MANA Update

MANA has been wonderful, as usual, and has gone quickly, as usual. I've attended sessions on, teaching cervical exams in a humane way, using social media (like this one) to expand business or advocate for a cause (like I'm doing now), cultivating cultural sensitivity, and using storytelling to teach instinctual birth. I will use all of this new knowledge in teaching my nursing students, and in furthering my work at home with lactation, infant mortality, and humane maternity care. I'm off to have breakfast, stroll the beach (dip my toes in the ocean/bay one more time) and visit the Red Tent which is always a treat. I will also listen to Ina Mae give her keynote address this morning- which starts right about now...

Rebel with a Cause

I'm here in Monterey California at MANA 2009 sitting on white sand beaches, in temporate weather, contemplating my role in materal infant health in the United States. What mark will I leave on future generations of mothers and babies? I came here to see and hear my heroes in the cause, only to hear how overwhelmed they sound and defeated they sometimes feel. Still I must take up the charge. Morningstar's book, "The Power of Women" is making it's debut here at the conference. I make a solemn vow to myself, that next year, I'll be sitting at the author's table. People have begun to approach me about 'my work'. So far my work has been verbal and written, now I feel the universe telling me its time to get some skin in the game. I have an idea for a pilot program, to increase utilization of prenatal care for high risk women. I have to secure funding from somewhere, and I have to coax the powers that be to partner with me. Now that I sit on the FIMR board, I can use it as a jumping off place. I've been offered a leadership role on the Health Commission. There are lighthouses here- beacons of light and hope to ships lost in dark and dangerous waters. How do I shine a light on the darkness of infant mortality?

Doctor Dick

Okay, Even though I would run screaming from the facility if a physician handed me the following document, I still find something refreshing about his or her honesty. Most docs just say, "sure okay, we can try that" and then when labor hits they do whatever the hell they want.

A healthcare consumer posted this on another blog. She stated her plan to find another physician. Good for her.



DR. ________ "BIRTH PLAN"

Dear Patient:
As your obstetrician, it is my goal and responsibility to ensure your safety and your baby's safety during your pregnancy, delivery, and the postpartum period. My practice approach is to use the latest advances in modern obstetrics. There is no doubt that modern obstetrical advances have significantly decreased the incidence of maternal and fetal complications. The following information should clarify my position and is meant to address some commonly asked questions. Please review this information carefully and let me know if you feel uncomfortable in any way with my approach as outlined below.* Home delivery, underwater delivery, and delivery in a dark room is not allowed.* I do not accept birth plans. Many birth plans conflict with approved modern obstetrical techniques and guidelines. I follow the I follow the guidelines of the American College of Obstetrics and Gynecology which is the organization responsible for setting the standard of care in the United States. Certain organizations, under the guise of "Natural Birth" promote practices that are outdated and unsafe. You should notify me immediately, if you are enrolled in courses that encourage a specific birth plan. Conflicts should be resolved long before we approach your due date. Please note that I do not accept the Bradley Birth Plan. You may ask my office staff for our list of recommended childbirth classes.* Doulas and labor coaches are allowed and will be treated like other visitors. However, like other visitors, they may be asked to leave if their presence or recommendations hinder my ability to monitor your labor or your baby's well-being.* IV access during labor is mandatory. Even though labor usually progresses well, not too infrequently, emergencies arise suddenly, necessitating an emergency c-section. The precious few minutes wasted trying to start an IV in an emergency may be crucial to your and your baby's well being.* Continuous monitoring of your baby's heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion. This is the only way I can be sure that your baby is tolerating every contraction. Labor positions that hinder my ability to continuously monitor your baby's heart rate are not allowed.* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.* Epidural anesthesia is optional and available at all times. The most recent scientific data suggest that epidurals are safe and do not interfere with labor in anyway even if administered very early in labor.* I perform all vaginal deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It also provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.* Episiotomy is a surgical incision made at the vaginal opening just before the baby's head is delivered. I routinely perform other standard techniques such as massage and stretching to decrease the need for episiotomies. However, depending on the size of the baby's head and the degree of flexibility of the vaginal tissue, an episiotomy may become necessary at my discretion to minimize the risk of trauma to you and your baby.* I will clamp the umbilical cord shortly after I deliver your baby. Delaying this procedure is not beneficial and can potentially be harmful to your baby. * If your pregnancy is normal, it should not extend much beyond your due date. The rate of maternal and fetal complications increases rapidly after 39 weeks. For this reason, I recommend delivering your baby at around 39-40 weeks of pregnancy. This may happen through spontaneous onset of labor or by inducing labor. Contrary to many outdated beliefs, inducing labor, when done appropriately and at the right time, is safe, and does not increase the amount of pain or the risk of complications or the need for a c-section. * Compared to the national average, I have a very low c-section rate. However, a c-section may become necessary at any time during labor due to maternal or fetal concerns. The decision as to whether and when to perform this procedure is made at my discretion and it is not negotiable, especially when done for fetal concerns.

Spawn of the Devil or Angel of Destruction?

Josiah turned 3 last week. While he is cute and adorable, inquisitive and intelligent, we seem to be experiencing a greater volume than normal of broken electronic major appliances in our home, lately. It seems in the last couple of months he has broken our TV (poured water over it to 'wash' it), our computer (kicked it over in a fit a rage, hasn't worked since), lost an IPOD (last seen in his pudgy little hands), broke the IPOD port on our CD player, and has been implicated in the malfunction of several cell phones. We went to look at computers yesterday, and will budget for a replacement TV next month. Has he been sent to us as a plot by Satan to break all our stuff? Well even if that turns out to be the case, he's still a lot of fun to have around. His vocabulary increases every day, he's spoiled rotten, and still insists on sleeping in bed with us or one of his siblings. Potty training is optional, right? He's still in the throes of a Batman fetish, and insists on being Batman for Halloween. Later today we head to a local pumpkin patch so he can pick out some pumpkins. Despite how expensive having him around is turning out to be- we couldn't be more thrilled. Thankfully, he hasn't broken anything today.... wait... what was that crash???

Obituary

Our 17 year old cat, Indigo passed away quietly at home yesterday. We found her late in the afternoon on our bed where she had snuggled up to nap. She never woke up. When our son Greg was 14 (now 31), his friend found Indigo as a kitten abandoned in a box in an alley en route to our house. He heard her meowing and picked her up and brought her to us. She's been ours ever since.
She was a very wild kitten, earning herself the nickname "Crazyhead" She had 2 litters of kittens early in life, and then settled down to become the mellow stranger-shy cat we grew to love. Her secret to longevity? She was an indoor cat, who didn't like to over exert herself. Many years ago, she had to have surgery that cost us $1,000 and I told her she had to live at least until we paid off the bill. She happily complied. She was always good for a snuggle, loved a good head scratch and enjoyed a high quality of life up until the end. The day she died, I saw her last in the kitchen eating her morning meal of catfood and water, while the dog and our other cat, Carl, patiently waited their turns until she was finished. She was very arthritic and slow moving, but the other animals aways gave way for her. She was always the matriarch of our animal family and beloved by our human family. She will be missed.

Indigo "Crazyhead" Payne
date of birth: unknown
deceased: October 9, 2009

PS: People have asked where we got the name Indigo. At the time she came to us, I was reading Ntzoke Shange's novel, "Sassafras, Cypress, and Indigo" a story of 3 sisters. Indigo was a midwife. It seemed to fit. I think the name Crazyhead came from the baby of the family at that time, Evan.

The Spirit Catches You and You Fall Down

I've started reading one of the two books I purchased at the conference on cultural competency called, "The Spirit Catches You and You Fall Down: A Hmong child , her American doctors and the collision of two cultures." The other book was about medical missions. Spirit catches you is the well written assessment of what happens when a non-English speaking refugee family intercepts with the American healthcare system. It is a riveting story, though the author at times becomes bogged down in clinical analysis. I remember the Hmong refugees. I was a young teen in the 1980s when they seemingly 'invaded' the housing project where one of my aunts lived. They were quiet solitary people who kept to themselves. I could only imagine how foreign our world must have seemed to them. Could anyone have possibly chosen two more unalike populations to put together- Hmong refugees fresh from the mountains placed in the urban core housing projects with low income Americans, mostly African-American? Each group kept to themselves and there were few clashes, but only because there was no interaction. Each eyed the other suspiciously as I recall. In the book, the Hmong parents of the story present to the emergency room with a child afflicted by seizures. Since they don't speak English and this is prior to the time of having interpreters on staff- the doctors don't know what the problem is. It takes several visits, until the child is brought in still in the throes of a seizure, for them to figure it out. The book goes on to catalog the highs and lows of treatment for this child with all miscommunication and misunderstanding that accompanies their interactions. It is a fascinating read- amusing in some places, heartbreaking in others. It makes me want to work harder to impress upon my students the importance of taking the time to understand the health beliefs of the person for whom you are caring. It's also changed my mind about another thing. It is not enough to seek patient compliance as the highest goal for the nurse's efforts, but rather client collaboration. The healthcare consumer has to have buy-in. Clinicians and consumers must work together to create and individualized plan of care- this is the only way, in fact, that it can be individualized- the individual has to help create it. We in our authoritative cloak cannot arbitrarily decide what is best for someone else. For true healing, rather than merely curing, to take place, we need to involve the body, mind, and spirit of the client. All of these aspects of the person are embraced by culture. In the book, progress begins to be made, when a few astute clinicians, inadverdantly begin to ask some of Kleinman's Questions, such as what the child's illness means to the parents. I can't wait to finish this book.

What is Cultural Competency?

I attended a conference yesterday (what a shock right! Everyone must think I have a hidden trust fund to attend all these conferences, when really I'm just resourceful and I live in a metropolitan area that has lots of conferences to choose from). The topic was cultural competency. I attended because, 1. I think cultural incompetence feeds greatly into health disparities which greatly impacts the health of African-Americans and Latinos, and 2. I guest lecture on the topic and felt the need for more info, and 3. it was free to nursing students of the school I attend where I'm working on my masters.

What a lovely conference! It was hosted by INMED whose focus is international medical missions, so the focus was more on healthcare professionals dealing with clientele from other countries of origin, but as we all know there are plenty of American subcultures that are misunderstood by the majority of healthcare providers, whether those subcultures are characterized by race, class, religion, region, language linguistics, language dialect, health literacy levels or any other number of factors. The conference did an fairly nice job of pointing to the fact that healthcare is a 'foreign culture' unto itself.
(I have long been an ardent supporter of this philosophy. Healthcare has its own language, its own mode of dress, its own customs, power systems, etc. Since it is populated mostly by educated caucasians, their norms have become the norms of the this 'foreign culture' we call healthcare. So even caucasians entering the healthcare system to some extent have to step into this culture in the 'patient' role. Everyone else has that to contend with putting on the patient role plus whatever cultural divides exist, known and unknown.)

The sessions were on such topics as, 'Health thru the lens of culture,' Health beliefs and traditional health practices,' 'Health disparities in relation to cultural identity,' Defining culture and cultural competency,' and much more. Fabulous topics all. The most practical information was Kleinman's Questions which are 8 questions this researcher came up with for pulling out the health beliefs (or illness narrative as one speaker so eloquently put it) of the healthcare consumer- so if you learn to incorporate these questions into your history taking, it doesn't matter if the patient is from the same or a different culture than your own. Almost every speaker quoted Kleinman's Questions so google it for yourself to find out what they are. I'm incorporating them into my history taking lab for my students.

At lunch I approached a table of older caucasian gentlemen. (This is how I challenge myself now, to sit at a table of folks I don't know and suspect that I don't have much in common with.) After polite introductions we launched into an animated discussion on what cultural competency looks like in our individual practices. There was a surgeon (I think he was a cardiologist, but he never said), a homehealth case manager/manager who was a nurse, a home health physical therapist, and me, a nurse educator. The surgeon made the (for me) shocking but typical statement that it was enough that he was kind and polite to everyone he saw, that was his idea of cultural competence. I reminded him that he could very politely offend the hell out of someone by not understanding the customs or health beliefs of their given culture. As we talked more the nurse manager gave many excellent examples of how he ammended his care to the cultural needs of the client, but the surgeon really didn't get it. I told him I could 'blow his mind' with some examples of things he didn't know about his African-American client's health beliefs that he probably wasn't taking into account when he treated them. "Name me three," he challenged me. Only three? Sure.

1. Your African-American clients don't trust the healthcare system, and by extension don't fully trust you.
   
2. You are not the final authority for your African-American clients, you are at best a second tier authority on health and wellbeing.
3. Most if not all your African-American clients indulge in folk medicine practices that you are unaware of.

I don't know if nurse manager and I convinced surgeon of anything, but we gave him some food for thought. This is why I always try to sit with strangers over a meal. Good rousing conversation always is a possibility. There's nothing I love more than thrashing around ideas with good conversationalists. I also remind myself that as an African-American woman, my voice and my story is seldom heard, and others need the benefit of my healthcare narrative and perspective.

All in all a fabulous conference and time well spent.

Have you looked up Kleinman's Questions yet?