Dear Editor,

First, I would like to show gratitude for the article you published in American Nurse Journal, volume #19 on date April 2024 titled “Turning the tide.” This subject of health disparities among the maternal population in the USA is such an important and under-discussed topic. Not only is it imperative that we talk about how high the maternal mortality rate is in the United States I completely agree with you when you state the reason for these tragic outcomes is complex and multifactorial. There is no doubt socioeconomic status is a huge factor and might be quite cumbersome for us as nurses to take on the challenges of tackling these disparities.

However, we can do our part by continuing to be our patients’ biggest advocates while also teaching them to self-advocate. Many minorities feel like their complaints or concerns are not being taken seriously. For instance, I look at cases like Serena Williams, where she kept complaining that she was not feeling well, and doctors disregarded her concerns. They figured she was being overly concerned as a new mom. She fought and continued to advocate for herself and ended up finding out she had a potentially deadly blood clot.

This is someone with a high-profile status and significant financial resources. Just imagine the predicament of an average person like me or the uninsured/underinsured person. I think it’s amazing we have The Black Maternal Health Momnibus Act! This is a huge step forward. Nurses should be more involved with their state to help pass legislation so more policies and procedures can be implemented. We as health professionals must do our part in reducing the maternal/infant mortality rate among Blacks and Hispanics in the USA.

Derronica Collins
Jersey City, NJ

There were 97 reported cases of measles in the first quarter of the year, the Centers for Disease Control and Prevention (CDC) reports, representing nearly a third of all cases since the beginning of 2020.

“Risk for widespread U.S. measles transmission remains low because of high population immunity,” the CDC wrote in a report released last week. “However, because of the increase in cases during the first quarter of 2024, additional activities are needed to increase U.S. routine measles, mumps, and rubella vaccination coverage, especially among close-knit and undervaccinated communities.”

The CDC began analyzing reported measles cases after two outbreaks in 2019 in unvaccinated communities in New York. Its report noted 338 confirmed cases from Jan. 2020 to March 28, 2024. The jump in cases in the first quarter of this year represented a seventeenfold increase of the mean during the first quarter of the previous three years. CDC has reported an additional 24 cases since the end of March, bringing the year’s total to 121 as of April 11.

The CDC notes that 93 cases from the first quarter were directly imported from other countries, either from foreign visitors (34) or U.S. residents (59), almost all of whom were either unvaccinated or whose vaccination status is unknown. The increase in measles cases globally and the decline in vaccination rates in this country make for a risky mix.

“Increasing global measles incidence and decreasing vaccination coverage will increase the risk for importations into U.S. communities, as has been observed during the first quarter of 2024,” according to the report, “further supporting CDC’s recommendation for persons to receive MMR vaccine before international travel.”

Research comparing bacteria in the microbiome – those colonizing our noses, skin and other areas of the body – with the bacteria that cause pneumonia, diarrhea, bloodstream infections and surgical site infections shows that the bacteria living innocuously on our own bodies when we’re healthy are most often responsible for these bad infections when we’re sick.

Our newly published research in Science Translational Medicine adds to the growing number of studies supporting this idea. We show that many surgical site infections after spinal surgery are caused by microbes that are already on the patient’s skin.

Surgical infections are a persistent problem

Among the different types of heath care-associated infections, surgical site infections stand out as particularly problematic. A 2013 study found that surgical site infections contribute the most to the annual costs of hospital-acquired infections, totaling over 33% of the $9.8 billion spent annually. Surgical site infections are also a significant cause of hospital readmission and death after surgery.

In our work as clinicians at Harborview Medical Center at the University of Washington – yes, the one in Seattle that “Grey’s Anatomy” was supposedly based on – we’ve seen how hospitals go to extraordinary lengths to prevent these infections. These include sterilizing all surgical equipment, using ultraviolet light to clean the operating room, following strict protocols for surgical attire and monitoring airflow within the operating room.

Still, surgical site infections occur following about 1 in 30 procedures, typically with no explanation. While rates of many other medical complications have shown steady improvement over time, data from the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention show that the problem of surgical site infection is not getting better.

In fact, because administering antibiotics during surgery is a cornerstone of infection prevention, the global rise of antibiotic resistance is forecast to increase infection rates following surgery.

BYOB (Bring your own bacteria)

As a team of physician-scientists with expertise including critical care, infectious diseases, laboratory medicine, microbiology, pharmacy, orthopedics and neurosurgery, we wanted to better understand how and why surgical infections were occurring in our patients despite following recommended protocols to prevent them.

Prior studies on surgical site infection have been limited to a single species of bacteria and used older genetic analysis methods. But new technologies have opened the door to studying all types of bacteria and testing their antibiotic resistance genes simultaneously.

We focused on infections in spinal surgery for a few reasons. First, similar numbers of women and men undergo spine surgery for various reasons across their life spans, meaning our results would be applicable to a larger group of people. Second, more health care resources are expended on spinal surgery than any other type of surgical procedure in the U.S. Third, infection following spine surgery can be particularly devastating for patients because it often requires repeat surgeries and long courses of antibiotics for a chance at a cure.

Over a one-year period, we sampled the bacteria living in the nose, skin and stool of over 200 patients before surgery. We then followed this group for 90 days to compare those samples with any infections that later occurred.

Our results revealed that while the species of bacteria living on the back skin of patients vary remarkably between people, there are some clear patterns. Bacteria colonizing the upper back around the neck and shoulders are more similar to those in the nose; those normally present on the lower back are more similar to those in the gut and stool. The relative frequency of their presence in these skin regions closely mirrors how often they show up in infections after surgery on those same specific regions of the spine.

In fact, 86% of the bacteria causing infections after spine surgery were genetically matched to bacteria a patient carried before surgery. That number is remarkably close to estimates from earlier studies using older genetic techniques focused on Staphylococcus aureus.

Nearly 60% of infections were also resistant to the preventive antibiotic administered during surgery, the antiseptic used to clean the skin before incision or both. It turns out the source of this antibiotic resistance was also not acquired in the hospital but from microbes the patient had already been living with unknowingly. They likely acquired these antibiotic-resistant microbes through prior antibiotic exposure, consumer products or routine community contact.

Preventing surgical infections

At face value, our results may seem intuitive – surgical wound infections come from bacteria that hang out around that part of the body. But this realization has some potentially powerful implications for prevention and care.

If the most likely source of surgical infection – the patient’s microbiome – is known in advance, this presents medical teams with an opportunity to protect against it prior to a scheduled procedure. Current protocols for infection prevention, such as antibiotics or topical antiseptics, follow a one-size-fits-all model – for example, the antibiotic cefazolin is used for any patient undergoing most procedures – but personalization could make them more effective.

If you were having a major surgery today, no one would know whether the site where your incision will be made was colonized with bacteria resistant to the standard antibiotic regimen for that procedure. In the future, clinicians could use information about your microbiome to select more targeted antimicrobials. But more research is needed on how to interpret that information and understand whether such an approach would ultimately lead to better outcomes.

Today, practice guidelines, commercial product development, hospital protocols and accreditation related to infection prevention are often focused on sterility of the physical environment. The fact that most infections don’t actually start with sources in the hospital is probably a testament to the efficacy of these protocols. But we believe that shifting toward more patient-centered, individualized approaches to infection prevention has the potential to benefit hospitals and patients alike.

Dustin Long, Assistant Professor of Anesthesiology, School of Medicine, University of Washington and Chloe Bryson-Cahn, Associate Professor of Allergy and Infectious Diseases, School of Medicine, University of Washington

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Simply asking about a veteran’s service can provide validation. PsychArmor’s 15 Things Veterans Want You to Know course can help healthcare providers become more culturally competent.

1. Not all veterans are soldiers. The U.S. military has five branches: Army, Navy, Air Force, Marines, and Coast Guard. Each has its own purpose, jobs, rankings, and uniforms. Only army personnel are soldiers.
2. Reserves are part of the military—all branches have reserves. Part-time soldiers with civilian jobs train once a month and 2 weeks per year, are always ready to serve when called, and face unique challenges.
3. Not everyone in the military is infantry. In 2023, there were 1.3 million active-duty military personnel and 750,000 reserve military personnel in the United States. Their jobs range from communications to cooks, doctors, mechanics, and musicians, and they receive specialty training that can last from months to years.
4. The military has leaders at every level in the chain of command. Every branch of a business has a unique ranking structure with different types of leadership. Veterans prioritize taking responsibility and accountability for others, putting others first.
5. The military is always on duty, ready 24/7. They can be called back to duty anytime, even on leave. This can cause disruptions in family plans.
6. Appearance and conduct are essential. Military members must be physically fit and ready at all times. They’re held to a high standard of conduct, including how they should appear in uniform. They’re accountable by law and can be convicted for disobeying.
7. Not all killed someone—and those that did don’t want to talk about it. This is a question that should never be asked.
8. Not all have PTSD—combat can be traumatic, and so can being away from their loved ones.Most veterans who experienced a traumatic event have recovered and are doing well. Individuals respond differently. Providers should ask veterans about the best and worst days of their military experience.
9. Invisible wounds do not make a veteran dangerous. PTSD, traumatic brain injury, depression, and substance use disorders are actual injuries. They’re not a mental illness or a psychiatric condition. They deserve to be treated the same as visible wounds. Veterans with invisible wounds aren’t prone to become dangerous or violent.
10. It takes a lot of work to ask for help. Military personnel are encouraged to be independent and put others first. They were trained to be emotionally and physically perfect.
11. Military service changed them—the change is permanent and needs to be accepted. As with all experiences, we adapt and change, and military service is no different.
12. They differ in how much they identify with the military after they leave active duty. Military experience varies from person to person and day to day. Military experiences changed them.
13. Their families served with them. Military families often experience separation from loved ones, making it difficult to establish roots and relationships. They have to be adaptable and flexible, and families take on additional responsibilities while their loved ones are away. When veterans return home, they sometimes feel a sense of displacement.
14. They would die for each other and their country. Thank them for their dedication to freedom.
15. They all sacrificed for one reason: To serve something more important than themselves—their country. They are honored and committed. They define our culture. Some were drafted. Some enlisted. They all served for us.

Military service has a direct correlation with the illnesses and symptoms that veterans face at the end of their lives. Evidence indicates that exposure to environmental and chemical hazards during service has caused various health issues, such as cancer, lung diseases, and neurological disorders. A veteran’s health is affected by the time and place they served.

The lack of treatment options led to mental illness, paraplegia, lung problems, blindness, and amputations among World War I veterans due to the absence of research on medications in the early 1900s.

World War II lasted from 1941 to 1945, with veterans today being over 90 years old. Antibiotics were discovered in the mid-1930s, saving many lives. Veterans faced harsh weather conditions and unique health risks, including exposure to mustard gas, infectious diseases, frostbite, radiation, and nuclear chemicals.

The Korean War, from 1950 to 1953, was extremely cold. As many veterans age, they develop complications from the cold weather, such as diabetes and peripheral vascular disease. Unique health risks includeperipheral neuropathy, skin cancer, arthritis, ambulation disturbances, and nocturnal pain.

Veterans serving during the Vietnam War from 1962 to 1975 are 60 to 80 years old today. The growing list of unique health risks include PTSD, depression, substance use, hepatitis C, reactions to Agent Orange, and skin diseases from poor hygiene and herbicides. The Vietnam War was viewed as a failure because the military didn’t accomplish its goal. Veterans weren’t welcomed back formally to the United States, causing an increase in mental health illnesses.

The Persian Gulf War was a brief military operation that began in 1990 and ended in 1991. Although one of the shorter conflicts, many people were exposed to toxic agents and smoke, and they experienced long-term side effects from preventive medications and immunizations. Unique health risks include chronic fatigue, muscle and joint pain, fibromyalgia, forgetfulness, headaches, rashes, asthma, depleted uranium, and amyotrophic lateral sclerosis.

Operation Enduring Freedom and Operation Iraqi Freedom took place in Afghanistan and Iraq, respectively. Veterans who served in these operations encountered numerous health risks, such as exposure to contaminated water and air pollution and infectious diseases. Many also experienced mental health issues. They faced unique risks such as cold injuries, high altitude illnesses, vision loss, and exposure to depleted uranium.

It is important that we acknowledge the sacrifices that our veterans have made for our country. We need to strive to provide them with the best care and support possible, and that includes understanding their unique experiences and challenges. By being culturally competent and respectful, we can improve the lives of our veterans and show them the gratitude they deserve for their service. Let’s honor our veterans by giving them the care and support they need, and by remembering their sacrifices.

Angie Meyer is a home health and hospice clinical manager at Gundersen Palmer Lutheran Hospitals & Clinics in West Union, Iowa.

References

National Hospice and Palliative Care Organization. We Honor Veterans: Service-related diseases, illness & conditions. wehonorveterans.org/resource-library/service-related-diseases-illness-conditions

PsychArmor Institute. 15 things veterans want you to know. va.gov/HEALTHPARTNERSHIPS/docs/PsychArmor_15ThingsCourseNotes.pdf

An analogy that I often use to describe my own experiences in tough caregiving situations is to say, “I have a fork in my eye.” I feel distressed by what I’m seeing or feeling. Having a fork in the eye would be painful, irritating, and obstruct the ability to see. Imagine my surprise when Mrs. Bunge gave me one of her serving forks that she had on display as a symbol of welcome, sharing food, and giving.

She didn’t know that when I think of “fork” it’s usually in my eye. Looking through her lens of “welcome, sharing food, and giving,” I reflected that her gift was bigger than the fork itself. Provision 3 (Statements 3.5 and 3.6) of the American Nurses Association Code of Ethics with Interpretive Statements states that we, as nurses, must address questionable practices, including impaired practices. A “fork in my eye” means that I’m impaired; my physical condition isn’t my normal. I may not be able to see clearly. My care for others is in jeopardy. Receiving a fork as a gift, with the intention of conveying “welcome, sharing food, and giving” was a reminder to me, from a trusted colleague, that I matter. My well-being matters and I can and must do something about it if I’m in distress.

Messages and feedback come from many spaces, places, and people. Looking out for each other makes a difference. Listening to the messages our colleagues share matters. Be your own nurse.

Amy E. Rettig, DNP, MALM, MSN, BSN, RN, ACNS-BC, PMHNP-BC, provides nursing care for both professional and non-professional caregivers. She presents, publishes and studies well-being (developing the caregiver within) from the perspectives of holism, caring relationships, and systems.