Search for tag: "scope"

Mitch: For University of Utah Health and The Scope Presents, this is Clinical.

I'm Mitch Sears, producer for The Scope Radio, and you're listening to Episode 8 of our series "Unit On The Brink." This is a multi-part story that is told in order. And if you haven't listened to our previous episodes yet, we highly recommend you go back and start with Episode 1 in your podcast app.

"Unit On the Brink" is a story that intimately explores the firsthand experience of medical frontline workers during the coronavirus pandemic. The stories that are shared are raw and occasionally deal with personal trauma. Listener discretion is advised.

For nurses and providers working in intensive care, death is something that comes with the vocation. After all, medical workers in ICUs across the nation are tasked with treating the sickest and most severely injured patients, yet the severity of the COVID-19 virus and the safety protocols enacted to contain its spread was testing the emotional limits of even the most battle-hardened veterans in the medical intensive care unit, people like charge nurse Alisha Barker who had served through the H1N1 pandemic of 2009.

Throughout the winter surge, COVID death rates for Utah were increasing. Despite new and refine treatment procedures and protocols showing real promise in improving survivability, the sheer number of new SARS-CoV-2 cases were filling up Utah hospitals with extremely ill patients.

Where Utah had seen a statewide average of 1 to 5 daily deaths between March and August, those rates more than doubled throughout the cold winter months, with a high of 36 Utahns passing from the virus January 26, 2021.

We now return to the morning of December 10, 2020. Shift change in the medical intensive care unit, the frontlines during the winter surge of cases in Utah, to share what it was like for frontline workers that found themselves bidding farewell to more patients than many had ever had to before and how they found the courage and resilience to carry on and maintain hope through the dark winter months.

Presented by Clinical and written and reported by Stephen Dark. This is episode 8, "Saying Goodbye."

Stephen: By 7:40 a.m. that December 10th morning at the University Hospital Medical ICU, the charge nurse had finished going through the roster of patients. Nurses had chosen their patients for the day shift, and all that was left was to send them on their way.

Nurses and healthcare assistants fanned out to talk to the night shift about the patients they were taking over for more detailed insight into how the night had gone. The transfer of care complete, the unit went eerily quiet for a while as nurses busied themselves attending to their patients.

Then, at 10:00 a.m., proning began. That's when sedated patients on ventilators are turned over. Proning helps patients with their breathing because it aids delivery of oxygen to parts of their lungs that aren't otherwise reached when they're on their backs.

But staff knew that as more patients needed to be proned, some more of them were edging closer to not coming back from the brink that COVID-19 had pushed them to.

Being put on a ventilator, after all, was in no way a guarantee that they would survive the virus, but rather a reflection on how much damage the virus had inflicted on their lungs.

As more COVID-19 cases filled up the MICU's roster, staff had to organize into groups to do seemingly endless numbers of exhausting pronings. For larger patients in each of the equipment-crowded rooms, that means three nurses each side, along with the primary nurse or attending provider reading the protocols, and the respiratory therapists, if available, managing the patient's airway.

The physical energy and mental concentration that goes into each half-hour proning, especially when you have to repeat the process at the end of the shift, leaves staff drained.

One shift, charge nurse Alisha Barker recalls it was simply overwhelming in the number of patients who had to be proned.

Alisha: This was a couple of weeks back where it was a hellacious shift and we had a lot of patients to prone or unprone at the beginning of the shift, and then we had to flip the patients back over, like prone them again at the end of the shift. We were just exhausted, and it's 5:30 p.m., 6:00 p.m. We're all a bit delirious by this point, just going from room to room to the next room to prone these patients.

Stephen: As they moved from room to room to room end of shift, the mood was becoming increasingly brittle. Physical, mental, and emotional exhaustion had already exacted so greater toll on Barker's colleagues. She had to find a way to rally the troops to get them through these last pronings.

Alisha: So by the third patient, we're proning and we're all just like almost in tears. We don't want to be doing this anymore. I got the bright idea to start reading the instructions in a different accent, and it completely changed the mood of the room.

And everybody was talking back to me in their own version of the Russian accent that I was doing, and there was no other place in the world that I would have rather been in that moment than in that room with my coworkers, because we turned a very dismal, miserable situation into something that was really, really fun.

Stephen: Caring for a patient who can't communicate because they are sedated with a breathing tube down their throat leads some nurses, like charge nurse Cat Coe, to worry that they are losing sight of who they are caring for because of the very nature of the treatment they are called on to provide.

Cat: I think it's more the nature of the disease makes it pretty impossible for us on the MICU because a lot of them desat if they talk. So that means that basically their blood oxygen levels go dangerously low if they talk or eat or sit up or, God forbid, stand up. So I think it is hard to form relationships with them when some of them really can't talk without desating.

And this is not just with COVID, but I think in the ICU in general, it can be very hard because the patients are so sick that they can't communicate very well. It can be very hard to have any concept of what they are like as a human being outside of the hospital. And I think that that can actually be dangerous for a nurse to stop seeing a patient's humanness. You know what I mean?

Stephen: Nurses facilitating family members by using an iPad to allow them to talk to their sedated, intubated loved one can be one way of getting around relatives not being permitted to visit COVID patients due to safety policies.

But, Coe says, FaceTiming can also open the door to secondary trauma when it comes to being the only physically present witness to someone's death while assisting relatives in saying goodbye virtually.

Cat: Witnessing FaceTime conversations that would normally be a private conversation with families around the patient's bed, we're now facilitating these conversations and oftentimes having to stay in the room to deal with whatever technical difficulties. Or if it's a Zoom meeting, admitting another person to the meeting, or whatever. And we're witnessing these goodbye conversations or the families trying to get the patient to engage in a "Do you want to keep going?" sort of conversation and/or decision.

I think being in earshot of that often these days is just heavy. It's sad. It's so sad to see these families on FaceTime not able to touch their loved one and trying to figure out what is the best thing to do for them.

Stephen: Nurse Megan Diehl has also struggled with the realities of supporting relatives through the process of shifting a patient to comfort care when those relatives can only be present virtually. Helping loved ones say goodbye online, she says, as difficult as it is for them, is uniquely challenging for nurses who have to attend to facilitate these farewells.

For weeks, while a patient has been sedated and on a ventilator to battle the pulmonary ravages of the virus, they have been reduced to a silent slumbering form. Suddenly, in their last moments of life, as families say goodbye, the nurse learns who the patient was and how much they mattered to their loved one.

Megan: Being on a FaceTime call with a family, they will talk about the type of person that their loved one is, or they'll share stories. And it's different with each patient, but a lot of patients that I've done FaceTime calls with while they're saying goodbye . . . Death takes a little bit of time sometimes, and so we stay there the whole time to be able to give medications and do things and, with FaceTime, make sure the camera is pointed the right direction and things like that.

And they'll sit there and talk through stories about, "Oh, so-and-so, remember when we did this?" or talk about other family members that have also passed, like, "Oh, when you see grandma, you guys can do this together."

Stephen: If a patient up to that point has been a mix of numbers, heart rate, ventilator settings, and drug administration, all the medical information that has to be monitored to assess their health, suddenly all that falls away.

Megan: But it turns it from looking at those things into looking at the person, and it kind of takes all those numbers and things away. So you don't have to worry about any of that other stuff as well, which is part of it. When someone is passing away, you don't care what their heart rate is doing because you don't have to fix it. You don't care about ventilator settings because you're not going to add oxygen. You're not going to intervene and do treatments.

So instead of thinking about what treatments you can do, you don't have to think about that. You just think about whether or not they're comfortable and then you listen to the family. I think it's that, taking away everything else and making them more of a person, that makes it really hard.

You have to displace yourself from it almost because otherwise you can't handle it. Especially if you're in a PAPR, which we usually are. If you cry in a PAPR, you can't get to it. There's no sticking a tissue up underneath it and wiping your tears away. You're just crying, so it's so awkward. And then you don't want the family to see you crying because you're supposed to be strong for them too.

Stephen: Key to these online farewells are the stands on which the iPads rest.

Megan: We have some now that are on little stands and I usually try to get one of those. Or if it's something like that, I try to get one that I'm not holding because if you need to give medications or do anything, you want to have your hands free and not be like, "I'm going to lay you down for a second. Hold on."

So there's a little stand with the wheels on it and it has a bendy arm. And so you set it up and get them to where they can see the patient. And we'll call in a couple of different people, so it's three or four different little boxes on the screen, and then they're talking to their loved one and telling stories about them and telling stories about them.

Stephen: It's a delicate virtual process, trying to bring the family as close to the patient as possible.

Megan: So if the family can't be there, which usually they can't, we'll take the breathing tube out. Everything is turned off. We can put the monitor so where we can see the numbers, but it's not going to beep at us and make noises and everything because you don't want to distract from the moment.

And then I try to get to where they're just looking at their family member, like pretty close to their face. I don't usually do a full body. You want them to be close enough to see them.

Stephen: Relatives sometimes ask a Nurse us to physically connect with their loved one. Hold their hand, comb back a lock of hair from their temple, touch their cheek so they can say goodbye to them in a physical sense, leaving the nurse as the most intimate witness to their relative's departure.

Megan: It's things like that. The family will ask you to do things because they can't. And so you kind of have to step in and be there if that's what they want from you. Other people will just talk and you just tell them . . . you walk them through the steps of what's going to happen, how things are going to go. I always tell them, "If you think they look uncomfortable, let me know. We can give more medication."

Stephen: In such an intimate, painful space, a nurse finds herself a spectator to a farewell that feels almost unbearable.

Megan: It just breaks your heart to see these people. It's just us. It's a nurse there and then their family talking to them, which is better than nothing, but I can't imagine saying goodbye over a FaceTime call, being so far away or giving that to someone else to be there while my loved one died.

Stephen: In the face of so much trauma and so many patients' deaths, many nurses have found themselves for the first time seeking help. Whether that has meant connecting with the University of Utah's Resiliency Center or an independent therapist, Barker stresses how important being straight with yourself and others about your mental health needs has been during the pandemic.

Alisha: It's more so how are we dealing with the day-to-day? How are we getting through each day? And I will have some thoughts about that. How am I going to be when this is all over? I don't think there's anything wrong with needing to seek help from outside sources, whether that's therapy or medications or a combination of different resources. I think there's absolutely no shame.

And I think that one of the positives of this is that mental health will be more accepted and regarded and there will hopefully be less shame with people having mental health issues, being open about them, and dealing with them.

Some of the most meaningful conversations that I've had with my coworkers lately have been about being honest about how we're really feeling and how we're doing and how we're coping. And I feel like it benefits everybody when you are honest about how you're really doing and the things that you are doing to help cope with it.

Stephen: Simply through the process of reaching out for advice, for help, for sounding boards to answer her own doubts, Diehl found colleagues in the same troubled place as her.

Megan: I don't know. You have to step back and analyze yourself more than you did before. So I came to a point a couple weeks ago where I was like, "Maybe I need to start talking to someone. Maybe I need to start thinking about therapy or thinking about a way to figure out how to organize my emotions and how to deal with some of the stuff that I'm going through."

And I talked to another one of my coworkers about it because she was at that point. I had texted her about something and she had kind of let it out to me that she was not feeling okay emotionally. She told me that she had found someone to talk to that she really liked. And so I've started to try to reach out and find someone to talk to as well.

I reached out to a nurse we used to work with who was really open about going to therapy, and this was pre-COVID. I reached out to her and I was like, "How did you find someone that you felt comfortable talking to?" She gave me a bunch of information and she said, "There have probably been 10 other MICU staff that have reached out to me about this."

Stephen: Those last eight months taught many nurses that the defenses of gallows humor and camaraderie was simply no longer adequate to deal with the added stresses of the pandemic, particularly when it came to witnessing another way of saying farewell to a patient by a loved one that in some senses was even more grueling than FaceTiming, says Cat Coe.

Cat: I think the part that is still really heavy is seeing the families and just seeing them . . . if it's a COVID patient, they can't go in the room. I think it's one now that is allowed to stand outside the room while the patient is passing away, and seeing them have to do that is really heartbreaking.

I often put myself in their shoes and think how hard it would be to stay outside the room and how sad I would be to watch my mother, father, brother, whoever, pass away alone. It's heavy. I think a lot of us are going to therapy right now.

Stephen: One shift when the pandemic surge was pressing down on the MICU, Coe experienced an unfortunate personal record. She accompanied three patients down to the morgue, two of them having died from COVID-19 complications.

Cat: So there were I think two patient transporters, and they were super nice. I mean, they were just like, "Wow, we'll be back, and we'll be back." I don't know. I mean, it's part of the job. We go to the morgue a lot as MICU nurses. We have one of the highest death rates in the hospital, if not the highest, and we're all very familiar with the death packet.

We've had nurses float to us before, like nurses from other units, not familiar with the death packet or haven't had to fill it out in a year and a half or something, and we're all like, "Welcome to MICU."

Stephen: Charge nurse Alisha Barker finds a sense of comfort in the process of escorting a patient on their final journey.

Alisha: It's a very strange journey. I never have gotten used to it in my 13 years of doing this job. There are two transporters who bring a special cart up and we place the patient's body in what's called a post-mortem bag. And we place them on the cart and then we put a sheet over the cart.

So you wouldn't necessarily really know what it was if you were just a lay person walking through the hospital and you saw this cart with a sheet over it being pushed by two people. And then it's followed by the nurse because you've got to go and provide some paperwork and log the patient into the morgue.

Stephen: For Barker, each time she goes to turn away from having brought a patient to this way station before the journey that will lead to their final resting place, she can't quite let go.

Alisha: It's weird. You leave them there, and I always have this hesitation when you leave. Once you do your paperwork, you can leave and the transporters will take care of that patient's body from there. They just will put it in a holding area until the funeral home that the family has selected comes to pick the patient's body up.

And I always have this weird hesitation. It's almost like I'm dropping my kid off to school and I want to stay and look at them through the window or something, or the doorway. There's a weird hesitation there, and you just kind of have to take an inhale and an exhale and release and walk back to the unit.

Stephen: By the beginning of February 2021, like an eternally building tsunami that had finally crushed down onto land only to begin to recede leaving so much damage in its wake, the numbers of new daily infections began to drop along with the numbers of new hospitalizations.

The healthcare system, all its providers and nurses, both ICU and general floor, felt the first signs of pulling back from a brink that at moments had seemed close to, but never quite did, overwhelm it. Not that things would ever be quite the same, including at the MICU where familiar faces had departed or announced their decision to move on.

Charge nurse Cat Coe resigned, her last shift on January 2. She left for a change of pace working at U of U Health's ski injury clinic at the Snowbird Resort. There, she could continue working in critical care, but with the added bonus of backcountry skiing before work and hill laps during her lunch break.

Charge nurse Alisha Barker said she too was leaving in April to pursue her ambition of becoming a nurse anesthetist. If there's one thing that COVID-19 taught her, it's that now is the time to live your dreams.

For those that remain at the MICU, like newly appointed charge nurse Megan Diehl, they look forward to that growing glint of light on the horizon when the pandemic can finally be declared under control.

That December 10 morning, as the safety briefing heralded yet another change of shift, Diehl prepared to wrap up on B50. She considered the impending ramifications of vaccinations both soon and long term, and yet still she managed to joke.

Megan: Maybe. It seems so far away, because they say we're getting a vaccine, but that's only June or July maybe and that's so far away. So I don't know. Maybe eventually we'll be back to floating all over the hospital and complaining about floating instead of complaining about COVID. I don't know.

Stephen: And for some nurses, like 23-year-old Reagan Lowe, who began her career as a nurse in the MICU in May 2020, there are personal celebrations to look forward to. On May 1, 2021, she's getting married at the Highland Gardens in Utah County. Her fiancé is an electrical engineer and he's always careful, she says, to pay attention to how she's coping with work.

Reagan: Sometimes it's kind of hard to describe things the way he . . . like, when he describes his job and the math he has to understand, it goes straight over my head. And it's the same when I'm talking about certain procedures and situations and trying to explain. But also, it's nice to just . . . he's a break from the COVID. A breath of fresh air. It's kind of nice to have someone that just doesn't feel it and see it the same way.

Stephen: Whether it's in Lowe's commitment to her marital future as well as a nurse or Barker's decision to realize her long-held dreams, it's the resilience of the human spirit in the face of adversity that lingers most in the mind after months of talking to nurses at University Hospital's Medical ICU.

But there's a sense in something that charge nurse Barker argues that speaks to nurses, not only at the MICU, not only in University Hospital and so many other clinics and hospitals within The U's system, but indeed nurses across the globe. Even at the lowest points of the pandemic, she says, she and her colleagues were still able to find the strength to go on.

Alisha: Where you can find resilience in the pit of despair, in the bottom of feeling like you absolutely can't go on, and then all of a sudden you're laughing and having a great time, I'm like, "Wow, that's a miracle." That's a miracle of the human spirit, I think. And I hope that my coworkers can recognize that.

Yes, it's very hard and there are things that aren't fair about this and things that will make you angry if you let them, if you think about them and wish that things were being dealt with differently. There are always things we wish that could be different, but we also have the capacity to be extremely resilient in this.

And so, hopefully, people are experiencing their ability to do that and to realize that they're a lot stronger than they thought they were and that we're making it through.

Mitch: Next time on "Unit On The Brink," December 14, a mass vaccination effort in the state begins for frontline workers. Charge nurse Christy Mulder was the first person in Utah to receive the COVID-19 vaccine. We share her story and how the promise of vaccination was providing not only a boost of morale for the medical workers at University Hospital, but a glimmer of hope for a return to normalcy for everyone in the state, whatever form that new normal may take. Join us next time for "Unit On The Brink," Episode 9, "Keeping the Faith."

And if you'd like to see images from our visit to the MICU from the extremely talented photographer Brian Jones, take a look in the show notes for a link to the Keep Breathing multimedia story brought by Stephen Dark and designed by Stace Hasegawa.

Clinical is part of The Scope Presents network and brought to you by University of Utah Health. If you liked what you heard, please be sure to subscribe and share with your friends.

And if you haven't yet, why not give us a rating on Stitcher or Apple Podcasts? Those ratings really help new podcasts like ours and it makes our day to read them.

And to all the nurses, doctors, admins, interpreters, operators, technicians, and all of the other hospital employees out there, we know you're listening and we want to hear from you. Feel free to share at our listener line at 1-601-55SCOPE. Again, that's 1-601-55SCOPE. Or email us at hello@thescoperadio.com.

Clinical is produced by me, Mitch Sears, and Stephen Dark. Music in this episode by ANBR, Vortex, the Dave Roy Collective, Ian Post, Laurel Violet, and Yehezkel Raz.

And of course, a heartfelt thanks to the men and women who have shared their stories with all of us and fight to this very day to keep each and every one of us safe.

Dr. Gellner: Unless you've been avoiding all news reports, you know that vaping has become a huge problem in today's teen population. It's a problem both with the number of kids doing it and with what's in the vaping juice itself. I'll talk about why you should talk to your teens about not vaping on today's Scope. I'm Dr. Cindy Gellner.

Announcer: Keep your kids healthy and happy. You are now entering the "Healthy Kids Zone" with Dr. Cindy Gellner on The Scope.

Dr. Gellner: It's amazing how many times I'm asking questions about a child's tobacco use or exposure and the parents tell me, "Well, we don't smoke around the kids. We vape outside." Or I hear that parents have encouraged their teen to vape rather than smoke cigarettes. Most people know that cigarettes are filled with tobacco and they emit smoke. E-cigarettes or vape pens or mods which are used in vaping don't produce smoke, but more a mist that looks like water vapor.

When someone vapes, the pen basically heats up the juice or the liquid in the device, and then the user inhales the mist. The problem is that vapor is full of tiny cancer- and disease-causing chemical particles. Many parents are like, "Well, we don't use the kind with nicotine or let our kids use the kind with nicotine," which is the addictive substance in cigarettes, so they think it's a safer alternative.

There is one particularly popular vaping product JUUL, which looks like a USB flash drive, so it's easy to carry around and even hide, which is one of the reasons it's the go-to vaping device for middle and high school students. Vape juice also comes in fun flavors like fruit medley, double espresso, blueberry cheesecake, and cotton candy. Unfortunately, one flavor pod can have as much nicotine as an entire pack of cigarettes.

So what's in the vape juice anyways? Well, the main ingredients are either propylene glycol or vegetable glycerin. You've probably heard of propylene glycol before. It's the main ingredient in antifreeze. Yes, the kind you put in your car or that airports use to de-ice planes. In small amounts, the body is able to metabolize it. Too much of this will affect the nervous system, cause seizures, kidney problems or even abnormal heart rhythms.

Vegetable glycerin is a great moisturizer for your skin if put on topically,and it too can be okay to ingest. It's found in a lot of foods under the name glycerol. But inhaling it, the science is still out on that one. It does seem to be the safer of the two ingredients.

Generally speaking, unless you are inhaling a medication specifically designed to go into the lungs, inhaling anything in the lungs other than clean air probably isn't the smartest move.

The biggest toxins in vape juice are in the flavorings. Cinnamaldehyde gives a cinnamon flavor, and it's found in a lot of what we eat that's cinnamon. But note that cinnamaldehyde sounds a lot like formaldehyde. Formaldehyde is what dead bodies are embalmed in to preserve them. Cinnamaldehyde is a known skin irritant, which has been shown to inhibit mucous clearance when inhaled. Then there's o-Vanillin which tastes like vanilla but causes DNA damage. DNA damage leads to cancer. Another example is pentanedione, which gives a creamy or buttery flavor to the juice but has shown to cause lung fibrosis or stiffening of the muscles in the lungs.

Ask any pediatrician and they'll tell you vaping is dangerous and more and more kids are becoming seriously harmed or dying as a result. If you think your child may be vaping, talk to your pediatrician right away so they can help them to quit and learn the facts about how uncool vaping really is.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Dr. Jones: I was talking to a group of 11 college students, all women, about family planning. They said, "We aren't really interested in family planning because we aren't planning any children right now." Really? What am I not getting here?

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Sometimes you think people you are talking to know what you mean. Well, that's a mistake for sure. I make assumptions that young people in college know how their bodies work and about contraception, but maybe I'm wrong.

Today in The Scope studio we're talking to Grace Mason, a college student who knows a lot about contraception and is learning a lot about what her fellow students know and don't know. She is the founder and President of the Campus Contraceptive Initiative here at the University of Utah. Welcome, Grace.

Grace: Thanks for having me.

Dr. Jones: So, Grace, by the time young people get to college with all that's out there on the internet, they're pretty well-informed about contraception. Right?

Grace: Well, you would hope so, but unfortunately since less than half of the United States mandates contraceptive education and sexual education broadly, a lot of students come into college without having any sex ed. And a lot of students don't experience medically accurate sex ed in that regard. So if they come out, they may come out of high school with misinformation.

And so when we hope that students will turn to the internet to get better information, there's also a lot of misinformation on the internet that they're quite easy to find as many different people will tell teenagers what they should believe about sex ed rather than what their bodies do and how their bodies function.

So I think that students frequently come in believing things or not knowing anything and hoping that anyone will tell them the truth about how their bodies work.

Dr. Jones: Well, there's a lot of sex in the media, and there are books and there are songs, but none of them actually represent sexual initiation or contraception at all. No one says, "Oh, yeah, what are you using for contraception?" They never had that on the TV. So I read that one of the main reasons that men and women don't finish community college in the way they planned was an unplanned pregnancy. How can we change that?

I mean, if people are coming to college, they planned their college. But now they have to stop or have an interrupted course because of a baby that they didn't plan. What are we going to do about that?

Grace: I think that it is a broad issue, and it's something that Healthy People 2020, it's a huge part of their initiative is reducing the unintended pregnancy rate and increasing the intended pregnancy rate, because at the moment, 45% of pregnancies are unintended. And for students in college, who are 18 to 25, they are the most likely to experience an unintended pregnancy and they're also the most likely to be uninsured.

So there's a variety of issues there when it comes to a lack of knowledge and education coming into college. There's a coverage gap. There is the expense of care, which tends to be about $600 or more out of pocket for uninsured students.

Dr. Jones: For contraception?

Grace: For contraception.

Dr. Jones: If they want a long-acting method. It's cheaper if you're using condoms, of course.

Grace: Of course, but condoms are less reliable, and a lot of students don't like condoms in the sense of like their pleasure. And as they are less reliable, students are hoping to find a method that works with them.

Dr. Jones: So tell me about the Campus Contraceptive Initiative.

Grace: So the Campus Contraceptive Initiative is a interdisciplinary group of students, researchers and providers who are all targeting that issue of college completion, graduation and promoting family planning.

And so we are working through research and education to expand access to services, because we find that a lot of students don't know about the different options that they have when it comes to contraception. And so when it comes to finding the best method, they first need to have the education and that step of these are all the methods available to you. And then what does it look like in pricing? What does that look like for coverage? Where can you actually get those services?

Dr. Jones: So you've been doing a survey. You did a little survey last year, and you've been working on one this year. Any clues from your science so far in terms of what are people thinking out there?

Grace: Yes. We have definitely found out a lot of interesting things. That first survey, that went out last February, we got about 330 students to respond, and they were asked questions about their current sexual health, their knowledge as well as their desire or interest in a low-cost contraceptive clinic on campus.

We found out that 1% of students are currently going to the Student Health Center on campus, and that really blew us away because we found out that a lot of students are going to their doctor, but we know that a lot of students aren't comfortable with telling their parents about the services that they get.

And so that we have this huge uninsured gap of students where if they were able to access care at the Student Health Center, maybe they're being turned away because of the out-of-pocket prices, maybe they're being turned away of not knowing their options.

Dr. Jones: The Student Health Center, it may be student health, but it still has to be paid for. So students, unless they have that particular kind of student health insurance, still have to come up with money, and maybe their parents, if they use their parents' insurance, then their parents are going to get the bills or get the copays or get the information at home, so privacy becomes an issue.

Grace: It definitely does. And we saw that students, when asked about if they could have low-cost, affordable methods, 95% of students said, "Yes, I am interested in that." And many of those students said that they would actually partake in a service like that.

But broadly students want to know about the methods. We found that it wasn't just the birth control pill that was popular. If we were to have this contraceptive clinic, it was options. Across the board students want options for their birth control.

Dr. Jones: So where can college students get information about contraception? What methods are out there? How they work and where and how to get them? What's good information? What could they do right now?

Grace: Well, I would say that there are two wonderful resources out there. Bedsider.org is one. They have an incredible comprehensive list of different options, how they work, the different varieties. For example, since the IUD, there are several different types of IUDs, being able to click on each one and seeing how they're different and what they might do.

And they are wonderful because they also can connect you with emergency contraception to your door or sending your monthly birth control to your door rather than going in clinic. And so they have a great set of resources. Also Planned Parenthood Learn, which is an offshoot of the broader Planned Parenthood website, also has a really user-friendly interface that can compare methods and look at methods and connect you to one of their clinics.

Dr. Jones: Okay. So both of these options have a place where you could put in your ZIP code and you can find out clinics where you could get healthcare?

Grace: Yes.

Dr. Jones: Well, that's good to know, and people need to know more. And having a reproductive life plan, a family planning plan is important if you want to have the family that you want when you want it, or if you don't want it, get the knowledge that you need and get it right. You worked hard to get into a university and you're working hard to finish, and this part of your life takes a little effort, but it's worth it. And thanks for joining us on The Scope. And thanks, Grace.

Grace: Thank you.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Interviewer: Physician burnout. We know what it is. We've all heard of it. Today on The Scope we're going to talk about how medical students can learn how to cope with it later on in their careers. That's today on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Today on The Scope Radio we're talking with Tony Tsai. He's the Director of Education Strategy at the University of Utah School of Medicine. So, Tony, you and some colleagues at the University of Michigan where you used to work published this article essentially about burnout and how medical students can learn to cope with that later on in their careers by what they learn while they're in medical school.

Before we get to talking about that, though, what can you tell me about burnout and what it looks like?

Tony: When I was at the University of Michigan, we were looking at some admissions information, our applicants, whether their parents were doctors or not essentially. It was like if your parents were doctors, did you apply to medical school. And for a long time this number has been going up, but in the recent years, we've seen that number starting to dip and that was kind of an interesting statistic. I mean, that itself doesn't say everything but there is something in there.

And if you look in the literature, there's been a number of surveys recently done and what the surveys found is that about 50% of the clinicians experience some sort of burnout and that number is on the rise. As well as number of physicians who say they would choose medicine over again, that number has been dropping significantly. So this is what we know regarding the challenges of the current clinical practice environment.

Interviewer: So in the introduction of your article, Tony, it says that, "Most doctors also feel immense frustration as they attempt to deliver great care amid the demands, limitations and inconsistencies of today's healthcare system. Burnout becomes epidemic when this frustration kills physicians' sense of meaning and purpose." Tell me a little bit more about what that means.

Tony: When in medical school I talked to a lot of medical students and they say one of the reasons they chose to become a doctor was in order to be able to help patients. You can sense that they're very idealistic when they're starting. And then over time, they encountered the challenges of the healthcare system.

Charting. So once they see a patient, they have to document that encounter, and they have to interact with the electronic medical records, which is a very time-consuming process. Sometimes you're doing that and you're saying, "Did I become a doctor to do this?" Again, if you only get to see a patient for a couple of minutes and you don't really have the time for that meaningful dialog and you're making a prescription, sending them off, you're thinking to yourself, "Am I really helping this person?" There are these challenges currently in the way that we practice healthcare today that I think is putting pressure on a lot of clinicians to kind of reexamine what is it that they're really doing.

Interviewer: So burnout is something that medical students are thinking about, they're aware of. What is it that can be done in medical school to help them prepare for the stress in their career?

Tony: I had the chance to talk to a lot of doctors who I would consider resilient and I asked them, "What is it that makes you able to get up in the morning and go to work?" And they would say, for example, "When I was young, I had irritable bowel," let's say, "and so I know what that's like. So now when I go into clinic and I'm helping people with stomach issues, it's meaningful for me."

So I've seen a lot of doctors who despite all the challenges, again, the practice environment is consistent and yet different clinicians have different levels of satisfaction. So a lot of that can be attributed to, in a way, the meaning they create for themselves.

I wanted to maybe give you another quick example. There was an actual study done at the University of Michigan where they asked the custodial staff, "What do you do? What is your job?" Some people would say, "You know, I scrub toilets," and some other people would say, "I contribute towards the care of patients." And again, they're doing the same exact thing, but they create different meanings.

And what they found out was that the people who say, "I contribute to the care of patients," they were happier, more engaged, and they actually helped patients, so when let's say a patient got lost in the hospital, they would actually help them get to where they were going. So the actual meaning is something that I think we control. This is one of the things in medical school that our group, we were thinking, "How can we help medical students and residents and fellows develop that meaning so when they go into this challenging environment, they can be resilient?"

Interviewer: One of the concepts that you and your colleagues talk about in this article is the concept of the "why" and that medical education has maybe focused too much on the how and not so much on the why. What can you say about that?

Tony: I kind of think about education in two halves. There's the half that deals with knowledge and skills, and there's the half that deals with meaning and purpose. If you look back at your education, how much of it was dealing with knowledge and skills versus meaning and purpose?

One of the examples I give was the quadratic equation. How many hours did you spend solving for x in the quadratic equation? And then how many hours did you actually spend on using the quadratic equation in your job? Versus the question on the other side of what matters in your life. How much time did school actually devote towards helping with that? You look at the balance and you see that really things are quite imbalanced.

So if we look at the issue of meaning, if school does not help you, does not teach you how to create meaning, you go into these very challenging environments, you can only sort of see the tasks, I think that contributes to burnout. Then the idea was, okay, if we think about meaning and purpose, how do we get it? These things about meaning and purpose are never really finished.

You're really living your life and you're asking yourself these questions, and as you become more mature, the answer to these questions may be different. I'm hoping that one day having a much better clarity about certain aspects of their life through this reflection and they are set up through these questions that they can ask themselves in the future to be able to, you know, continue that journey for developing meaning and purpose for the rest of their lives.

Interviewer: So for medical students today, those that you deal with on a day to day basis, what would be your advice to them in how to find their own meaning and purpose in what they're studying as they're cramming for exams and they're attending class and they're getting ready for clinical experiences and all these things that they do in medical school?

Tony: When I talk to med students I see two types of med students. I see one type of med student that says, "I just need to get through med school so I can go to the next thing. And these tests I take, I just do it so I can just get them over with." Then I see another set of med students that says, "You know, it's a privilege to be in medical school. I want to use this time wisely to develop myself into a certain type of physician. And this is a good opportunity for me to go and explore what that looks like."

And I think that really changes the way that you behave in terms of your studying and in terms of how much you learn, really. One of the things about medical school is that people tend to be in their mid-20s, and it is a time where it is a transition between kind of childhood and adulthood. When you're a kid, learning is something that other people told you you had to do. You just go do what your teacher told you to do. But later on, what you'll realize is that as adults, we learn the things we want to learn. We don't have people telling us, "You need to learn this, you need to learn that."

Eventually what you'll need to be able to do is just, the things that you're interested in, you'll naturally be able to learn those things better. And so again, it's kind of like defining your own meaning. Now, if you have a real need or meaning to learn something, you'll learn that better, you'll retain that better. So that is scientifically proven.

So not only is this really just in the "soft domain," but actually once you have developed the meaning, it will actually help you as a medical student to learn better.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign me up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Interviewer: You're in a car accident and the paramedics ask if you need to go to the ER. ER or Not? That's coming up next on The Scope.

Announcer: Is it bad enough to go to the emergency room or isn't it? You're listening to ER or Not on The Scope.

Interviewer: So I don't know how often this would happen. We're with Dr. Troy Madsen, emergency room physician at University of Utah Healthcare, but I was talking to somebody and they said they were in a car accident one time and the paramedics actually said, "Do you need to go to the ER?" How do you answer that question? That's today's ER or Not.

Dr. Madsen: That is a great question because, my suspicion, if a paramedic is asking you if you need to go to the ER, they probably think you don't need to, but they want to make sure you have that option. Now, there may be exceptions to that. But my experience is a paramedic will call me when they think someone needs to go to the ER and that person refuses, and then we just have to confirm that person's capable of making their own decisions and they can refuse transport. So if they're telling you, "You really want to go to the ER?" they're probably thinking maybe you don't need to.

So the way I would answer that question, I'm thinking to myself, "Okay, am I concerned about any sort of head injury? Anything I might need a CT scan for? Is my abdomen hurting?" Again, a reason you might need a CT scan, to look for some sort of an organ injury. Anything I might need x-rays for? Is my arm hurting? My legs? You might be able just to get away with going to an urgent care for those sorts of things.

One of the biggest things in my mind after a car accident is neck pain. Very serious thing. If you had a whiplash injury and, potentially, have an injury to the spine, those are all things if I were having those symptoms, I would say, "I should probably go to the ER, get things checked out, and make sure things are okay there."

Interviewer: But if you're not experiencing those symptoms and you feel fairly confident, then probably okay? What about the next day, then all of a sudden pain comes on? Is that a different kind of pain then, normally?

Dr. Madsen: It often is. Usually, that pain that hits you the next day is from some of the musculoskeletal pain, maybe not a broken bone, but just being tensed up in that accident. Maybe you hit against something and you're going to have to gauge it. You could get away with going to an urgent care for some x-rays or to get checked out. But, usually, if you've gotten through that first day okay, you're not having nausea, vomiting, confusion, really no other pain elsewhere, probably more likely some bumps and bruises, and you're going to be fine.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Dr. Miller: Break a bone, where should you go? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists," with Dr. Tom Miller, is on The Scope.

Dr. Miller: This is Tom Miller from Scope Radio and I'm here with Justin Haller. He's an orthopedic surgeon here at the University of Utah. We're going to talk a little bit about level one trauma centers. Now, you know that if you have a very severe injury, you're likely to end up at a level one trauma center, whether you're referred or end up there initially. But if you've fallen and you hurt your wrist or break your wrist, being at a level one trauma center might not even be a better place to get cure than some of the other type trauma centers, such as level two and three.

And we're going to talk about that a little bit with Justin. Justin, tell me a little bit about what trauma one means or trauma one center. And then we're going to get into how patients who have a fracture or some other musculoskeletal injury would be treated.

Dr. Haller: Sure, Tom. So the level of trauma center designation, there's a level one, level two, and level three designations for hospital trauma centers. And it's based on the number of resources that are available.

Dr. Miller: So you generally have more specialists at a level one center?

Dr. Haller: So level one has the most services available and the most services available acutely. So they have a neurosurgeon, general surgeon, orthopedic surgeon in-house, ready to see patients, depending on their acuity. Level two and level three centers have some of those resources available, but they're just not within the hospital at the time when a patient might arrive.

Dr. Miller: Now, just briefly, what kinds of injuries would a level one trauma center see?

Dr. Haller: So level one trauma centers are best at treating patients with multiple injuries that span general surgery issues, such as chest injuries, head injuries, as well as orthopedic or neurosurgery injuries because they have all the medical subspecialties available. And again, they're available acutely.

Dr. Miller: Now, you're an orthopedic surgeon. So would you say that a level one center handles all kinds of fractures and musculoskeletal injuries that happen during accidents or other strange things?

Dr. Haller: Yes. So level one centers tend to deal with the whole spectrum of orthopedic injuries that a patient could have. And they tend to see anything from referrals from level two and level three centers that are transferred and are complex enough that they do not have the resources available, as well as they see patients from a motor vehicle accident, motorcycle accident from the scene, brought in by the emergency providers.

Dr. Miller: Now, the University of Utah has a level one trauma center, as I understand it. And there are a couple in the state. So we end up getting a lot of referrals, I would guess, from outlying hospitals for severe injuries.

Dr. Haller: Yes, that's accurate. We get referrals from not only within the state but also from surrounding states, including Montana, Idaho, Nevada, Wyoming.

Dr. Miller: Well, let me ask you this, let's say you have a less severe injury. Let's say that you fall and you hurt your ankle or you break your leg or you think it's broken. I mean, would you come to a level one trauma center or should you go to another trauma center, like a level two or a level three because there are more of those?

Dr. Haller: There absolutely are more of those and some might view the access there as being a little bit better. However, the benefit of a level one trauma center is that they have all of the resources available to actually evaluate what's going on with your leg. Because when you first injure it, it can be tough to know whether it's broken or not. And they have the resources available to figure that out and treat you appropriately. And sometimes, even though the access is easier at the level two or level three centers, if it's a complex problem, you'll ultimately get referred anyway. And so it might actually turn out to be easier in the long run just to go to level one.

Dr. Miller: Well, the way that the emergency rooms work, as you know, is they triage patients. And if you have a serious injury, even if that's a fracture, you're going to go ahead of a lot of people to get treatment. You're not going to sit in the waiting room very long with a fracture, I wouldn't think.

Dr. Haller: That's accurate, yeah. Normally, patients with obvious fractures are moved along the emergency room triage board.

Dr. Miller: So before the show, we started talking a little bit about some studies that had been done to show that level one trauma centers actually provide better outcomes, even for simpler injuries. Is that something that you can talk about?

Dr. Haller: Yeah, so there have been a few studies that have looked at level one trauma centers and if they're necessary because they do have a lot of resources available, and if they're cost-effective. And they've demonstrated that level one trauma centers with specialized orthopedic trauma surgeons are cost-effective at treating patients, especially patients with complex injuries.

Dr. Miller: So to wrap it up, if you're a person that has some type of an injury and you have access to a level one trauma center, whether it's something that you think is fairly simple or maybe even more complex, you should maybe come to a trauma . . . you would recommend coming to a level one trauma center. Is that right?

Dr. Haller: I would recommend it if it's reasonably accessible, in terms of geographic location.

Announcer: Thescoperadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at thescoperadio.com.

Dr. Miller: You've injured your knee, what's the next step? Should you have it scoped? We're going to talk about that next on Scope Radio.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Bruce Thomas. He's an orthopedic surgeon here in the Department of Orthopedic Surgery at the University of Utah. He also has a practice at our Farmington facility. And Bruce, what's the story? There's been a lot of changes. I think folks who have injured their knees and have some swelling or clicking or pain, it used to be that a number of people would obtain or go to the orthopedic surgeon and they would have an arthroscopic procedure. That is, they would put a little scope inside the knee and look around. And more recently, there's been some changes in that thinking.

Dr. Thomas: That's true. There's more of a collaborative effort. In the old days, a doctor told the patient what the treatment was, and these days the doctor will share information with them and make recommendations. Not every meniscus tear requires surgery. Many people can do their regular life activities and the pain will subside, and it's not clear, in those patients, that knee arthroscopy will help them.

Dr. Miller: It's interesting to me because, I mean, do they know that they have a meniscal tear before we do the arthroscopy, or do we do the arthroscopy to find out that they have a meniscal tear? Or there might be a misunderstanding among patients about the purpose of the arthroscopy.

Dr. Thomas: For many meniscus tears, you can tell if it's present by the patient's history and by the physical exam. If there's questions, an MRI is 96% accurate at predicting a meniscus tear.

Dr. Miller: So now we have way, radiologically, to look at the joint, find out if you have a tear, without doing a surgical procedure?

Dr. Thomas: That's correct.

Dr. Miller: So, if you have a meniscal tear and you either figure that out based on the examination or the MRI, what role would arthroscopy play nowadays?

Dr. Thomas: If the patient has significant symptoms that aren't resolving with conservative measures and it prevents them from doing their regular activities, arthroscopy can assist the restoration of function and decrease in pain. It's a small out-patient surgery with, usually, two or three very small incisions, and the meniscus is either repaired or the damaged portion trimmed out, depending on the findings at surgery.

Dr. Miller: So, what you said I think is important, is that you don't do the arthroscopy immediately, you try some conservative measures first.

Dr. Thomas: That's true.

Dr. Miller: Is that the standard now?

Dr. Thomas: I believe that's the standard, because many people can function with a meniscus tear. The older literature suggested that an untreated meniscus tear will lead to earlier arthritis. Subsequent studies are less clear on that, and it depends much on the size, location, geometry of the tear, as well as the patient's activity level.

Dr. Miller: You know, many years ago they used to go in, when you had a meniscal tear, and they just took out a lot of the meniscus, a large percentage of it, and I think that was the standard back in the day. Is that right?

Dr. Thomas: That's true. Before the invention of arthroscopy, an open procedure would be made and the entire meniscus would be removed. And there are some papers that suggest that those patients would have end-stage arthritis within seven years of that procedure.

Dr. Miller: So they don't do that anymore?

Dr. Thomas: We don't do that anymore.

Dr. Miller: So the concept was, if you used an arthroscope, you could go in and take smaller pieces of the meniscus near where it was damaged, and that that might result in improved function, less pain.

Dr. Thomas: True. That's true. It will decrease their pain, improve their function, and if we can save even a rim of 3mm or 4mm, that's been shown to still function in preventing arthritis for the patient.

Dr. Miller: What were some of the things that patients received arthroscopy for in the not-too-distant past that are no longer done? For instance, I know that some patients have had an arthroscope to wash out the knee joint. Do they still do that, and does that have any therapeutic value?

Dr. Thomas: That really, probably, has no therapeutic value. Arthroscopy is not a treatment for arthritis. You use arthroscopy to treat mechanical symptoms associated with meniscus tears or, infrequently, loose fragments of cartilage. Symptoms like catching, locking, giving out, those kind of symptoms.

Dr. Miller: After you do an arthroscopy, how soon can the patient get back to normal activity?

Dr. Thomas: If there are no surprises and the articular cartilage is in good shape, we usually encourage them to start walking the day of surgery. Swelling takes longer to go away. Maybe four to eight weeks, depending on the setting. Many patients can get back to most of their life activities within eight weeks.

Dr. Miller: Now, are there any risks with arthroscopy? Obviously, there are risks with any surgical or invasive procedure. I would assume that those risks are less than they would be if you had an open procedure, an open, standard surgical procedure.

Dr. Thomas: That's true. The risk of infection, for example, is going to be far less than 2% with arthroscopy. There is some evidence that once you've had a meniscus tear on one side, you're a little more likely to have it on your opposite knee. And with removal of meniscal tissue, the loads on your joint surface are higher, and so you do wear your cartilage quicker and may be a little more likely to get arthritis down the road.

Dr. Miller: So, bottom-line, basically, is if you have knee pain and potentially a meniscal tear, you're going to probably want to go through conservative treatment first, before proceeding onto an arthroscopic procedure, and that you're working with your orthopedic surgeon you can define the best time for that, if that needs to occur.

Dr. Thomas: That's true.

Dr. Miller: Thank you very much, Bruce.

Announcer: Thescoperadio.com is University of Utah Health Sciences radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at thescoperadio.com.

Dr. Jones: If women have told us that their holistic sense of health involves much more than their cholesterol level or their blood pressure, what do we want our health team to know about us? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care and this is "The Scope" of women's health.

Announcer: Covering all aspects of women's health, this is the "Seven Domains of Women's Health" with Dr. Kirtly Jones on "The Scope".

Dr. Jones: How should our medical home think about our overall health? The seven domains of women's health - physical, emotional, social, intellectual, environmental, financial and spiritual - are all important to us. Today in "The Scope" studio, we have two professionals who've thought a lot about these seven domains. Dr. Kathleen Digre is a neuro-opthalmologist who is a specialist in headache and is the director of The Center of Excellence in Women's Health. Dr. Caren Frost is the director of The Center for Research on Migration and Refugee Integration. Together, the published a book on the seven domains of women's health. Thank you for coming to "The Scope".

Kathleen, why is it important for the health professions to understand the seven domains of women's health?

Dr. Digre: So this is really not a new concept. The WHO (World Health Organization) really defined that health is more than just physical health, but it involves emotional health and other types of health. And at the Center of Excellence in Women's Health, our members have really thought about this that if we're going to be really healthy, we have to be thinking about all the various aspects that fit into health.

So I think the importance of this is that one domain is going to affect another. For example, if you have very poor social health and you have no social support, how are you going to get to a medical doctor's office in the first place?

Dr. Jones: Caren, you come at this problem from the social part, help me understand why this matters as we begin to educate health care professionals?

Dr. Frost: I think that we're moving more and more towards interdisciplinary teams, so health professionals, nursing professionals, as well as social work professionals, they need all be aware of these different seven domains so when there's a need for resources or identifying resources for people, somebody on the team can say, "Oh, I think you're having trouble with your financial health. Let's figure out someone that you can go and speak with." So I think thinking about it in a holistic way where we have different professionals working on things together is really why this is so important.

Dr. Jones: That's why the university has been so insistent that we think about our healthcare as a medical home with many professionals on the team. Kathleen?

Dr. Digre: I would like to just add that physicians are guilty in many ways of not thinking about health in these factors. Nursing has been way ahead of physicians in team care and I really feel that this is a sea change. This is a change in our new direction in medical home thinking and also in medical care thinking.

Dr. Jones: We've been trying actually to integrate this concept of multi-disciplinary teaming into our first and second year and third year curriculums now at the School of Medicine. So we're trying but also, folks, we need some help. We need a book. So what about this book, why this book, and why now? We talked a little bit about it but tell us about the book.

Dr. Digre: The idea for this book came many years ago. When we started the Center of Excellence over 10 years ago, we started having a problem talking about what is health and what involves health. So we tasked our librarian who is part of our team to actually research what are domains of health? And they came back to us with seven domains of health. And then all the members of the team really picked up on this as really vitally important especially for women's health because we are juggling so many things in our families and in our lives.

And then Caren, because she's so cool and has a social work background, she was able to work with students and start getting some literature together in each of these domains and then the idea came, actually, we should write a book. We should have a test. We should put this out to the public so that we can make this more freely available to everybody.

Dr. Jones: Caren, who are your collaborators? You two are the editors but I see you've got collaborators all over the university.

Dr. Frost: We do. We have collaborators from what we call main campus as well as the health sciences campus. What we tried to do with every chapter was to make sure that we had a medical health sciences professional as well as a professional from another field so we got an interdisciplinary kind of discussion going on with each of the chapters. So we have people from nursing and from the OB/Gyn as well as neuro-opthalmology. And we have people from public health, people from social work, people from the College of Health, communications, and we have people from all over campus who agreed to write pieces and parts of chapters so that we could pull that altogether and show a real interdisciplinary way of looking at these seven domains.

Dr. Jones: And who's your intended audience?

Dr. Digre: Of course, the medical students. We'll have to get that as part of the curriculum but who else?

Dr. Frost: I think we saw anybody involved in patient care. So medical students, nursing students, also the College of Health students, pharmacy students. It should be permeating everything that we do. So I would say anybody, any provider that provides care to patients.

Dr. Jones: Caren, I would say it's for anybody who cares for persons because sometimes people out in the community, maybe someone who's doing resources within the social domains for communities of refugees, those patients aren't patients. Those persons aren't patients. They're persons. So maybe as we think about those who care about persons should take that. What do you think about that?

Dr. Frost: I think that is an excellent suggestion. One of the things that the Center of Excellence group had been talking about is how do we make sure that this information becomes tangible to everybody out in the community as well so we've been talking about and using what we call our circle of health in different settings so for example when I do workshops with refugee women, we have translated what we call our circle of health into two or three different languages and when we present it to refugee women in that language who say that that's exactly it. That is health. All of those domains, they're all connected. And they're always so glad that we see it the same way they do so we've used that model.

Dr. Digre: I would like to add that I think that when we have presented this in public, it really resonates with people. They say yes, of course, all of this is related. We can't just separate one piece from another. It's all integrated into one piece.

Dr. Jones: So this book is unique because they're not just words, there are some added attractions. Tell us about that.

Dr. Digre: I think that one thing that's cool about this book are all the discussion questions. If we're in a classroom and we want to discuss a certain domain of health, we've got actual questions that help people guide discussions in a group setting and help you to explore the seven domains.

Dr. Jones: Caren?

Dr. Frost: We also have case studies at the back of the book and we were lucky enough to get a number of different professionals on campus to come in and one person was a simulated patient. Dr. Jones was one of our simulated patients.

Dr. Jones: I get to be an old, slightly demented person. It was fantastic. Thank you.

Dr. Frost: And then we had a number of professionals come in from health sciences, the medical field, as well as the social work field and talk about a variety of different kinds of needs that somebody would need to have addressed during that discussion with an interdisciplinary team. We have that in there as well and the link to those case studies is available for people to use.

Dr. Jones: We hope that our healthcare team and the professionals who teach them can realize that we as women take our healthcare holistically is this circle of health in our circle of life and thank you for joining us on "The Scope".

Announcer: TheScopeRadio.com is the University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Interviewer: This is one of those Scope podcasts we hope you never have to use, but it's good information to have in case you find yourself in this situation. How do you stop severe bleeding? We'll talk about that next on the Scope.

Announcer: This is From the Frontlines, with emergency room physician Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University Utah Healthcare. It's something you'll never have to do, but it could potentially save somebody's life, and buy medical experts the time they need if you have somebody who's bleeding severely, if you're able to slow that down. I'm in a situation where somebody is severely bleeding, what do I do?

Dr. Madsen: Well the number one thing to remember with severe bleeding is hold pressure. No matter what kind of bleeding it is. If it's oozing out, if it's spurting out, hold pressure on it, and just keep holding pressure. The biggest mistake I see with people is, let's say someone has, let's say a laceration on their arm from a knife or something they were working with.

People will want to keep looking at it. They'll say, "Wow, has it stopped?" They'll hold some pressure on there, or they'll put a bandage on it, and then they'll pull it off, 30 seconds to a minute later, they say, "Oh no, it's still bleeding." So they'll put it back on, and they'll say, "Oh no, it's still bleeding." They just keep looking at it.

The key is hold pressure on it, and just keep holding pressure. Don't keep pulling the bandage off to look at it. My recommendation is, if you're going to look at it, wait 15 minutes. Hold pressure on there, hold nice firm pressure. Make sure the pressure is firm, but also make sure it's also not cutting off circulation to their hand or their foot, or whatever might be below that laceration or that bleeding.

You want to make sure they can still move their fingers. Make sure their fingers still look pink. If you push on their fingernails it doesn't just turn white, and stay white, it turns pink again within about two or three seconds. So bottom line is, whatever it is, just hold pressure, and keep holding pressure.

Interviewer: All right, and then call somebody immediately.

Dr. Madsen: Yes. Call somebody immediately. Get in for medical attention, especially if we're talking about an arterial bleed. So the arteries are the vessels in the body that take the blood from the heart, so there you're seeing that pulsatile type bleeding where it's shooting out. That's definitely a more serious thing, and a person could lose blood very, very quickly with that. So that's something you want to call 911, get to a hospital quickly, so that can be addressed.

Interviewer: All right. But still, same thing, get like a cloth, a clean cloth, whatever, and hold pressure.

Dr. Madsen: Yes, exactly. One mistake sometimes you'll see too, maybe in a first aide class or scouts, Boy Scouts or something you learned about tourniquets. So you think to yourself, "Okay, this is an arterial bleed. I'm seeing this pulsatile bleeding shooting out, I'd better throw a tourniquet on this." The only time to use a tourniquet is when you expect that this person is going to lose whatever is below that tourniquet, whether it's their leg, it's their arm.

The only case I'd use a tourniquet, and the case I've used it, and I've seen it used would be someone who's been in say, some sort of motorcycle accident, something like that, and they've lost their lower leg. Basically, you're just trying to save their life. Their leg is pretty much lost, it's mangled, or it's pretty much gone. So you're just trying to control the bleeding into that area, and just assuming that everything below that tourniquet is gone.

Interviewer: Okay.

Dr. Madsen: So if you're going to put a tourniquet on, I would not recommend doing it. But the only scenario where you would do that would be where you just assume you're going to lose everything below that.

Interviewer: If I'm putting pressure on something like that, is their blood going to be getting out and around it? I mean, am I'm completely stopping the blood from escaping in most cases or not?

Dr. Madsen: With just putting pressure, or with a tourniquet?

Interviewer: Yeah. With putting pressure, what's that look like?

Dr. Madsen: So when you're putting pressure on something, you're just holding pressure directly over the wound, and you should have enough other arteries and veins, and everything running through there, you're still going to have blood flow to whatever is beyond that.

Interviewer: So it will bypass, it won't just continue to push past the pressure?

Dr. Madsen: Yeah. Exactly. Yeah, it's not like you just have one artery running down there that's then going to be blocked off, and everything's going to pool above it, or try to push back because so much pressure will build up where you're holding pressure.

Interviewer: It just reroutes.

Dr. Madsen: It will reroute, exactly. It's like a traffic jam where then everything goes on separate streets. Kind of same idea, but again, the key is just hold pressure, and avoid using some kind of tourniquet, or avoid tying something around the arm or leg that's going to cut off all the circulation down below there.

Announcer: Thescoperadio.com is University of Utah Health Sciences' radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at thescoperadio.com.

Interviewer: It could possibly be the easiest ER or Not? we've ever done. A gunshot wound, what should you do? We'll talk about that next on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician and University of Utah Health Care and today's ER or Not, where you try to decide whether or not something that's happened to you is worth going to the ER is probably the easiest one we've ever done. But it would still be interesting to know what somebody should do if it happens to them. A gunshot wound. I'm going to go ahead and go out on a limb here and say ER.

Dr Madsen: Yes.

Interviewer: And I would say that if you can, probably call 911 regardless of how serious you think it is.

Dr Madsen: Sure, yeah.

Interviewer: Yeah. But is there anything that somebody could do after it happens, you know, to help whatever it is you're going to do. And I'm talking like, it could be a hunting accident, it could be an accident in the home, any sort of thing like that.

Dr Madsen: Yeah, well with this, it's obviously the answer is pretty clear. If you do get shot by a gun you need to go to the ER and probably not an urgent care. They will probably send you to the ER. But it's funny because some people have actually questioned this and have been shot by a gun or thought maybe they were shot by a gun and thought "Wow, it's just a small hole. It doesn't appear to have done a lot of damage," and some gunshot wounds can be very small holes.

Interviewer: Okay, well sure, that sounds reasonable. But still.

Dr Madsen: But still, you need to go to the ER. And we do have cases of people who have come in after getting shot by a gun or multiple gunshots and you really have to look them all over very carefully for these gunshot wounds because sometimes they can be really small and just look like a mole and you could really miss it, but the damage they can do internally is fairly significant. But in terms of what you can do at home, let's say, and it's probably worth pointing out that it depends where you work, but where we work most gunshot wounds we see are actually self-inflicted.

Interviewer: Okay.

Dr Madsen: Either intentional or accidental. Sometimes people cleaning their guns or doing different things with their guns, something may misfire, there may be something in there, a bullet they just didn't know about, and they get shot. Oftentimes these gunshot wounds are through the leg, that's something we often see, sometimes in the hand. But in terms of what you do at home, first of all you control the bleeding, apply pressure to it.

If it's something where it's not bleeding profusely and it's say, through your hand or through your foot and you can put pressure on it, maybe you don't need to come in by an ambulance. I'm hesitant to just put that out there, but that's a possibility where if it's not like an arterial bleed where you're putting lots of blood out, you can have someone drive you into the ER. But definitely, you're going to want to hold pressure there and get to the ER to get things addressed.

The biggest thing we need to worry about again, is not just what you're seeing on the surface, but all the damage it can do internally. Maybe damage to ligaments, to nerves, to tendons, bones, all these sorts of things that we're going to be looking for once you get to the ER.

Interviewer: I have questions to ask but at the end of the day it really doesn't matter just because you would go to the ER and they would sort all this out. But, if a bullet goes all the way through versus lodges within you, is that a different situation insofar as what I would do to maybe prepare to go to the ER?

Dr Madsen: Yeah, not so much. Again, you've got two holes versus one that you're putting pressure on.

Interviewer: Sure, okay.

Dr Madsen: The damage that is done internally, the bleeding that could be happening internally, there's not a whole lot you can do about that and you need to get to the ER. Typically if you have a gunshot wound through your chest or your abdomen, you're going to go to the operating room.

Interviewer: Yeah.

Dr Madsen: In most cases, and I can't think of a lot of cases where you wouldn't, but if you have a gunshot wound through those very serious areas, you're going to go to the operating room so the surgeon can explore and try to find out exactly what kind of damage this has done. Maybe you get a CT scan first, assuming your blood pressure is stable, to look for exactly where this damage is, but often it does require going to the operating room.

Interviewer: Can you tell if you're bleeding internally? Is that something a human is aware of?

Dr Madsen: The one sign you might have of it would be you feel lightheaded, you feel like you're going to pass out. If that's the case, maybe it's because of the pain you're experiencing, maybe it's because of internal blood loss. You could look and see that your abdomen is expanding, which would be a sign of some very, very serious internal bleeding. Those are all things you might see, but it's not like there's anything where you could rule it out and you could say "Wow, I've been shot by a gun. I'm going to be just fine." There's going to be additional testing that's needed.

Interviewer: And I guess ultimately, don't drive yourself to the ER because the pain could cloud your judgment, internal blood loss could cloud your judgment, you could lose consciousness.

Dr Madsen: Exactly, I wouldn't recommend driving yourself. Especially, the only times I'm even thinking you could maybe drive or have someone drive you would be if you got shot through the hand or the foot, but there you can't really drive if you've got a gunshot wound through your hand or your foot,

Interviewer: Not if you're keeping it and 10 and 2 you can't.

Dr Madsen: You sure can't if you're trying to do that. So you're going to have to have someone drive you in at a minimum or call 911 and have them get you in, especially with these more serious gunshot wounds because time really is of the essence if you have some sort of internal bleeding.

One other question that does come up sometimes, you mentioned if you have a gunshot that goes through you and the bullet exits versus if it's in you. I have had patients who have asked me "Well, doc, aren't you going to take the bullet out?" Some of these gunshot wounds they get lodged in there and it's more effort and more risk to go in there and try to remove this bullet than to just leave it in there.

And I've had cases of people who were shot years before and have then come into the ER as this bullet has worked its way out near their spine or wherever this was lodged, and you see it as it's kind of worked its way out near the surface and we can just easily remove it at that point. But some of these bullets, they will eventually work their way out but it's not like "Hey, we've got to get the bullet out," like you see in the movies.

Interviewer: That's not the danger.

Dr Madsen: It's not the danger, exactly. And there's often more risk from doing that than from just leaving it there.
Announcer: Thescoperadio.com is University of Utah Health Sciences radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at thescoperadio.com.

Dr. Gellner: You just took your preschool-aged child to the bathroom and now they say they need to go again. Should you be worried? Is something terribly wrong, or is this normal behavior? We will discuss that today. I'm Dr. Cindy Gellner for "The Scope".

Announcer: Keep your kids healthy and happy. You are now entering The Healthy Kids Zone, with Dr. Cindy Gellner, on The Scope.

Dr. Gellner: Sometimes it seems that your child suddenly has to go to the bathroom every 10 to 30 minutes, and as often as 30 to 40 times a day. This usually happens when your child is around four or five.

You'll also notice that your child only passes a small amount of urine. It doesn't hurt when she pees. They don't wet themselves during the day, or if they do, it's just a small amount of urine on the underwear. That's mainly because they waited too long to go because they didn't want to stop playing. Your child doesn't drink excessive amounts of fluids, and they don't wet themselves at night time. So, what's going on here?

Frequent urination sometimes reflects emotional tension. Your child is not doing this deliberately. The symptoms are completely involuntary, and urinary frequency may begin within one to two days of a stressful event or change off the child's routine.

This is very common, and we see it often when a child starts a new school or daycare, or there is a new sibling or a move in the family. You can make the problem worse by worrying about a serious disease, punishing your child, or teasing them if they continue to do it.

So, you may wonder, how long is this going to last? Am I going to have to take my child to the bathroom this often for months? No, usually not. Overall, this is pretty harmless and it goes away by itself. Once you figure out what is stressing your child, it will get better in about one to four weeks.

A few children, who also have small bladders and problems with bedwetting, even before this urinary frequency happens, may have the symptoms over and over. But, as long as you figure out that this is not something serious, your child will be okay.

How can you help your child if they are dealing with this? The first thing is to reassure your child that he is physically healthy. Reassure him that he can learn to wait longer before he really has to go to the bathroom.

One thing we recommend is to do timed voids. That is where you have your child hold their urine for about 30 minutes, then they can have a bathroom break. Then you have them hold it for 45 minutes, and so on, so that you gradually work back up to their normal urination pattern.

The other thing is to have your child relax. Make sure your child has enough free time and fun time everyday, and try to figure out what's going on with your child that may be stressing them. Again, try to think of a stressful event that occurred just before these behaviors.

Also, ask the school or daycare staff for ideas, if there is something going on there. When your child is using the toilet frequently, don't comment on it. Commenting reminds them that the symptom is worrying you.

Stop keeping a record of the amount or frequency of urination, and be sure that none of your child's caretakers or teachers is punishing them either. Stop all conversation about the frequency. The less said about it, the less anxious your child will be about it.

Finally, you can also avoid bubble baths and other irritants because bubble baths can often cause frequent urination in children, especially girls. It can irritate the opening of the urinary tract and make girls feel like they have to go over and over again.

If your child is having symptoms where they are having issues with wetting their self during the day and it is not due to this, or they are drinking an excessive amount, and by excessive we mean they could be drinking a lot through the day because they're hot and playing hard, but drinking large quantities of water every hour is not normal.

So, if your child is going to the bathroom very frequently and is in the preschool age, remember, this is a very common condition for them and unless they have other abnormal symptoms, reassurance is all that is needed.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: May 25, 2018
originally published: May 11, 2015

Interviewer: Precision Medicine, some perspective next on The Scope.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope. University of Utah Health Sciences radio.

Interviewery: Dr. Will Dere is a Director for the Program for Personalized Health at University of Utah. It's a conversation that a lot of people are listening to right now, the President's Precision Medicine Initiative. I need some help here understanding how excited I should be about this.

Dr. Dere: I'm optimistic Interviewer and also realistic about what the President's speech and what precision medicine can offer. First of all, let's describe it a little bit because the term "precision medicine" maybe as a new initiative makes it sounds like what we have been doing has been imprecise medicine or the like. Just in terms of definitions, President Obama is really talking about the fact that we're in the midst of a biologic and genomic revolution, and our understanding of biology and the mechanism of disease is growing by leaps and bounds, and I find that extraordinarily exciting. Furthermore, the insights gained initially from the Human Genome Project and from our work subsequently has made the opportunities of finding disease causing genes, identifying patients at particular risk for disease and potentially preventing that, and also identifying new therapies directed against these disease causing genes also provides a very exciting time.

Interviewer: So the President decided now is the time to talk about this. Why? Why now? Why not five years ago? Why not 10 years from now? Why is now the time?

Dr. Dere: Well, now is the time because, again, there are so many advances. There are so many advances, and it's now the time because we can do better. We can do better in terms of maximizing the value of interventions in patients that we treat, whether these interventions could be with screening and looking at prevention also.
Another reason is the cost of health care is skyrocketing, and we need to improve the outcomes of our precious dollars in patients. So with increasing health care costs, if you just use the example of say in the field of oncology, one half of patients, who have a mutation in the ras oncogene, should not be getting an epidermal growth factor receptor antibody. Those types of things we can actually do better in terms of saving money.
The third thing is that with the President and the health care providers' emphasis on quality, we want to really make sure that we use all the tools possible. We've been talking about genetics, but all the tools possible to make sure that again the right patient is getting the right intervention, at the right time, for the right cost. We will be dependent on electronic health records, on important reminders, decision support technologies to really help physicians improve their prescribing and their interventions, and also tools in which patients can better understand, therapies and how to take therapies correctly and the like.

Interviewer: So it's $215 million. First of all, is that a substantial amount of money? I mean, it sounds big to me but . . .

Dr. Dere: Yes, it is a substantial amount of money, and it's going to take a lot more. I think it's going to take focus. It's going to take kind of a broader national commitment, both in the public and the private sector, to really do better for our citizenry.

Interviewer: You used to be in industry, so you're a businessman. Is this $215 million investment a good investment?

Dr. Dere: Yes.

Interviewer: It's going to really return dividends you feel?

Dr. Dere: Yes, but certainly having been in industry also, we have a higher calling also. I know there have been analyses done on the return on investment of the Human Genome Project, which it looks very, very promising. But ultimately we need to serve the public. Ultimately, whatever we spend and whatever we do needs to serve the public. Hence, I think the initiative is a great investment, and this is a great start because, again, we can do better within the field of health care to serve patients.

Interviewer: Is this our best chance to do better, do you feel?

Dr. Dere: It is a very important chance right now, and it's going to require continued energy and momentum.

Interviewer: Would you say precision medicine is a revolution in health care?

Dr. Dere: I think it's an evolution of health care.

Interviewer: Evolution. This is my final question. So as a regular person, what should I take away from this conversation? What mindset should I be in going forward?

Dr. Dere: I think you should be optimistic, because despite the limitations in budget and the like, there really is incredible expertise in this country in the field of biology and the life sciences, both in the public sector and the private sector. So there's incredible knowledge and I think a very strong will to do good things.
So I'm optimistic, and also our understanding of the science, the basis of what we're going to be doing is growing. So I'm optimistic, and we need perseverance and patience, because everything that looks so promising, there will be a lot of failures within this. But I believe that history has told us we're going to continue to have progress, sometimes by leaps and bounds, sometimes by little increments. I have heard the term "relentless incrementalism." That might be the way too, but I do believe that this is a wonderful opportunity to kind of reboot, to re-energize our commitment to science and to our citizens.

Announcer: TheScopeRadio.com is University of Utah Health Sciences radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.