In the wee hours of the morning of November 7, 2001, my wife and I were awakened by a strange, eerie, unearthly melody. You can imagine my shock and amazement when I discovered that this shrill unearthly tune was emanating from me.

The day before Carol and I had celebrated our 36th wedding anniversary by going out to dinner and to a show. We returned home late and went straight to bed. About 2:30 a.m. I was awakened by a loud whistling sound. It was loud enough to awaken Carol as well. I suffered from asthma and hay-fever as a child, but I hadn’t had an asthma attack in over 40 years. We arose, and searched the house for one of our son’s old allergy inhalers, but we couldn’t find one. My wife is extremely allergic to peanuts, so we keep Benadryl on hand. Carol went down to the kitchen to get a couple of capsules for me. I took two. I wasn’t having any trouble breathing, which is unusual for an asthma attack, nor was I having any pain. I was simply wheezing loudly, so loudly in fact, Carol said that she could even hear me all the way downstairs in the kitchen.

After about 20 minutes, the wheezing slowly evolved into a loud gurgling sound. It sounded as though I had swallowed a percolator. It reminded me of the old “Maxwell House” coffee commercials. I still had no pain or any difficulty breathing. After about 30 minutes of listening to the “happy coffee pot,” Carol suggested we drive to St. Mary’s Emergency Room so I could get a shot to relieve the asthma symptoms, and then, maybe, we could both go back to sleep? We got dressed and headed for the hospital.

St. Mary’s Hospital is not more than a mile from our house, but about half way there my breathing became quite labored. Panic and fear gripped me to the core. I broke out in a cold clammy sweat. I asked Carol to hurry, because I couldn’t breathe, Carol drove up to the Emergency Room and stopped the car. The difficulty I had breathing was now starting to subside, and I thought the Benadryl was starting to take effect. I told Carol I thought I was going to be all right, and we could go back home. Carol suggested, that as long as we were there, she thought we should go in to make sure everything was OK.

As I approached the admitting desk, the lady behind the counter, asked me what was wrong? She said she could hear the gurgling in my chest as I walked through the door. I replied, “I thought I was having an asthma attack.” A man in “scrubs” and two other women rushed around the end of the counter towards me. The man said “You’re not having an asthma attack. You’re having congestive heart failure!”

They got me into a wheelchair and rolled me into one of the examining rooms. They peeled off my clothes, gave me a couple of injections, and hooked me up to oxygen. They shaved my chest, and attached leads for an EKG.

I told them what had happened at home. They said I was extremely fortunate that Carol brought me to the hospital when she did. They said that, if I had waited another 10 or 15 minutes, I probably wouldn’t have survived.

They drew some blood, for a blood work-up, and gave me a few additional injections. After a short time I was feeling fine. The gurgling was gone, I could breathe all right, and I felt normal. I got up and asked for my clothes. I thought I would go home. The doctor snorted, “wrong!” He said that he thought I should stay the night. The doctor said that the EKG showed no heart damage, but the blood tests confirmed I had had a heart attack. The doctor insisted additional tests were necessary to determine my exact condition, and to insure that no lasting damage had been done to my heart. The doctor said that they would do an Echocardiogram around 9:00 AM, followed by a stress test later in the afternoon. He said that the results of my blood tests indicated I had had some heart problems, but he repeated that the EKG showed no heart damage. He felt the additional tests were necessary to corroborate the EKG and insure that there was no permanent heart damage.

They checked me into a room, hooked me up to oxygen, gave me several pills, and I went to sleep. Later that morning, they took me down to Cardiology in a wheelchair to get an Echocardiogram. The girl who did the scan was warm and friendly, and we were joking and kidding with each other from the time I arrived. I got out of the wheelchair, and climbed onto the examining table. We were still joking as she was preparing me for the procedure. Shortly after she started the scan, a surprised and frightened look came over her face, and her total demeanor changed. She became very serious, and seemed to be very concerned about my well-being. When she finished the procedure, I started to get up from the table and return to the wheelchair, but she didn’t want me to move. She called three other technicians into the room. They lifted me from the examining table, and transferred me to a gurney instead of the wheelchair. These were four strong girls! I didn’t say anything at the time, but that made me keenly aware of the severity of my circumstances.

The Center for Nursing Advocacy has issued its list of the best and worst media portrayals of nursing during 2003. The list highlights a variety of depictions of nursing-from television to the print media, from fiction to news, and from Milwaukee to Malaysia-that the Center believes deserve, recognition, for better or worse. “The Center offers congratulations to those responsible for items on the ‘best of’ list,” said Center executive director Sandy Summers, “and we encourage continued strong efforts from them. We are also reaching out to those responsible for items on the ‘worst of’ list, in the hope that we can help them improve their treatment of nursing issues in 2004.”

The Ten Best Portrayals of Nursing in the Media 2003

Golden Lamp Awards

1. Angels in America, Directed by Mike Nichols, Screenplay by Tony Kushner, HBO, Dec. 2003-to date.

2. Newspaper columns, Ronnie Polaneczky. Philadelphia Daily News. Nov.-Dec. 2003.

3. “America’s Biggest Health Care Crisis,” John Pekkanen, and “One Day in Critical Care: A Nurse’s Story,” Anonymous, Reader’s Digest. Sept. and Oct. 2003.

4. “A critical shortage: With nurses’ ranks thin, scramble to fill shifts intensifies,” and “Looking for a shot in the arm: Programs aim to make nursing more fulfilling, efficient,” Joel Dresang. Milwaukee Journal-Sentinel. Feb. 22 and 23, 2003.

5. RN: The Past. Present and Future of the Nurses’ Uniform. Mark Dion and J. Morgan Puett, The Fabric Workshop and Museum, The Center for the Study of the History of Nursing, School of Nursing of the University of Pennsylvania, at The Fabric Workshop and Museum, Philadelphia, PA, October 2003-February 2004.

6. “At Hong Kong Hospitals, SARS Takes a Heavy Toll on Nurses,” Keith Bradsher. The New York Times. May 8, 2003.

7. “Drawn to nursing care,” Catherine Siow. The Star (Malaysia), Dec. 1, 2003.

8. Doctors Without Borders: Life in the Field: Cool Hand Luc, Producers Diane Best and David Wald, National Geographic Channel. July 2, 2003.

9. Television health expert appearances, Pat Carroll. CNN Headline News, May 2003. and Donna Cardillo. Today Weekend. NBC. October 4. 2003.

10. “Nurses brace for SARS,” Kirsten Downey. The Washington Post, June 10, 2003.

Honorable Mention

“Whistleblower nurses stood bravely for cause,” The Australian. December 19, 2003.

Overall coverage of nursing issues, National Public Radio. 2003.

“Nurse’s gadget saves NHS millions,” BBC News. U.K. Edition. October 24, 2003.

“Flexible hours ward off sickness,” Raekha Prasad. The Guardian (UK). May 21, 2003.

Paul Flowers episodes. Scrubs. Executive Producer Bill Lawrence, NBC, January and February 2003.

Ten Worst Portrayals of Nursing in the Media 2003

1. “My Fifteen seconds.” episode of Scrubs, written by Mark Stegemann, Executive Producer Bill Lawrence, NBC, November 20, 2003.

2. “Dear Abby” and “Freefall.” episodes of ER. written by R. Scott Gemmill and Joe Sachs, respectively, Executive Producers John Wells, Michael Crichton and Christopher Chulack, NBC, October 9 and November 20, 2003.

3. Passions. Executive Producer Lisa de Cazotte. NBC, March 2003-to date.

4. “Militant angels of mercy.” Christie Blatchford. National Post (Canada), June 7, 2003.

5. “His and Her Body Test.” The View. Executive Producer Barbara Walters, ABC, June 16, 2003.

6. Comments, Sara Edwards, entertainment reporter at WHDH (Boston NBC affiliate), as reported in “Smock-clad Sara Edwards nurses her role on ‘ER,’” Boston Herald, February 12, 2003.

7. “The Long Goodbye.” episode of judging Amy, written by Barry O’Brien, Executive Producers Joseph Stern, Amy Brenneman, Connie Tavel, Alex Taub and Karen Hall, CBS, November 11, 2003.

8. “Secrets to a Happy (and Healthy!) Pregnancy,” Leah Hennen; “Should I Call the Doctor?” Jessica Snyder Sachs; “Simple Truths All Moms Can Use,” Barbara Rowley; Parenting. October 2003.

9. “How medical errors took a little girl’s life,” “From tragedy, a quest for safer care,” Erica Niedowski. The Baltimore Sun, Dec. 14-15, 2003.

10. The Nurse, Bangkok. Thailand retail outlet of the Pacific Cigar Company. as described in various Dress nieces. July 2003.

Best Attempts to Remedy Negative Media Portrayals of Nursing 2003

Clairol Herbal Essences television commercial. Procter & Gamble, early 2003.

Lion Red advertising campaign. Lion Brewery (New Zealand), February 2003.

The Center for Nursing Advocacy, founded in 2001, is a Baltimore-based non-profit that seeks to increase public understanding of the central, frontline role nurses play in modern health care. The focus of the Center is to promote more accurate, balanced and frequent media portrayals of nurses and increase the media’s use of nurses as expert sources. The Center’s ultimate goal is to foster growth in the size and diversity of the nursing profession at a time of critical shortage, strengthen nursing practice, teaching and research, and improve the health care system.

The Lists in Greater Detail

The Ten Best Portrayals of Nursing in the Media 2003

1 Angels in America, Directed by Mike Nichols, Screenplay by Tony Kushner, HBO, Dec. 2003-to date-Mike Nichols’ film version of Tony Kushner’s epic play exploring faith, politics and sexuality in the AIDS era includes one of the best depictions of nurses in feature film history. Angels in America rightly places nursing at the center of AIDS care. The main nurse character is Jeffrey Wright’s former drag queen Belize, who-despite a few questionable choices-balances skill and determination, cynical wit and tough love, as he fights to keep his friends alive and sane. Nursing the nasty, AIDS-afflicted power broker Roy Cohn (Al Pacino), Belize provides Cohn with a measure of comfort and dignity, even as they trade high grade invective across a chasm of mutual loathing. Belize is the moral center of the entire 6-hour work. In addition, Emma Thompson plays the autonomous, compassionate AIDS nurse Emily.

Editor’s note: AORN’s “Recommended practices for surgical hand antisepsis/hand scrubs” appear on pages 416 to 431 in this issue of the Journal. AORN encourages readers to refer to this document when undertaking any evaluation of scrubbing practices in their facilities.

Brushless scrubbing is a relatively new concept. Traditional surgical scrubbing of the hands and forearms with a brush or sponge has been the policy for surgical team members for decades. Can this tradition be changed if other methods of cleansing the hands and arms before surgery prove effective? Can the traditional scrubbing practice, which mandates friction and no touching after scrubbing, be changed to a practice that is much less stringent? This paradigm shift was considered by a 380-bed acute care hospital in the southeastern United States. The hospital conducted a clinical evaluation to investigate brushless scrubbing.

Traditional surgical scrubbing has been the norm for many years. It is abrasive to the skin and may provoke allergic reactions. Compromised skin integrity may increase the chances of bacteria colonization on the hands and under the nails. In 2002, the Centers for Disease Control and Prevention said that using a brush or sponge no longer was necessary to reduce the microbial count on hands as long as an alcohol-based scrub product was used.Studies show that alcohol-based solutions that contain between 60% and 95% alcohol have the greatest ability to decrease the bacterial count on hands after scrubbing compared to other agents.

Brushless scrubbing is the surgical scrubbing of the hands and forearms with an antimicrobial agent without the use of a brush or sponge. The person’s hands serve as the friction agent. Brushless scrubbing is believed to be less caustic and abrasive to the skin than traditional scrubbing and can aid in maintaining skin integrity, even after repeated use in the perioperative setting. The antimicrobial agents used in conjunction with agents for persistence (eg, zinc pyrithione) have been shown to have long-lasting effects, thereby minimizing the chances of patients acquiring postoperative surgical site infections (SSIs).

EVALUATION PARAMETERS

The project director at the hospital where the evaluation was conducted wanted to examine the effectiveness of brushless scrubbing to determine whether it would irritate perioperative staff members’ hands and arms and whether it would result in changes in patients’ postoperative SSI rates. Perioperative staff members’ satisfaction with the alcohol product and their acceptance of brushless scrubbing also were investigated.

Many factors and variables contribute to the development of postoperative infections; therefore, the facility limited the evaluation to specific procedures–laminectomies, craniotomies, and colectomies. Generally, patients undergoing these procedures have fewer contributing medical problems that would make them more susceptible to postoperative SSIs.

CONDUCTING THE EVALUATION

The evaluation was conducted at a not-for-profit, 380-bed, acute care hospital that is part of the Baptist Health South Florida hospital system. There are 10 OR suites in the main hospital and four OR suites in the outpatient surgery center. To examine staff members’ satisfaction and compliance with a brushless system, those who perform surgical scrubs (ie, surgeons, nurses, surgical technologists, house physicians) participated in the evaluation. To examine the potential increase in participants’ skin irritation that could lead to skin infection and thus SSI in patients, information was collected postoperatively on staff members’ skin breakdown, irritations/allergic reactions, pain/itching, and skin moisture. The evaluation took six months (ie, 27 weeks).

PRODUCT EVALUATED. The project director had to determine which alcohol-based brushless scrubbing agent would be used. She evaluated all available products and chose an antimicrobial agent approved by the US Food and Drug Administration (FDA). The product chosen is a 70% ethyl alcohol-based solution that contains emollients and the preservative zinc pyrithione, which enables the product to increase its persistence. According to the FDA’s Tentative Final Monograph for HealthCare Antiseptic Drug Products, ethyl alcohol is classified as a category one agent, meaning it is safe and effective) The monograph for the chosen product states that it exceeds the highest requirement for antimicrobial activity for a five-day period. The director liked this product because it is used with water, as is traditional scrubbing. The hospital’s infection control committee approved the use of the product in the clinical evaluation. All perioperative staff members attended an inservice program regarding the proper use of the product.

DATA COLLECTION. Two data collection tools were developed. One was a satisfaction data collection worksheet, and the other was an infection control data collection worksheet. The satisfaction data collection worksheet included a three-point rating scale that staff members used to rank their skin integrity from poor to excellent. This tool was used to identify the brushless product’s effects on their hands and arms after application. The infection control data collection worksheet was used to gather information about patients’ development of postoperative SSIs.

Scott Foley is returning to NBC’s comedy “Scrubs.”

Foley, who first appeared on the medical sitcom in its freshman season, is set to reprise his role as a fumbling, insecure patient who developed a crush on his doctor, Elliot Reid (Sarah Chalke).

He is set to guest star in six episodes this fall, beginning with the season premiere.

“Scrubs” is returning for a third season this fall in the 7:30 p.m. Thursday slot.

“Felicity” co-star Foley is preparing for his role in Manhattan Theatre Club’s production of “The Violet Hour” on Broadway this fall.

His wife, “Alias” star Jennifer Garner, filed for divorce in May after a six-week separation. They have been married since 2000.

Every woman has her own unique idea of what makes her feel attractive. For some, it’s clear, wrinkle-free skin or the perfect shade of lipstick. When you’re in the beauty business, a philosophy about beauty becomes an integral part of the work you do. We asked five veterans of the industry how they stay true to themselves when they’re beset by short-term stress, long-term responsibilities and the world’s often arbitrary standards of attractiveness. One thing they all agree on: Good health habits and self-confidence are always the most important ingredients to feeling your finest and looking your loveliest.

donna perillo Owner, Sweet Lily Natural Nail Spa & Boutique in New York City

I love being barefoot. I like the feeling of the ground beneath my feet. Sand, grass, dirt–I love it all. Winning way to recharge: “I live for my morning cup of chamomile tea before I head out and walk my dog [a Maltese named Lilah] on the piers of the South Street Seaport. That quiet moment helps me connect with the natural world.

Daily living consciousness: I’ve always been aware of what I eat and what I put on my body. It’s an impossible task to live naturally all the time, but I do what I can and that makes a definitive physical difference for me.

Getting comfortable: When I’m spending a relaxing Sunday with my boyfriend–going to brunch, sitting around in sweats–that’s when I feel like I look my best. It’s not about what I’m wearing or how I’ve done my hair, it’s just a feeling I get.”

jeanine downie, m.d.

THE GUARDIAN

I don’t wear much makeup during the day, but applying even the slightest bit of lipstick can be a pick-me-up.

Dermatologist in Montclair, N.J., and author of the forthcoming book, Beautiful Skin of Color

Growing up as the daughter of the first African American woman to graduate from her medical school in the early 1960s, Jeanine Downie, M.D., always knew she’d be a doctor one day. After first trying her hand at pediatrics, Downie found her calling in dermatology.

“Healthy, glowing skin was something I strived for as a child, but it didn’t happen because I had acne and eczema,” says Downie, who has since gained the know-how to care for her complexion. “I leave work each day fulfilled and gratified because I know I’ve helped so many people feel better about themselves.”

“On skin and self-esteem: I keep my skin tone even by exfoliating, wearing sunscreen and drinking 10 glasses of water every day. I have my regimen down and my skin is where I want it to be, and that gives me self-confidence. My skin isn’t perfect, but that’s fine because I know it’s the best it can be.

Practicing what she preaches: Many African Americans, Latins and Asians believe that they don’t need sunscreen because they don’t burn as easily. But that’s just not true. I’ve been using a sunscreen with SPF 30 every day since I turned 21, and it’s been completely worth it in terms of keeping my skin looking youthful.

Down time: I’m my most relaxed when I’m on vacation on Martha’s Vineyard with my husband and daughter. We spend a lot of time catching up with a great community of friends who’ve vacationed together for years. We all learn from and grow with each other.”

daria myers Senior vice president and general manager, Origins

THE VISIONARY

For me to feel beautiful, I need to feel healthy. It’s more of a physical feeling than something superficial.

Throughout Daria Myers’ 27 years with the Estee Lauder Co., she’s been a visionary. She was a founding member of the team that created the Origins brand in 1989. Ten years later, she joined the Aveda division of Estee Lauder before recently returning to Origins, her first love.

In keeping with the original philosophy of the botanically based beauty brand–”beauty begins with your well-being”–Myers believes that much of how she feels when she looks in the mirror has to do with how healthy she is. “When we started Origins, my whole life changed,” she says. “I realized the essential connection between wellness and beauty.”

“Selfish acts of beauty: I take leisurely baths every night. It’s a ritual I believe in. A bath helps you wind down, reduces the stress of the day and helps you sleep much more soundly.

Quick fix: I use Origins Peace of Mind On-the-Spot-Relief every single day. It’s become a ritual that helps me create a sense of calm and balance. I used to suffer from migraines and I’d put a few drops on my temples to take the edge off the headache. Now, I’ll rub some on my ears before a big meeting to ease any anxiety.

In downtown Manhattan sits an oasis, the year-old Sweet Lily, Donna Perillo’s cozy nail salon that embodies her holistic and healthy approach to life.

With fresh flowers and warm lighting, the salon feels just like a living room. Clients perch for their pedicures in overstuffed comfy armchairs, dangling their toes into enameled, antique-style tubs filled with peppermint oil and slices of apple or grapefruit.

“I want customers to feel at home–and a home doesn’t smell like acrylic,” says Perillo.

Except for the polishes and polish removers, all of the products used at Sweet Lily, like the nonabrasive sugar scrubs with essential oils, contain natural ingredients and are made on-site.

In the world of Fashion, we call it “grooming,” that umbrella term for everything a man does or doesn’t do to make himself hygienically and aesthetically acceptable. Too often, though, this includes harsh deodorants and soaps, aftershaves and mouthwashes that sting, and a lack of concern for protecting the skin. In fact, you rarely see the word “gentle” or “for sensitive skin” on labels of men’s products. But in spite of marketing cues to the contrary, more and more men are evolving their personal care choices based on science and smarts, not just popular images aim studly slogans. And there are untold rewards–not just quick fixes–to be discovered in the new generation or naturally potent (as opposed to synthetically harsh) personal care products for men. Here are just a few.

Funny commercials suggest that if we dutifully swish harsh mouthwashes around and take all that torture like a man, the hard earned payoff will be a healthier, germ-free mouth. But several medical experts warn that alcohol-based mouthwashes can dry out the mouth, contributing to tooth decay.

It is also important to note that several studies, including a 1991 study conducted by the National Cancer Institute, found that mouthwashes containing more than 25 percent alcohol dramatically increased the risk of oral cancers. Seek out mouthwashes and toothpastes that are not merely free of alcohol and other harsh ingredients such as sodium laurel sulfate (which, in toothpaste, can contribute to canker sores), but also those that are crammed with powerfully therapeutic ingredients such as coenzyme Q10 (CoQ10)–proven to heal gum tissue when applied topically–or xylitol and green tea, both proven to kill bacteria in the mouth without irritation or drying it out. No blind faith or self-abuse is required.

Synthetic deodorant bar soaps have no benefit to the skin, and strip it of its protective barrier. Try essential-oil-containing natural soaps For much healthier skin. For dry skin, use a soap high in olive or coconut oil. For oily skin, seek extra antibacterial protection with soaps containing neem, tea tree or other naturally purifying oils. Note that terrific smelling essential oils such as sandalwood and lavender make you smell great while also fighting bacteria without leaving the skin dried out and vulnerable the way synthetic antibacterial soaps do.

For your Face, forget soap altogether, and go for a good cleansing milk or cream instead. Choose a shaving cream with nourishing plant oils rather than mineral oil, which blocks the pores. Skip the alcohol-based, synthetic aftershave, and go for either an aloe-based anti-inflammatory and anti-aging skin healing gel if you have acne or inflamed skin, or a natural aftershave with great-smelling essential oils that moisturize while addressing irritations such as ingrown facial hairs (read more about folliculitis in my Q & A section at www.betternutrition.com).

For fighting wrinkles, choose collagen-building and skin-thickening ingredients instead of harsh acids and gritty scrubs, which can irritate and inflame the skin and have uncertain long-term effects. Then stock up on truly natural, broad-spectrum sunscreens containing a protective and anti-inflammatory zinc oxide and titanium dioxide duo, which–unlike synthetic sunscreens–in animal studies have not been found to have estrogenic effects or collect in the body.

Hold On to Your Hair

If you’re currently using or considering prescription or over-the-counter hair-loss drugs, some of which have been linked to erectile dysfunction (such as Propecia) and heart changes (as in the case of minoxidil), consider supplements and topical preparations from your health food store, several of which have been proven in clinical studies to reverse male pattern baldness by blocking the hormone dihydrotestosterone (DHT) without side effects. For more on hair health and hair loss, see my in-depth story “Hair Today, Gone Tomorrow …” at www.betternutrition.com. In the meantime, use a shampoo and a conditioner that purify and nourish the scalp with essential oils and marine extracts while inflicting no pore-clogging petro-chemicals or perfumes on the scalp.

Smell Like a Man, Not a Man-Made Smell

And now for some major news about antiperspirants: The US Food and Drug Administration (FDA) will soon require a warning label to be displayed on antiperspirant deodorants containing aluminum. Recently confirmed findings have shown that these deodorants can cause harm to people with kidney problems. The FDA asserts, however, that accumulation of aluminum in individuals with normally functioning kidneys is considered minimal.

For those seeking aluminum-free deodorants as well as those free or irritants such as perfumes and propylene glycol (PG) but who have been disappointed at the lack of truly effective choices, there is also some very good news to report: The first PG-free stick deodorant technology has finally been perfected and paired with odor-inhibiting substances such as lichen.

The hectic urban life we lead nowadays boosts destructive stress in almost every person. Our health is broken: weight problems and nervous disorders are current maladies in the modern world. We all have forgotten what it is like to feel carefree and relaxed, and our body seems to be older than our actual age. Gyms and fitness centers are a good choice to fight back against these, problems, but regular visits to a health spa can become a more complete solution to keep us in the condition we should be in. You can choose a day spa to take some hours off to pamper yourself for a while, or you could energies at a resort spa and enjoy actually run away for a couple of days to restore your a pleasant vacation at the same time. Here are some five-star spas you might want to consider. You owe it to yourself!

This is an amazing Italian Renaissance style resort in the heart of Palm Beach, one of the most legendary destinations in the US. It is a 140-acre oceanfront property with a 20,000 square foot luxury indoor/outdoor spa. If you are on a family vacation, there are all sorts of activities at the resort to amuse everyone: swimming pools, golf course, tennis courts, kids center, restaurants, and boutiques. The family can enjoy the resort’s facilities while you head out for a prime experience at the spa.

The Breakers Spa is warm and elegant, and it is the only spa outside Paris to offer the exclusive Guerlain Institut de Beaute’ facial. Massages, facials, purifying body scrubs, and wraps are all performed by a trained staff of experts who will individualize treatments according to the client’s needs. The spa offers thirteen different massage techniques and a wide variety of facial and skin care and body treatments. If you want a new hairstyle or a makeover, there are also beauty and salon services. Many treatments incorporate sea and citrus ingredients indigenous to Florida. Besides the seventeen treatment rooms and the salon stations, the spa offers a state-of-the-art oceanfront fitness center with an outdoor lap pool, ocean lawn for fitness classes, a courtyard for relaxation, and jacuzzi.

You may have heard “The operation was a success, but the patient died” as the punch line of an old joke, but, sadly, it is too often true. Surgical-site infection (SSI) can be a life threatening complication following a successful operation.

In a study by Leape et al, it was reported that 14% of all adverse events in hospitalized patients were due to SSIs. (1) The Centers for Disease Control and Prevention (CDC)’s “Guideline for Prevention of Surgical Site Infection, 1999,” noted that SSIs were the “third most frequently reported nosocomial infection, representing 14% to 16% of all nosocomial infections among hospitalized patients.” (2) The guideline also stated that hospitals in the CDC’s National Nosocomial Infection Surveillance System who conducted SSI surveillance from 1986 to 1996 reported 15,523 SSIs resulting from 593,344 operations. SSIs were the most common nosocomial infection among surgery patients, accounting for 38% of infections. Of these, two thirds of the infections were confined to the incision, with one third affecting organs or spaces accessed during the operation. The deaths of 77% of the patients with SSI were reportedly related to the infection.

Patients experiencing SSI have their hospital stay prolonged by 7.3 days on average, to the tune of $3,152 in extra charges. (2,3) Studies by Boyce et al (4) and Poulsen et al (5) also associate increased length of hospital stay and cost with SSIs. Patients who develop an SSI need, on average, 4.6 more ambulatory-care visits than do patients who escape SSI. (6,7) Clearly, SSIs cause substantial morbidity and mortality and create a financial burden on already stressed budgets of healthcare systems.

Certain interventions can reduce SSI rates. Method of hair removal, use of appropriate antiseptics to prepare the operative site and for surgical hand scrubs, and the timing of antibiotic prophylaxis should be reviewed to ensure that practices deviating from standard guidelines are not contributing to elevated rates. (7)

Vicki Brinsko, Infection Control Coordinator, Vanderbilt University Medical Center, Nashville, Tennessee, related how their department made a matrix, basically a check list, comprised of the CDC’s recommendations outlined in the SSI guide line. (2) Brinsko explained, “When there is a rise in SSIs, a meeting is called, and we go over the matrix to make sure we are in compliance with the guidelines.” Vanderbilt has the necessary steps in place to prevent SSIs, as much as it is within their power. Even religiously using the guidelines will not completely stop SSIs because the infections are transmitted by colonized healthcare workers, and the colonizing germs are endemic to hospitals and other healthcare facilities. The most that can be hoped for is to hold them down. The CDC SSI guidelines are very specific about measures to take to reduce the incidence of SSI.

Timing of Administration of Antibiotics

Often,” Brinsko said, “it’s a matter of the timing of administration of antibiotics being off. The CDC recommends antibiotics be given to patients 30 minutes before ‘cut time,’ so that the antibiotic has time to work. Delaying administration of antibiotics can easily be come a problem. Sometimes nurses are assigned the task of administering antibiotics, sometimes anesthetists are assigned to do it, and no matter who delivers the antibiotics, there can be reasons it’s delayed. If a previous operation has run longer than expected, for example, that can delay the patient in getting to the operating room, so antibiotics may not be given within the recommended time period.” Brinsko also pointed out that “If cutting comers has been a problem, it will be revealed during the investigation of an outbreak.”

Limiting Room Traffic

Another area that Brinsko and her team track is traffic in a room. Each time a door is opened, a way is provided for organisms to enter. “You’d be surprised how many times a door is opened as healthcare personnel gather items, such as intravenous fluid solutions, when preparing for surgery; so, we put counters on the door.”

Skin Preparation and Hand Cleansing

“Artificial nails are a hot issue. The Association of periOperative Registered Nurses (AORN) says not even to use nail polish, but everybody loves artificial nails. They look great, but if you are in health care and touch patients, especially in the operating room or intensive care unit, do not wear them. Bacteria and fungi, particularly, can grow in the spaces between the nail and the tip of the finger, and scrubbing can’t get rid of these organisms. Operating nurses have to be very cognizant of nail cleansing.”

“Skin preparation also is very important, explained Brinsko. “The CDC recommends clipping rather than shaving hair to cut down on infection.” Shaving can cut the skin, giving bacteria an opportunity to infect. “Surgical skin prep solutions should be applied in an aseptic fashion, as recommended by AORN.”

In March 2003, an infection called Severe Acute Respiratory Syndrome (SARS) made its way to the Greater Toronto Area from Guandong Province in China. On March 23, 2003, North York General Hospital (NYGH) SARS ICU received its first critical SARS patient. The SARS ICU was a converted hospital ward where engineering and building services created negative air pressure airflow in patient rooms. Personal protection protocols to enter the unit and then the patients’ rooms required us to wear hospitalprovided scrubs, N95 masks, double isolation gowns, double boots and bonnets, double gloves and protective eyewear. The environment was claustrophobic and scary. With no air conditioning, and two nurses and the ICU equipment crammed into each small room, I had to think cool and not touch the mask. Close skin seal to ensure proper fit was crucial. I tried not to think of the possibility of contamination, but at the time, we didn’t know how the disease was transmitted. As there were no windows into patient rooms, I had to enter the rooms to access charts and physically assess patients.

An important component of infection control was limiting patient contact with personnel and visitors. During the first outbreak, I visited only for initial assessments and weekly follow-ups, relying on daily telephone contact with the nurses for updates, and computer monitoring of blood work. Effective use of time when in the room was not always what it seemed, as nurses welcomed the distraction and prolonged my visit with much needed conversation. These nurses were isolated from the rest of their colleagues (and were sometimes shunned by friends or family) and I saw this companionship as an unavoidable part of my work. How to deliver intensive care efficiently and compassionately to both patients and health care workers, while protecting oneself and others from infection will be one of the important lessons learned from the SARS epidemic (Rubinfeld, 2003).

I was in a patient’s room for about an hour at a time. I assessed two to three patients consecutively so as not to have to return to the unit. In doing so I probably increased potential exposure, but nurses did 12-hour shifts, sometimes for five straight days. I don’t know how they did it. I got nauseous and dizzy from my relatively short time in the rooms and I was grateful then that I was only part-time.

I couldn’t take my binder of patient profiles and assessment tools into the unit, so I put copies in each chart, and then recorded notes upon return to my office. I was permitted to take in a calculator, encased m a zip lock bag, then cleaned with VIROX antiviral samtizer and rebagged between rooms and when leaving the unit.

The non-SARS ICU was still open during the first outbreak, and the need to wear masks and gowns gave us a taste of what might become the new normal in hospital care. I looked forward to the scheduled opening of the new ICU for june 23; with four isolation rooms with antechambers, and 20 regular rooms, all with glassed-in doors and walls.

On May 23 everything changed. What started out as a ‘typical day’ (with new non-SARS ICU admissions to assess, three ICU SARS patients to follow, and a dietetic intern to coach), turned into a nightmare. At the end of the day back in the non-SARS ICU, I was handed a mask. At this time NYGH was allegedly at the end of the first outbreak. I, as others had done, relinquished my mask for non-SARS patient contact according to Ministry directives. We were advised not to go home until the Unit Adminstrator (UA) returned from a meeting, as we might all have to be quarantined. Indeed, we learned that we had been re-designated a Level 3 hospital; SARS had transformed from a communityacquired infection to a hospitalacquired infection with our own staff being admitted with the disease. NYGH was described as the epicentre of SARS II (Adamson, 2003).

It was 9 p.m. by the time the intern and I went home, where we were to remain on ten-day work quarantine - we could only go to work (by car or taxi, wearing a mask) or stay at home. No physical contacts and we were to wear a mask if in the same room as others. We were to take our temperatures twice daily, call in any fever, and stay home if ill. I called my family to have them get ready the basement room where I lived for the quarantine period. I awoke the next morning with a relentless cold. I took my temperature several times a day and thankfully, had no fever. I was advised to stay home until symptomfree. Regular phone contact with my Coordinator of Professional Practice kept me informed of hospital e-mails and plans to move into the new ICU on May 25, finished or not. While at home, I was more concerned about the possibility I had inadvertently exposed my family and friends to SARS than the thought that I might have SARS myself. I was worried and wanted the ten days to pass. At the same time, I wondered why I would ever return to such a high-risk environment.

During quarantine, I learned that NYGH was designated a Centre of Excellence for SARS treatment. The hospital was accepting only SARS patients to our newly designed SARS ICU and SARS ward. My part-time ICU RD position became exclusively a SARS ICU RD position until further notice. The duty to treat is strong, and health care professionals are expected to take some personal risk to do their duty (Maser et al., 2003). I never questioned that, but I also never dreamed of this. I didn’t really know what it meant, but I had my doubts. The SARS outbreak suddenly presented significant issues for ICU care and work life. I needed to assess the degree of risk in assuming this role.

As a result of a two-year repermitting emigrants to retain their original citizenship despite naturalization elsewhere. Many are also establishing official ministries to address the needs of citizens living abroad. Several of the authors suggest that these efforts are driven by the growing dependence on the remittances sent from immigrants in the U.S. As one presidential candidate in the Dominican Republic said in 1996, “These people send back more than a billion dollars a year to our country. Their voices deserve to be heard” (p. 95).

In her interesting chapter, “Transnationalism Then and Now,” Nancy Foner argues that such cross-national ties are not new. She points to the strong links that many Italian immigrants had to Italy in the early part of the 20th century. But she also acknowledges that technology– both communications and travel–has facilitated more frequent and intimate contacts.

The chapters in the second part of the book focus on the incorporation of immigrants into the social and economic fabric of New York, and specifically on the ways in which race matters in this process. Atone extreme, Johanna Lessinger’s chapter on Indian Americans describes a group of successful immigrants who place themselves emphatically on the “White” side of the color spectrum, distance themselves from other non-White minorities, and largely deny poverty within their ranks. At the other extreme, the two chapters on Caribbean immigrants portray a group that has been unable to identify and integrate with other racial goups. In chapter 10, Vilna Bashi Bobb paints a sobering picture of West Indians who grow increasingly disheartened about the extent of racism in the U.S. Meanwhile, in chapter 9, Philip Kasinitz and Milton Vickerman persuasively argue that race has directed the development of ethnic employment niches for Jamaicans and limited the effectiveness of their social networks. While Jamaicans enjoy re latively high levels of employment, they are heavily concentrated–like African Americans–in sectors (e.g., the public sector) that provide few opportunities for upward mobility and accumulation of wealth.

Because the book was published in August 2001, before the attack on the World Trade Center, there is no description of the effect of this tragedy on the different ethnic minorities. It is difficult to read a book about the “meaning and experience of contemporary immigration to the United States” (p. 1), particularly one set in New York City, without wondering about how the events of September 11, 2001, might have affected this book.

A conspicuous absence that the editors could have addressed is the book’s lack of any discussion of immigrants and public education. Public schools have traditionally been the avenue through which we “Americanize” immigrants and teach them the country’s language, values, and customs. A chapter or two exploring how our schools are helping immigrant children adjust to life in the U.S. would have enriched this volume considerably. Are our schools encouraging transnational identities or are they contributing to a full assimilation? One final quibble is that the book’s audience would have been broader had the use of academic jargon been more limited. Still, planning practitioners will find some useful lessons here as they face growing immigrant populations in their cities.

This collection ultimately delivers a nuanced portrait of the contemporary immigrants to the United States. Each chapter typically focuses on immigrants from a particular country and as such offers unusual derail. At the same time, the tone and themes of the various chapters are consistent. The clearest theme is the complex and multifaceted nature of relationships and identities. In today’s global world, the authors suggest, it is quite possible (and even perhaps inevitable) to hold multiple allegiances.

Ellen is an assistant professor of urban planning and public policy at the Wagner School at New York University. Her research focuses on neighborhoods, housing, and residential segregation. She is the author of Sharing America’s Neighborhoods: The Prospects for Stable Racial Integration (Harvard University Press, 2000).