A Nurse-Teacher’s Thanksgiving Reflections

By: Fidelindo Lim, DNP, CCRN
Clinical Assistant Professor
New York University College of Nursing

         The nursing profession continues to evolve. My role as a nursing faculty allows me the privilege to see future nurses embrace what is yet to be, beyond the linear columns of the nursing care plan. What I see students do in clinical, outside the bulleted educational outcomes, are subtle reminders that caring cannot be truly taught in school, they simply manifest as the natural, almost evolutionary tendencies of women and men in nursing. Recently, a student of mine spent a good hour braiding the hair of her patient who was diagnosed of stage 4 ovarian cancer – two days earlier. The patient had bilateral above knee amputation and will probably never set foot in a hair salon, but the student brought a semblance of normalcy to a life thrown off balance. Outside the room, I could hear beauty parlor reflective conversation between the student nurse and the patient. Suddenly, cancer seems insignificant. When the patient examined her neatly arranged corn rows in front of the mirror, we all saw life, not imminent death. I often recall this story to myself to remind me that the very essence of nursing is human bonds. As a faculty, I partner with my students not simply to teach them learn the ropes but to strengthen nursing’s umbilical connection with life – till the end.

This Thanksgiving…

Think and thank those who continue to move us in positive ways, including the patients who enrich our nursing practice simply because their lives have crossed with ours – by accident or incident.

Note:  The above essay was chosen one of the 12 winners of Inspired Nurses contest through Lippincott Solutions. The essay will be featured in the 2016 Lippincott Publisher calendar.

Are we over-treating fever?

By Chen, Leon MS, RN, AGACNP-BC, CCRN, CPEN

Nurse Practitioner, ICU – Memorial Sloan Kettering Cancer Center in NYC

“You took away her fever. You raised her spirit.” Those words echoed to the tune of soft pleasant music in the new Tylenol commercial. The uplifting, alleviating effect of antipyretics can be attested by many who have suffered from a fever at one point in their life. I still remember in simulation labs, we’re quizzed on the temperature considered to be febrile and our expected immediate follow-up answer of “I’ll administer some Tylenol”. Treating fevers has been drilled into our core medical knowledge. But in actuality, our ability to mount a fever stem from an evolutionary need to survive from an infection and to take it away may not be beneficial.

Our body’s ability to generate heat actually produces a hostile environment for bacterial growth. In vitro studies have shown that pathogen growth is stunted at a core temperature above 37 degrees Celsius. (1) In clinical studies, the patients who are able to generate a febrile response have been associated with lower risk of mortality. (2)(3) Of course, fever has its downsides, including increasing metabolic demand, oxygen demand and in children, potential febrile seizures. So what are we to do? Do we treat the fever or do we not treat the fever? And what do we do about fever in the ICU population? To help us answer the question, the Acetaminophen for Fever in Critically Ill Patients with Suspected Infection study (HEAT trial) has just been published by New England Journal of Medicine. In the study, researchers randomized 700 ICU patients with fever (body temperature>38 degrees Celsius) to either receiving IV Tylenol or placebo every 6 hours until ICU discharge, resolution of fever, cessation of antibiotics, or death. The primary outcome was ICU-free days from randomization to day 28 on follow-up.

The result of this study showed that early administration of Tylenol to treat fever due to probably infection had no effect on the number of ICU-free days. (4)This study adds on to the increasing number of negative trials showing that less intervention or more conservative management strategies are acceptable and does not cause harm. Given that ICU patients are already at risk for organ dysfunction in the setting of polypharmacy and their critical illness, I hesitate to further burden their system with Tylenol. Therefore, in patients with suspected infection, antibiotic is the ultimate treatment and antipyretics should only be an afterthought.

References

1. Prescott, Lansing M, John P. Harley, Donald A. Klein, Gloria Delisle, and Lewis Tomalty. Microbiology. Boston, Mass: WCB/McGraw-Hill, 1999. Print
2. Weinstein MP, Iannini PB, Stratton CW, Eickhoff TC. Spontaneous bacterial peritonitis. A review of 28 cases with emphasis on improved survival and factors influencing prognosis. Am J Med. 1978 Apr;64(4):592-8.
3. Ahkee S, Srinath L, Ramirez J. Community-acquired pneumonia in the elderly: association of mortality with lack of fever and leukocytosis. South Med J. 1997 Mar;90(3):296-8.
4. Young et al. Acetaminophen for Fever in Critically Ill Patients with Suspected Infection. N Engl J Med. 2015 Oct 5. [Epub ahead of print]