Are we there yet?

I have been craving all the food Sean told us about since last week!  See you all in the morning!

Medication Knowledge

So after interviewing my friends and family I realized many of them are unaware of the medication that they take. The individuals who were most aware were my parents and in laws. I’m not sure if it is an age reason, or the fact that they take daily medication for comorbidities such as hypertension and cancer. Not only did they know the name of the medication they were taking, but they also knew dosing and side effects. The people closer to my own age however  were very unaware about  the medications they take. Most of the people I asked do not take anything on a regular basis,  but when asked about common over the counter medicines, many of them were naive to the side effects and correct dosing. To be totally honest, even my own husband has no idea how much Tylenol to take. When he is sick I have to remind him to check labels on cold medicine so he doesn’t consume too much acetaminophen. This is an issue nurses must be aware of though,  and we must know the right questions to ask to assess the history of our patients. In regards to homeopathic medications, I know that many of the individuals who use these remedies do not know that side effects are common and should be anticipated. I have never checked the label on homeopathic remedies, but I would hope that side effects are listed somewhere on the container for consumers to access.

Knowledge is Power

When it comes to my family, my step-dad is the only one that takes prescription medications. He has hypertension and hyperlipidemia. Prior to this assignment, I was even unsure what he was taking so it was interesting for me to ask him. Here is a recap of what was said:

Me: “Do you know what medication/s you are taking?”

Ray: “Yeeeea, ummm- let me walk into the bathroom and look at it.”

Me: “Would you recognize it if I said it, or have you never looked at the label?”

Ray: “No, I would recognize it, it’s fairly new becuase the last one I was on didn’t have a generic version so it was super expensive. Ok, its Benicar HCT.

Me: “Do you know what that is or what that means?”

Ray: “Yea, I did ask my doctor and from what I understand, it’s a heart medication with a diruetic to get rid of some of the fluids in my body.”

Me: “Wow, I am impressed. That is right.”

Ray: “Well honey, I only am on one medication. If I was on more than one, I would most likely mix them all up and have no idea what is what!”

Me: “See, that’s the problem that most people face….”

So, my stepdad passed my test! I was actually impressed becasuse he isn’t really the kind of guy that would care too much about the medication he is on. He is more of a “do what the doctor says and don’t ask questions” sort of guy. I thought his comment on him only knowing the medication because it is only on one was interesting. As I told him, that is a major issue with non-compliance today. People have so many prescriptions, they can’t keep them all straight and because of that, the desire to maintain their treatment because they “know” why they need the medication falls to the wayside. Then, they are back in the hospital- a trend that is happening far to often in America. This emphasis once again, the importance of patient education.

 

 

 

Packing List

Cahartts: Check. Rain boots: Check. DEET spray: Orange can.

Owens Valley: Field Experience in Water Management Practices

This past weekend, I journeyed to Owens Valley to see first had the impacts of water management practices on society and the ecosystem. The valley has served as an important source of water for the city of Los Angeles since the construction of the aqueduct in the beginning of the twentieth century. Moving water from the valley was controversial, and local opposition culminated in attempted dynamiting of the aqueduct in 1927. Since then, water management in the area has been a source of contention between LA Department of Water and Power, the Inyo County Water District and the Paiute Tribe native to the area. Below is an account of my time in Owens Valley.

The first stop in our field trip was Owens Lake, which looks less like a lake and more like the surface of the moon. Meeting with the Department of Water and Power introduces one central perspective of water usage in the area. Owens Lake was drained early in the twentieth century after the construction of the LA aqueduct, a monument to the human engineering. Evident from the dry, saline lakebed, the construction of the aqueduct has devastated the environment. The dry lakebed creates a huge problem that the city of Los Angeles is now responsible to mitigate: dust and particulate matter. To keep the dust down “bubblers” are employed to re-water the lake. Water is taken from elsewhere in the valley and sprinkled in pools and onto the lake bed. The intention here is to create habitat for birds, as the lake is an important stop for migratory fowl. DWP claims that more water is poured onto the lake than is transported to Los Angeles. Before we departed, a flock of avocets disturbed by a harrier took flight from the surface of a pond. As the birds changed direction, the color of the flock flickered back and forth from black to white. The spectacle, something that birdwatchers would travel great distances to witness, was something to behold. The main takeaway from the lake tour: the ecosystem can be drastically impacted from human interference, and mismanagement can devastate important communities.

In contrast with the optimism heard from DWP, a presentation from Daniel Pritchett of the Owens Water Committee discussed the failures of water management practices in the Owens Valley. The talk began with the history of the LA aqueduct, Mulholland and the Water Wars of 1927. But in the discussion of justice for local farmers or the utilitarianism of the aqueduct, the group overlooked is the native Paiutes. Where is justice for them? Locals had the water taken from them by LA, but the locals took it from the Paiute. A different perspective to be sure. The talk also discussed the Owens Valley Meadow System, a vanished ecosystem that thrived when the water table was higher. Due to the geologic nature of the valley, the water table might experience seasonal changes, but is capable of saving water in the alluvium at the foot of the mountain preventing total loss during drought. DWP might say otherwise, but the current lack of water is not due to drought but extraction. The recent joint management plan has been hailed as revolutionary by DWP, but is really just causing gridlock when the two parties cannot reach a compromise. The only hope, according to Daniel, is the voice of the Paiute Tribe on the Water Council. Is it realistic that the voice of the native tribe will be heeded? Time will tell, but this is an important step in the right direction for Owens Valley.

The Rush Creek Hydroelectric Project is another example of human ingenuity and environmental impacts. The dam also exemplifies the often arbitrary nature of political decisions. According to California State law, 33% of energy must come from “renewable” sources. So what constitutes a renewable source of energy? According to Jeremy Finker, our tour guide of the dam, a hydro plant producing 28 megawatts or less is “small hydro” and is a renewable resource. Anything larger is non-renewable. This is a completely arbitrary number. The dam is also an example of complex decisions that water companies have to face. Built too close for comfort near a fault line, the antiquated dams that feed the station will crumble when the next earthquake strikes. The company must choose between shelling out more than $60 million dollars to reinforce the dams or demolish them. However, removing the dams will dramatically alter the hydrology of the area. No dams means no control of floods, and that could mean devastation downstream. The tour of the hydroelectric facility was fascinating from an engineering standpoint, especially considering that the machinery is nearly a century old (as well as most of the safety measures!)

Owens Valley is a spectacular place to study geology, and travelling with an expert in geomorphology is a great way to learn about the processes that created the magnificent landscape. On our way to June Mountain, Dr. O’Hirok describe the glacial processes that sculpted the Sierra Nevadas. A sure sign of glacial activity are the hills at the base of these mountains, called moraines. Deposited over time by melting glaciers, the moraines have flat, elongated ridges along their peaks in contrast to the uneven eroded tops of the Sierras. Of the glacial events in the past, of which there may be as many as seven, the most recient occurred in the Pleistocene, approx. 11,000 ybp. The glaciers carve U-shaped valleys in the mountains, easily seen form the valley floor. Other aspects of the valley include alluvial fans, aretes, erratics and Tarn lakes, each feature can be seen during the drive. The journey to Mammoth will likely never be the same again!

As emphasized during Daniel Pritchett’s talk, the Paiute have a long history in the valley, and this history can be told through an ethnobotanical tour of native plants in Owens Valley. COSA, the Conservation Open Space Area, was developed to give visitors a place to learn about native plants and how the Paiute used them for food, structures and medicine. Walking through the open space, it is apparent that the landscape is extremely dry. Is this how a healthy ecosystem should look? Invasive species, like blackberry bush and pepper weed, are another problem in the area as they outcompete rare, endemic species. Some of the goals established by COSA are to reduce invasives and propogate endemics, while creating a suitable habitat for the Owens Valley pupfish. As an endangered species, the pupfish is difficult to obtain a permit to cultivate. If the fish were to escape the pond in COSA and make it into the DWP water, Los Angeles would have to take steps to prevent loss of the fish.

The last major stop on our trip was Mono Lake. As a terminal lake, all water that drains into the lake has nowhere to go. As the lake evaporates, ions are left behind in the water. Over time, this process has led to an increase in the salinity, pH (9.8, almost 100 times as alkaline as the ocean) and other chemical concentrations, including arsenic! The salinity of the lake increase the buoyancy of anything floating in it, an effect that I was able to experience firsthand when I took a swim in the freezing water. One might think that the alkaline water might be inhospitable to life, but a hidden jungle can be found in the lake if one knows what to look for. Algae is extremely productive, which in turn supports brine shrimp and fly larvae that provide a food source for local birds. Geology of the lake is intriguing as well. When calcium from underwater springs mixes with carbonate in the water, a chalky white precipitate is formed: calcium carbonate. The precipitate settles on the lake bed, and over time forms pillars of solid rock called tufa, found all over the shores and in the lake. Water level has far receded from historical levels, a fact that is evident in the tufa far from the current shore. This is largely due to extraction by LA, and drought. The goal of restoration efforts is to raise the lake another thirteen feet, which will be an enormous boon to the riparian areas of Mono’s tributaries, which are heavily impaired from drought and historical floods. Mono Lake is unique from a water management perspective, in that it is one of the few places in California with a specific water plan. If the lake falls another two feet, all diversions must cease. Noting the ecological value of a place and not simply the monetary value of the resources it holds, gives me hope that our view of nature is shifting towards a more ethical treatment of the biota and landscape we inhabit.

Owens Valley and Water Resources

I recently went on a class trip to Owens Valley and the Eastern Sierras to learn about water resources and the history of Los Angeles’ water supply. We started the trip by visiting Owens Lake, or what should have been Owens Lake. Since the operation of the Los Angeles Aqueduct in 1914 the flow of water into Owens Lake has been diverted to Los Angeles, and the lake has basically diapered. The City of LA had the power to divert the water of Owens Valley by buying most of the land in the valley and acquiring the water right associated with the land. It wasn’t until the 1980’s and 90’s that LA had to reintuduce some of the water back to Owens Lake for Dust control measures.

Later in the trip we visited Mono Lake and say the amazing Tufa. Mono Lake is a saline lake and home to thousands of migratory birds. The lake is also at historic lows similar to Owens Lake due to LA’s water diversions and ground water pumping. Yet due to the fact Mono Lake is bird habitat they have more protections and LA is required to divert less water until the level of the lake rises to a specified height.

The historic shoreline of Owens Lake.
Early morning trout fishing on the Owens River.
The Eastern Sierras at sunrise.
IMG_7326
Mono Lake, It’s for the birds.
Tufa, a calcium carbonate structure created from the reaction when calcium from natural springs interacts with carbonate present in the lake.

 

“I’ll just have itchy, watery eyes!”

Let’s start with a little comic relief…

While Jeff Foxworthy makes a funny joke with some exaggerated side effects caused from medications, sadly, he isn’t far from the truth!  You only have to watch about 15 minutes of tv in order to see a commercial advertising a new medication. The commercials always present the drugs as the quick-fix, miracle pill that will make that specific health problem disappear in a snap. The drug may be effective in treating the specific health concern, but the commercials fail to paint the whole picture of the medication. They  always save the potential side effects for the very end of the commercial and list them off at a barely comprehensible speed, usually ending in “and in rare cases may cause serious injury or death.”  As Jeff Foxworthy so candidly stated, “I’ll just have itchy, watery eyes.”

With the combination of pharmaceutical advertisements and uninformed media coverage of medications, most of the American population approaches prescription medication in one of two ways. They either blindly take whatever their doctor prescribes or their neighbor lets them try because it “worked wonders” for them, or they stay as far away from all medications because they just poison the body. As nurses, we have a great opportunity to step into both camps of thinking and help our patients (and family and friends) have a more accurate understanding of medications so that they can make informed decisions about their health.

For my informal survey, I decided to ask my mom about the medicines that she takes. Thankfully, she does not take any prescription medications and is very healthy. However, she does take some OTC medicines.

-Do you know the names of the medications you take? And why you take each of them?

“Yes, I take ibuprofen for joint pain and headaches. And I recently started taking melatonin at night to help me go to sleep. I very rarely take Tylenol with ibuprofen instead of melatonin. Ibuprofen is the same the as Advil and Tylenol is acetaminophen.”

-Do you know the potential side effects of those medicines?

“Well, ibuprofen can cause stomach bleeding or something like that so I have to take it with food and not on an empty stomach. I took it on an empty stomach when I was also sick and I had bad stomach pain after. Now I always take it with food. I don’t know about any side effects of melatonin; it’s a natural supplement.”

-Do you know if any of those medications interact with each other when you take them together?

“Well, for a long time I thought that ibuprofen and tylenol could not be taken at the same time, but I looked into it a bit and it seems like it is totally fine to take them together. I don’t know about the melatonin.”

I have talked with my mom about some of the medications she takes, so I was encouraged to know that she is understanding and retaining a lot of the information. Talking with her about melatonin reminded me that most people take vitamins and natural supplements without thinking twice about potential side effects or whether or not they even need it  because they do not consider it a medicine. I didn’t know much about melatonin (as a natural supplement) either so we looked it up and made sure it was okay to take with ibuprofen and was appropriate for her to be taking on a regular basis.

I think this was a good reminder for her as well to be more aware of the medications she is taking and gave her some specific key questions to ask before taking new medicines.

Remote medical support at home

As people live longer with chronic disease and depend more often on complex medication regimens at home, the burden of managing home therapy continues to fall, unassisted, on the patient and family. As I sat listening to my overwhelmed and tearful friend tell me about how her father ended up in the hospital for CHF exacerbation, I couldn’t get this out of my head. He had not been taking the increased dosage of one of his heart medications that the doctor had prescribed because the information had simply gotten lost in the mix. Though my friend typically helped her parents keep track of these things, issues with her own family came up, her brother tried to help but is not well versed in medical lingo… They had each done their best but before they knew it her father’s condition had deteriorated, and here we sat.

Unfortunately, programs and services designed to support patients in the management of their chronic conditions at home have not grown at the same rate as the complexity of the home regimens themselves. Case management in the hospital focuses on medical equipment, and home health nursing services catch those patients without adequate support at home, but where is the support for everyone else? My friend is the most medically literate family member involved in the care of her father and her understanding of the medications that he takes is limited to a general understanding of what it is for (e.g. heart, blood pressure, blood thinner), where to look on the bottle to find how much he should take.

What our healthcare system needs is more robust case management that works in association with the primary care provider and regularly checks in with patients living with chronic disease, to confirm that the patient is taking the right medications, at the right dosages. This service could be staffed by nurses trained in over the phone triage that can discuss with the patient, or primary caretaker, any questions regarding their current condition, and changes to home therapy regimen made at the previous doctor’s appointment. This service would compensate for the ever decreasing amount of time that doctors can spend with their patients, would decrease the number of turn-around admissions to hospitals, and provide support to the patient’s support network… which in the end would improve everyone’s quality of life.

 

Pre-Trip

Posted from Camarillo, California, United States.

Getting ready for the trip. Looking forward to a great trip with great people!