or hard to handle.
Tolerating
Even if you are not the person who caused the mental of physical abuse, you are still liable to the law if you witnessed the abuse being done on the patient and you did nothing to act on it. This is called abetting.
Unlawful imprisonment
It is true that some patients need to be isolated to prevent communicable diseases from spreading. However, there is correct procedure to this. Confining a patient against his/her will is unlawful.
Privacy Invasion
Even though a patient is under your care which includes taking care of his/her personal hygiene like bathing and toileting, you need to do so with his/her permission. You should also be careful not to expose the patient’s body parts to others. Protecting the privacy of patients also includes keeping their personal affairs private. For example, you need to keep out of their personal belongings and let them speak privately with loved ones.
Neglect
It is the main duty of the CNA to take care of the daily needs of patients and residents under his/her care. If any of these responsibilities are neglected, it is a violation of the legal ethics of CNAs. And it does not matter whether the neglect is intentional or accidental. Especially if it led to putting the condition of the patient in danger, it will be an even more serious case.
Abuse of patient
Negligence
Carelessness is also against the legal ethics of CNAs. This includes not performing the procedure in the way that you were taught. So if you are doing shortcuts and not following the standard operating procedures, you are committing negligence.
Theft
Of course, this should be common sense and it would not be legal wherever and to whomever this is done. Taking whatever is not yours is definitely a criminal act. This can be quite common considering how exposed CNAs are to the patient’s valuables.
These are of course all things you can/will lose your certification for.
Remember: Be nice and wash your hands!
These are acts that can cost them their job, license, and even call for legal action. Here some legal ethics a CNA must keep in mind:
Abuse of patient
It can be infliction of physical injury. However, mere verbal threat can pass for abuse. Not only physical but bringing mental harm to a patient is against legal ethics. This is something CNAs should guard against even though some patients can be abusive or hard to handle.
Tolerating
Even if you are not the person who caused the mental of physical abuse, you are still liable to the law if you witnessed the abuse being done on the patient and you did nothing to act on it. This is called abetting.
Unlawful imprisonment
It is true that some patients need to be isolated to prevent communicable diseases from spreading. However, there is correct procedure to this. Confining a patient against his/her will is unlawful.
Privacy Invasion
Even though a patient is under your care which includes taking care of his/her personal hygiene like bathing and toileting, you need to do so with his/her permission. You should also be careful not to expose the patient’s body parts to others. Protecting the privacy of patients also includes keeping their personal affairs private. For example, you need to keep out of their personal belongings and let them speak privately with loved ones.
Neglect
It is the main duty of the CNA to take care of the daily needs of patients and residents under his/her care. If any of these responsibilities are neglected, it is a violation of the legal ethics of CNAs. And it does not matter whether the neglect is intentional or accidental. Especially if it led to putting the condition of the patient in danger, it will be an even more serious case.
Abuse of patient
Negligence
Carelessness is also against the legal ethics of CNAs. This includes not performing the procedure in the way that you were taught. So if you are doing shortcuts and not following the standard operating procedures, you are committing negligence.
Theft
Of course, this should be common sense and it would not be legal wherever and to whomever this is done. Taking whatever is not yours is definitely a criminal act. This can be quite common considering how exposed CNAs are to the patient’s valuables.
3-D TV Doesn't Raise Seizure Risk for Kids With Epilepsy: Study
SUNDAY, Dec. 4 (HealthDay News) -- Children with epilepsy do not appear to face an increased risk for seizures while watching 3-D TV, a new German-Austrian study suggests.
However, the results did reveal that about one in five of these children is vulnerable to other unpleasant reactions when viewing 3-D television, including nausea, headaches and dizziness.
"Normal people have a very low risk to get a seizure while watching 3-D," explained study author Dr. Herbert Plischke, executive director of the University of Munich's Generation Research Program. In contrast, he noted that people with epilepsy --particularly children -- could be expected to have a "higher vulnerability" in terms of overall seizure risk in such a setting.
However, among a group of young people with epilepsy, "we could not see any provoked seizure which was caused by 3-D," Plischke said.
He and his colleagues from the University of Salzburg in Austria are scheduled to present their findings Sunday at the American Epilepsy Society annual meeting in Baltimore.
As a concept, 3-D technology is hardly a cutting-edge idea, harkening back more than half a century to the 1950s Vincent Price classic film "House of Wax." But the experience of donning special glasses to view an "extra-dimensional" effect has undergone a cinematic renaissance in recent years, led by the box-office success of the movie "Avatar."
Jumping on the bandwagon, TV manufacturers have sought to bring the experience right into the living room, with TV sets that are hard-wired to provide 3-D viewing of properly formatted shows.
The move has raised concerns over how the technology may impact various audiences. Recently, some researchers cautioned that nearly one-third of all viewers may be prone to experiencing headaches and/or eye fatigue when viewing a 3-D movie because of poor eye coordination. The resulting strain, they said, could prompt an unpleasant experience equivalent to that of seasickness.
People with epilepsy are a more specific worry, given their sensitivity to the flashing lights and red and blue light alterations contained in certain TV programming and video games. As a result, some TV manufacturers (such as Samsung) have published public warnings, alerting viewers to the potential risk for epileptic seizures or stroke when viewing 3-D technology.
Against that backdrop, the current investigation set out to assess the impact of 3-D on children with epilepsy viewing the technology on TV.
The team focused on 100 children (average age 12) who had epilepsy or were deemed to be at risk for epilepsy.
All the kids underwent a standard test for photosensitivity. Each was then asked to wear 3-D glasses and sit about six-and-a-half feet away from a 50-inch plasma 3-D TV.
During 15 minutes of viewing, only one child experienced a seizure, and that particular child was noted as being prone to routinely experiencing three to four seizures per day.
Symptoms of nausea, headache and dizziness went up during both photosensitivity testing and 3-D TV-watching (in 15 percent and 20 percent of cases, respectively). But the near total absence of seizures, combined with the benign results of EEG readings taken during sensitivity testing and 3-D viewing, led the team to conclude that 3-D TV viewing posed little risk to children with epilepsy.
The team suggested that seizure risk is probably more a function of differences in TV content rather than TV technology, with certain patterns, colors and flickering images raising the threat of seizure more than 3-D images.
Dr. Orrin Devinsky, director of NYU Langone Medical Center's Epilepsy Center, agreed.
"It sounds perfectly in line with what I might expect," he said. "If there was to be a problem, it would be with the content, namely flashing imagery. And that would be a present concern in 2-D or 3-D."
"So I wouldn't expect 3-D TV to be a specific issue," said Devinsky, who is also a professor of neurology, neurosurgery and psychiatry at NYU School of Medicine. "I wouldn't say that no child in ten thousand would have a problem. But I would expect it to be very rare, if it occurs at all."
Research presented at meetings should be considered preliminary until published in a peer-reviewed medical journal
However, the results did reveal that about one in five of these children is vulnerable to other unpleasant reactions when viewing 3-D television, including nausea, headaches and dizziness.
"Normal people have a very low risk to get a seizure while watching 3-D," explained study author Dr. Herbert Plischke, executive director of the University of Munich's Generation Research Program. In contrast, he noted that people with epilepsy --particularly children -- could be expected to have a "higher vulnerability" in terms of overall seizure risk in such a setting.
However, among a group of young people with epilepsy, "we could not see any provoked seizure which was caused by 3-D," Plischke said.
He and his colleagues from the University of Salzburg in Austria are scheduled to present their findings Sunday at the American Epilepsy Society annual meeting in Baltimore.
As a concept, 3-D technology is hardly a cutting-edge idea, harkening back more than half a century to the 1950s Vincent Price classic film "House of Wax." But the experience of donning special glasses to view an "extra-dimensional" effect has undergone a cinematic renaissance in recent years, led by the box-office success of the movie "Avatar."
Jumping on the bandwagon, TV manufacturers have sought to bring the experience right into the living room, with TV sets that are hard-wired to provide 3-D viewing of properly formatted shows.
The move has raised concerns over how the technology may impact various audiences. Recently, some researchers cautioned that nearly one-third of all viewers may be prone to experiencing headaches and/or eye fatigue when viewing a 3-D movie because of poor eye coordination. The resulting strain, they said, could prompt an unpleasant experience equivalent to that of seasickness.
People with epilepsy are a more specific worry, given their sensitivity to the flashing lights and red and blue light alterations contained in certain TV programming and video games. As a result, some TV manufacturers (such as Samsung) have published public warnings, alerting viewers to the potential risk for epileptic seizures or stroke when viewing 3-D technology.
Against that backdrop, the current investigation set out to assess the impact of 3-D on children with epilepsy viewing the technology on TV.
The team focused on 100 children (average age 12) who had epilepsy or were deemed to be at risk for epilepsy.
All the kids underwent a standard test for photosensitivity. Each was then asked to wear 3-D glasses and sit about six-and-a-half feet away from a 50-inch plasma 3-D TV.
During 15 minutes of viewing, only one child experienced a seizure, and that particular child was noted as being prone to routinely experiencing three to four seizures per day.
Symptoms of nausea, headache and dizziness went up during both photosensitivity testing and 3-D TV-watching (in 15 percent and 20 percent of cases, respectively). But the near total absence of seizures, combined with the benign results of EEG readings taken during sensitivity testing and 3-D viewing, led the team to conclude that 3-D TV viewing posed little risk to children with epilepsy.
The team suggested that seizure risk is probably more a function of differences in TV content rather than TV technology, with certain patterns, colors and flickering images raising the threat of seizure more than 3-D images.
Dr. Orrin Devinsky, director of NYU Langone Medical Center's Epilepsy Center, agreed.
"It sounds perfectly in line with what I might expect," he said. "If there was to be a problem, it would be with the content, namely flashing imagery. And that would be a present concern in 2-D or 3-D."
"So I wouldn't expect 3-D TV to be a specific issue," said Devinsky, who is also a professor of neurology, neurosurgery and psychiatry at NYU School of Medicine. "I wouldn't say that no child in ten thousand would have a problem. But I would expect it to be very rare, if it occurs at all."
Research presented at meetings should be considered preliminary until published in a peer-reviewed medical journal
Study Puts Brakes on Nursing Shortage
Study Puts Brakes on Nursing Shortage
Researchers mine census data, suggest impending RN shortage won't become reality.
Recruitment campaigns, 2-year associate degrees spurred interest in nursing programs.
By Catlin Nalley
A surge of young nurses (age 23-26) entering the profession signals hope the long-predicted shortage of registered nurses original expected to begin in 2020 might be avoided.
A study reported in the December issue of Health Affairs shows a 62 percent increase in the number of young nurses entering the workforce between 2002 and 2009, at a rate not seen since the 1970s.
"This is a very welcome and surprising development," said David Auerbach, lead author and health economist at RAND Health. "Instead of worrying about a decline, we are now growing the supply of nurses."
While Auerbach and co-authors Peter Buerhaus of Vanderbilt University and Douglas Staiger of Dartmouth College find this change promising, they said it is not guaranteed to continue.
ADVANCE Perspective: Nurses
Nursing Shortage Is Over? Really?
Vigorous recruitment campaigns and the availability of 2-year associate degrees have spurred interest in nursing programs.
In addition, the recession has made nursing an appealing career choice. While other fields have declined, healthcare continues to grow despite economic hardships.
Population Study
The researchers utilized 35 years of annual survey data from two Census Bureau surveys, the Current Population Survey and the American Community Survey, to evaluate the state of the nursing community, past, present and future.
Their analysis of the data provides a picture of the age and number of RNs per capita through 2030.
In 2009, there were about 165,000 full-time equivalent, young RNs in the workforce, up from a low of 102,000 in 2002, according to the study.
These results suggest a reverse in the trends 10 years ago, which saw a significant decrease in the number of young women becoming RNs due to expanding career opportunities in other industries.
The number of RNs under age 30 dropped from 30 percent in 1983 to 12 percent in 1998, according to the study.
These indicators led to the prediction that if trends did not shift, the country would see a shortage of 20 percent by 2020. Instead, the RN workforce is now expected to grow at roughly the same rate as the population through 2030. While this newest study shows such a reversal, challenges remain that could affect the future of nursing.
Potential Difficulties
Appropriate training, mobility, and hiring "bottlenecks," must all be taken in consideration when looking forward.
It is not only critical that there are enough individuals to fill positions; the labor force must also meet the population needs.
The Institute of Medicine recently released two reports noting the need for RNs who are trained in geriatrics as well as those who are able to work in ambulatory settings.
"It is great to have the quantity, but if we don't educate nurses for the positions that the healthcare delivery system requires, then this is a problem that needs to be addressed," Buerhaus said.
A different study led by Christine Kovner of New York University, also published in the December Health Affairs, looked at the low "mobility" of new RNs.
A survey of newly licensed RNs in 15 states found that 52.5 percent work within 40 miles of where they attended high school. These results suggest a problem could arise if a more even distribution of the labor force is found.
Next to teaching, nursing has the lowest mobility of any profession, according to the study.
According to the American Association of Colleges of Nursing, the number of qualified applicants turned away from entry-level baccalaureate nursing programs grew from 16,000 in 2003 to 38,000 in 2007 and to 55,000 in 2010.
The impact the economy and the challenges faced by new grads will have on the continued growth of the nursing profession, cannot yet be determined, according to Auerbach and his colleagues.
Event & Conference Photos
Featured Nurse Photos
Enjoy quality photo journalism from ADVANCE, and submit your own photos to see your event on the web.
Time Will Tell
This study reveals a dramatic change in nursing trends and calls into question the shortage that has been looming overhead for many years. However, the future remains uncertain.
Many factors will determine whether this upward trend continues or if the nursing industry will revert back to its previous momentum.
"Nevertheless, at least in the near future, there is likely to be continued growth of the nurse workforce, at a rate projected to grow more rapidly during the next 2 decades than previously anticipated," the researchers conclude.
Catlin Nalley is editorial assistant at ADVANCE.
Researchers mine census data, suggest impending RN shortage won't become reality.
Recruitment campaigns, 2-year associate degrees spurred interest in nursing programs.
By Catlin Nalley
A surge of young nurses (age 23-26) entering the profession signals hope the long-predicted shortage of registered nurses original expected to begin in 2020 might be avoided.
A study reported in the December issue of Health Affairs shows a 62 percent increase in the number of young nurses entering the workforce between 2002 and 2009, at a rate not seen since the 1970s.
"This is a very welcome and surprising development," said David Auerbach, lead author and health economist at RAND Health. "Instead of worrying about a decline, we are now growing the supply of nurses."
While Auerbach and co-authors Peter Buerhaus of Vanderbilt University and Douglas Staiger of Dartmouth College find this change promising, they said it is not guaranteed to continue.
ADVANCE Perspective: Nurses
Nursing Shortage Is Over? Really?
Vigorous recruitment campaigns and the availability of 2-year associate degrees have spurred interest in nursing programs.
In addition, the recession has made nursing an appealing career choice. While other fields have declined, healthcare continues to grow despite economic hardships.
Population Study
The researchers utilized 35 years of annual survey data from two Census Bureau surveys, the Current Population Survey and the American Community Survey, to evaluate the state of the nursing community, past, present and future.
Their analysis of the data provides a picture of the age and number of RNs per capita through 2030.
In 2009, there were about 165,000 full-time equivalent, young RNs in the workforce, up from a low of 102,000 in 2002, according to the study.
These results suggest a reverse in the trends 10 years ago, which saw a significant decrease in the number of young women becoming RNs due to expanding career opportunities in other industries.
The number of RNs under age 30 dropped from 30 percent in 1983 to 12 percent in 1998, according to the study.
These indicators led to the prediction that if trends did not shift, the country would see a shortage of 20 percent by 2020. Instead, the RN workforce is now expected to grow at roughly the same rate as the population through 2030. While this newest study shows such a reversal, challenges remain that could affect the future of nursing.
Potential Difficulties
Appropriate training, mobility, and hiring "bottlenecks," must all be taken in consideration when looking forward.
It is not only critical that there are enough individuals to fill positions; the labor force must also meet the population needs.
The Institute of Medicine recently released two reports noting the need for RNs who are trained in geriatrics as well as those who are able to work in ambulatory settings.
"It is great to have the quantity, but if we don't educate nurses for the positions that the healthcare delivery system requires, then this is a problem that needs to be addressed," Buerhaus said.
A different study led by Christine Kovner of New York University, also published in the December Health Affairs, looked at the low "mobility" of new RNs.
A survey of newly licensed RNs in 15 states found that 52.5 percent work within 40 miles of where they attended high school. These results suggest a problem could arise if a more even distribution of the labor force is found.
Next to teaching, nursing has the lowest mobility of any profession, according to the study.
According to the American Association of Colleges of Nursing, the number of qualified applicants turned away from entry-level baccalaureate nursing programs grew from 16,000 in 2003 to 38,000 in 2007 and to 55,000 in 2010.
The impact the economy and the challenges faced by new grads will have on the continued growth of the nursing profession, cannot yet be determined, according to Auerbach and his colleagues.
Event & Conference Photos
Featured Nurse Photos
Enjoy quality photo journalism from ADVANCE, and submit your own photos to see your event on the web.
Time Will Tell
This study reveals a dramatic change in nursing trends and calls into question the shortage that has been looming overhead for many years. However, the future remains uncertain.
Many factors will determine whether this upward trend continues or if the nursing industry will revert back to its previous momentum.
"Nevertheless, at least in the near future, there is likely to be continued growth of the nurse workforce, at a rate projected to grow more rapidly during the next 2 decades than previously anticipated," the researchers conclude.
Catlin Nalley is editorial assistant at ADVANCE.
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