"When you get those rare moments of clarity, those flashes when the universe makes sense, you try desperately to hold on to them. They are the life boats for the darker times, when the vastness of it all, the incomprehensible nature of life is completely illusive. So the question becomes, or should have been all a long... What would you do if you knew you only had one day, or one week, or one month to live. What life boat would you grab on to? What secret would you tell? What band would you see? What person would you declare your love to? What wish would you fulfill? What exotic locale would you fly to for coffee? What book would you write?"

Tuesday, May 19, 2020

The Coronavirus Chronicles: Nurses on the Frontlines

This post has been a long time coming, and has been one of the hardest to write. A month or so ago, I had the idea to interview local nurses that I know about their experiences with COVID. We all hear about hero or tragic stories on the news but I wanted to be able to hear how local, real, close to home nurses were experiencing the same battle. I interviewed 6 different nurses, all from different backgrounds and roles to give you unique perspectives. I will also throw in my 2 cents where I see fit, coming from a nursing informatics background.

These 6 nurses are all from North-East Pennsylvania and Western New Jersey. I have chosen to keep their identity and the organization they work for anonymous, because I wanted them to feel as if they could truly be honest with me and my audience. I have changed their names to something not their own, and any details that make you think you know this person are purely coincidental.

All of these magnificent nurses are ones that I know personally. Some have trained me in my practice. Some I have worked side by side with. Some I have trained. Some have been my mentor. All bring a different perspective to the table here.

Miranda is a Medical Surgical Nurse in Allentown, PA with over 6 years bedside experience.
Chris has a Doctorate of Nursing Practice and practices in a PA ICU with over 20 years experience.
Reagan is a newer Emergency Department Nurse in Stroudsburg, PA with under 5 years experience.
Nicolette is a Medical Surgical Nurse in Hackensack, NJ with over 10 years of bedside experience.
Kayla is a nurse in the ICU in Easton, PA with over 6 years bedside experience.
Tyler is a nurse manager in charge of 20-30 nurses on an inpatient Medical Surgical Unit in Pennsylvania, and has over 10 years of bedside experience.

Okay well that was the easy part. Introducing them. The hardest part is going to be what comes next. Taking their honest, heartbreaking, gut wrenching words and doing them justice. Presenting them in a way that will never be forgotten. Not tomorrow. Not next year. Not in ten years. Not when this goes away. Never. So here goes.

This virus has come in like a tidal wave no one saw coming. All agreed that when training to be a nurse or before they decided to be a nurse, no one saw this coming in our future. No one. No one predicted we would have a world-wide pandemic and shutdown. No one saw coming how hospitals would be right up there with the rest of the world, losing millions and millions of dollars and cutting staff left and right during a health crisis. No one saw a three month quarantine coming away from their loved ones, their own children. No one saw the stable ground being ripped up from under them but still showed up to work every day, ready to fight. THAT is what has inspired me the most about this group. All agreed that if they knew this global pandemic was coming back when they decided to become a nurse, would they still do it? They ALL agreed YES. They would still become a nurse. Miranda stated, "We are making history right now. This has made me honored to become a nurse." Kayla from the ICU shared, "I would still become a nurse because even feeling fearful, frustrated at times, and dispensable, I know I am saving lives that no one else could. If I wasn't watching over their loved ones as they struggle to breath, these patients would not have made it out of the unit. I am making a difference and that is empowering."

But despite always choosing nursing no matter what, this time certainly has been anything but easy. It has taken a toll on some of their emotional health, physical health and their families. When I asked what is their biggest fear right now, every single one of them said something regarding "fear of a loved one getting the virus", whether that was their child, spouse, or a parent. They didn't even mention fear of themselves getting it, only their loved ones. I too, can agree that is my biggest fear. In order to protect their own loved ones, they've each had to go through intense measures. Reagan shared, "I have a little girl at home and my husband and I are both ER nurses. It's tough for us because we can't just stay at home to keep ourselves and little one safe."  So, appreciate that you can out there.  Kayla shared that she hasn't seen her family, including mother, stepchildren and Nana since the beginning of the quarantine as she has been self isolating in between shifts. She shared that no matter the wait, when she gets to hug her family again for the first time, she will never let go.   Nicolette actually acquired the virus herself which took a significant toll on her, her young son and husband, "My husband is an engineer that works for a company that makes ventilators. We were both much needed at work and at home with no alternative child support. Things only got worse once I got sick with COVID and had to isolate from my family. My husband became the only caregiver to our son, in addition to intensely working."

This has changed each and every one of them as a nurse and in how they approach their view of nursing, in some good ways and in some negative ways. Miranda shared, "Every day is uncertain and because of that I am anxious. I have been heartbroken many times when I see patients uncomfortable and fighting for their life...alone." As a nightshift nurse, Miranda shared that she was never personally a fan of family members lingering at the bedside but now sees the vital role and importance of family members being able to be present at their loved ones side- having that critical support system is key to recovery. She stated that is something in her nursing career she will never take for granted again.  Reagan agreed from the Emergency Department sharing, "I have seen more people die in the past few months than I have in the past year. I've watched as someone cried at their diagnosis knowing they were likely never going to see family and grandkids ever again. We deal with tricky diagnoses every day, but this is just so heartbreaking."  Christopher from the ICU shared that this pandemic has made nursing the dominant bedside force. Others felt differently in how they experienced this pandemic, sharing "This pandemic has strained my love for bedside nursing. Its not the sick patients or numerous deaths, its the political and poor administration support that we have at the bedside that I have never felt so dispensable", shared Kayla from the ICU. Nicolette agreed, stating "I lost trust in organizations and felt abandoned to drown more times than I can count". On the shift before she got sick herself, she had all 8 COVID patients, all in need of frequent and intense care. Tyler as a nurse manager shared how positive it has been seeing all of the love and the support (donations, food, cards, letters) outpouring from the local community. But as a nurse manager in a leadership position, he states "Its a difficult time to manage staff. They are scared and there is a lot of unknown. I feel like information is always evolving and changing and it's difficult to maintain trust amongst staff."

A common theme from the group was a newfound sense of anxiety but also calm and a mixture of both, for some. Everyone thinks nurses are immune, that they've seen it all so they can't be affected. But they certainly can. They too are so human and take in everything that is happening directly to their soul.  Miranda shared that "this pandemic has brought out the cranky part of me. I've been on edge at work. We are all working so hard and stressed out. It's very exhausting at times. I've recognized this flaw and am working on channeling my inner peace."  Reagan shared that "I am typically a very calm person but I struggled with a lot of anxiety in the beginning because there is so much unknown with the virus." But they all shared something positive that is keeping them sane during this tough time. Christopher goes out running between shifts. Reagan has picked up a new hobby to stay busy and tries to get outside with her family during the nice weather. Nicolette is looking into counseling services. Tyler disconnects from work when he goes home and plays games with his children and works on house projects. Kayla is working on her degree as a nurse practitioner. Kayla writes, "If I could give any advice, always keep your body and mind busy and the stress is easier to handle." I challenged them all to share a positive thing this crisis has brought them, and they shared many. Extubations and discharges home, seeing a newfound kindness and humanity in strangers, seeing themselves grow with new skills and hobbies, seeing a decline in COVID cases (thank you social distancing!) and seeing their own loved ones get better. Miranda shares from her organization "Every time a COVID patient is discharged from the hospital they play a song for the patient and we all line up at the door to cheer them on as they exit the building. The patients love it and we get to celebrate with them. This proves that there is hope out there. We can always turn negatives into positives." That was beautifully said by Miranda and I can attest with my own experience, after strenuous bedside work- having those positive moments where you can cheer a patient on together as one big community is something she will likely remember forever from her nursing practice.

American Healthcare will change, we have no way around changing at this point. We have already changed drastically and will continue to do so. Things we didn't think were possible "yet" or were on the backburner, now suddenly are the top priorities. As an informatics nurse, I've seen first hand a huge shift in the way patients are seeing their doctors. What once was a "once in awhile thing" that was originally advertised as an option a patient could do if they had the flu and just wanted to connect with a doctor via Facetime, is now a common occurrence. Most of our well visits and sick visits have been converted to "telehealth" visits. Doctors and nurses are also using I-pads to be able to round with their patients electronically from outside the room without having to enter into a COVID room multiple times. This prepares nurses to assemble themselves and get what they truly need to be able to "bundle their care" and handle multiple tasks for the patient at once. Patients are using I-pads to communicate with family members and to connect with specialist providers that may be home, in the office or another hospital.  These are all things we were "slowly working on" that launched into all-hands on deck to make happen in a matter of weeks. But it truly all has made a difference and will permanently shift how we provide American healthcare. Miranda experienced that exact shift in technology, sharing "I have adapted to using more technology and allowing patients and family to see each other on Facetime on Ipads."

There are other shifts happening in healthcare, non-technology related also.  Nurses are seeing a new sense of community, within and outside the hospital. "A lot of flaws in the system were exposed and with every tragic event we learn from that experience. I have seen great teamwork, also. What once used to be a battle of the departments has become a unity of the hospital. We are all in this together." Shared Miranda from the Medical Surgical floor.  The Emergency department is also seeing a shift in care, Reagan states "the ER has been filled with true emergencies and less non emergency cases"- like the ER was always meant to be. This has shifted peoples train of thought to, "do I really need to go to the ER for this sore throat or can it wait until Monday when my doctor is open?" It has opened up more avenues for urgent cares and other forms of healthcare delivery with a primary care provider. The ER was always meant to be there only for true emergencies, as if you must be close to dying in order to come in (heart attacks, strokes, loss of some sort of function, a broken limb, a missing limb, trauma, etc.), but has evolved over the years into being that level of trauma but also bogged down with the "my leg has been sore for 2 years" and "i have a runny nose" cases. I too hope that the ER can see a permanent shift in care delivery mindset. The ultimate goal is to keep people out of the hospital that don't need to be there, and shifting as much care as possible to be in peoples homes.

These six nurses are some of the strongest people I know. They are exhausted. They are suffering. But they are showing up every day. For you. So YOU can stay home. They are working beyond their normal job roles to make sure you stay safe. Their hearts break a thousand times over each shift they endure. They are crying for and WITH your family members that they care for. They are scared. They need a little bit of extra love right now. So if you know a nurse in your life, give them some extra (non-physical) love right now. Kayla from the ICU asks of everyone in the community, "Don't call me a hero. Just say thank you, practice social distancing, and follow the recommendations of the department of health. Remember, practicing social distancing and wearing a mask is not about you, it is about the people you come in contact with. The world is smaller than you think. Don't think your actions do not have consequences, they can kill someone.  It's also not just nursing that needs extra love and kindness right now, remember food services, grocery store workers, truck drivers, warehouse workers, police, firemen, and others in public service. Without them, we would be in true chaos." I couldn't have said it better myself, Kayla!

Thank you to my audience for reading and for listening to these six nurses stories. I am so thankful they all agreed to participate in my idea and to share their feelings, emotions, honest thoughts and stories. This is no where near over but we are adapting, we are getting stronger, we are learning. Healthcare is changing. We will come out stronger from this. Our nurses will come out stronger than they ever were before when this is over.

Thank you for reading. Thank a nurse.

Below is a picture that I saw from another local nurse. This is not one of the nurses that wrote in, but when I saw the picture, it composed every single emotion and honesty that every nurse out there understands, so with her permission I wanted to share.

Photo credit: Miguel Farias
A Writer in  Nurse's Body

Friday, April 24, 2020

Predictive Analytics: Breaking it Down

Hi There! I am BACK. And I wanted to share what my main focus in life right now is. 

But first, a little background on where I've been for the past 4 years....

I am a Registered Nurse, and have been for 8 years. I have been in healthcare for 13 1/2 years. About 4 years ago I took a position that actually removed me from the bedside but instead I got to be a part of helping to design and change our electronic health record in a way that improved patient safety and made more sense for nurses and physicians to use.

I remember within my first month on the job, I was quickly drawn to the fact that we could use this electronic health record to capture data and summarize data on hundreds of patients. Better yet, in this new electronic health record, we had abilities to build our own reports! Someone very influential to me, someone I think was placed temporarily in my life for the sole purpose of steering me in my life's direction, sat with me or initially two hours and gave me my first high level crash course in reporting. I-was-hooked!

From there, I continued to grow and expand the use of reporting and my passion for it became apparent. I became the person on my team that was known for being able to whip up new reports and to also be a whiz in Microsoft Excel. These skills allowed me to not only create and put together data from within the system, but to also summarize and track that data.

About a year or so into the job, I knew I had to advance my degree. I have a Bachelor's of Science in Nursing, but I needed more. I've always loved school and am a total school nerd. I enrolled into my local college for a Masters in Nursing with a clinical nurse leader track. I was doing well, about 2-3 courses in- but......I hated it. Guys, nothing felt more nauseating and not right to me in my entire life. It was all research papers and evidenced based practice and blah. Not for me. I didn't really know what else to do, so I switched to a Masters in Nursing Administration. In this track I started to see how cool the whole business aspect of the degree was, but again felt nauseated in what I was learning with regards to how broken our healthcare system is. I spent years on the floor doing my best and it was never enough to the same people that I was in a degree trying to become. Again, it didn't feel right. I took a break from school when I was pregnant with my daughter and in the post partum period as well. I thought long and hard about returning and what felt right.

Then I saw it: A new program at the same college- It was a sign! A Masters in Science in Predictive Analytics. Technically this isn't a healthcare degree, its a business degree. I always had felt that I had to stay in nursing because that's what my background was, even if I hated the pursuit of anything further in it. But this degree.... it felt right in my bones. Multiple people have told me that when I start talking about data analytics/predictive analytics, they can visibly see the light in my eyes go on fire, the rise in pitch and rate of speed in my voice increase, and I could talk about it forever. That right there everyone, is passion. And I knew I had to pursue it. I always joked in the last 4 years in my job that if I could wake up and spend all day in an Excel spreadsheet, I would love-my-job. Data to me makes sense. Its tangible but also infinite. It's like a math equation. There's an answer at the end but also infinite answers! It makes me jump up and down inside, can you tell?

So I started this program in January of 2019, when my daughter was ~ 5 months, leaving my husband to watch Abby for the 3 hours a week I spent in class. It sure has been a whirlwind ever since, and I still am spending 12-15 hours a week involved in the program with homework, reading and in class time. But, what's difference in this is that those 12-15 hours don't even feel like "homework" or "work". Sure I need to make sure I get it done within the deadlines, but its FUN! When I make a dashboard or create a model I get a sense of immense joy and celebrate in my newfound abilities. It kind of feels like what I imagine it felt like for Spiderman to suddenly wake up and realize he has superpowers. This is my superpower.

But, as I started meeting other moms and introduced myself and what I do or mentioned my degree, or talked with friends and family about it, I started noticing a frustrating pattern: No matter who it was, within a minute of talking about it, people's eyes started glazing over and they'd switch the topic. I told new people that I was getting my degree in Predictive Analytics and they acted as if I said I was getting the degree in astrophysical quantum mechanical engineering (if that's even a thing?).
It was sad for me because this was my passion and I wanted to tell the world about it. To me, at work or in school, it was all common talk and people understood it, but I wanted to be able to share it with more than that.

So, I'm here to break it down as best I can.

I don't want to give any fancy definitions of what it is, because even I don't understand those. Lots of statistics and blahblahblah.

To me, predictive analytics is as simple as using and understanding data from the past to predict future events. That's it!

Ok so let me break it down into a real elementary example, then I will advance a little from there.

This example brings in my love of epidemiology also, so its fun. Let's say there was a big gala held last weekend celebrating something. 100 people were in attendance. There was a lot of food served, but lets focus on 5 foods: They served chicken, salmon, filet mignon, and ham as the meat choices. They had a big salad on the side for vegetarians.  However, unfortunately, a few days later the party hosts found out that 20 of their guests got really sick! They called and blamed the food they ate. So the hosts had to find out, what was it that made everyone sick? So they interviewed each of the sick to find out what they ate. But what is important here, is where predictive analytics comes into play is not just interviewing what the sick ate, but what the non-sick ate too. For example, if the 20 sick people all had the ham, but so did 70 non-sick people, it's probably not the ham that made everyone sick. But how could we really say for sure? Well, nothing is ever really sure in data analytics. Data analytics treats words like "always" and "never" like the black plague.

So what we do here is treat each one of those food items as variables. (I'll explain that more). Each variable would be "Did this person eat the ham, yes or no?" or "Did this person eat the turkey, yes or no?"  By then viewing the list of the 20 people and what they ate, we could likely identify a pattern of the common thing(s) that the people ate that got sick. OK now stay with me- we can use that knowledge of understanding what we THINK got sick and assign them values. So perhaps those that ate the turkey were 80% more likely to have gotten sick and assign it a value of 0.8. We now PREDICT, will the rest of our guests get sick? So we take that list we have of our 80 non-sick people, and essentially run it through a model to determine a prediction of how likely that person is to be sick. If we found out that ham and turkey were the culprits that made everyone sick, if we took one of the non-sick people and found out he too had ham and turkey, we could give him a pretty accurate high prediction that he may end up also getting sick. However, if one of the non-sick people say they only had the salad, and non of the sick people ate the salad, we can give that person a pretty accurate prediction that they won't join their friends in the quarantine.

This sounds like a silly example, but its how these predictions work. In examples I am involved with at work, the "20 sick people" that are used to learn and understand the variables, is actually 500,000+ people (perhaps more likely in the millions). Taking data from only 20 people can lead to a lot of inaccurate predictions. Maybe they were lying or forgot details. But if we are seeing common patterns on half a million people, we can gain better accuracy in applying what we learn to future predictions. Instead of the "variables" being 5 food groups, we instead look at hundreds of variables to better understand everything we can about these instances. In this way, we actually can learn new things that may be correlated to a disease or effect.

Some examples I am working with in healthcare now are predictive models that can predict how likely a patient is to have a cardiac arrest event, or code blue. We use close to a hundred variables that were studied on thousands of patients that DID have a cardiac arrest (think back to the gala example-the people that DID get sick). By learning what was unique about those patients that did have a cardiac arrest, we can then match that set of variables up to a new patient that walks in the door, to see how closely they align to those variables. Perfect match? Yikes, lets get the code cart ready! Hardly a match at all? Pretty good chance they aren't coding on our watch (Again, nothing is certain).

But think of how useful these models are to us, in healthcare and around the world (I'll get to that). By having a prediction like how likely a patient is to have a code blue, we can better prepare as healthcare workers to make sure that doesn't happen. We can better plan staffing ratios, adjust the treatment plan, get other specialists on board, etc.

I'm working on a few other models in healthcare right now, but there are more than I can even count that are actually out there. We are gathering the ability to predict who will experience a fall, who will contract sepsis, who will come to the emergency department, who will not show up for their appointment, who will come back to the hospital, etc. In each of these cases, these accurate predictions allows us to prepare.

But think of it more globally. These same concepts can and are applied to other "predictable" events. We could essentially predict tidal waves, hurricanes, tornadoes by understanding what variables or conditions were in place before those events happened in the PAST to help us predict the FUTURE. We could predict mass shootings by understanding conditions and variables that were attributed to past mass shootings. We could predict train delays or breakdowns, airport delays, stock markets, retail surges, etc. With the growing amount of data being made available to all of us, even you, we will have more and more ability to predict almost any event that can have attributable data to it.

Anyway, I hope I didn't lose you all! If you can't tell, this stuff is my life's passion and I can't wait to see where it takes me. This is really just the beginning. There is so much more involved to it all than what I wrote about in this blog, hence the need to get an entire degree in it (and even that will barely scratch the surface), but I wanted to at least get the concept out there as easily understood. Maybe I'll even inspire someone to go chase the dream for themselves, too!

Thank you for reading.


_ A Writer in an Informatics Nurse's Body

Monday, February 29, 2016

What's Next

Hey everyone! Welcome back. 

So, the past couple months have been a whirlwind of excitement, turmoil, and an incredible learning experience. Let me recap. 

I spent the entire fall not only learning my hospital networks newly adapted Electronic Health Record system, but then teaching it in segmented classes to all of my networks nurses and nurse managers, supervisors and executives. I loved it so much. I never thought I'd make a good teacher, but once I got up there I had the incredible need to share as much information with everyone that I could. I wanted them to know as much as I did, I wanted them to get as excited as I was. I saw how much better this would make our healthcare for patients and I wanted them to see it too. Being a nurse, I was able to bring the information to the nurses and make it relatable. I was able to give them scenarios on why this was helpful for them, a good change. I got great reviews because I was so relatable. I loved it and I wanted more. More teaching, more IT, more knowledge. But then we went live with our software change and unfortunately I was faced with the challenge of my temporary assignment being over and I was then assigned to go back to my nursing unit to work as a nurse until further notice. At first I was terrified, and disappointed. I was terrified because I had been off of the unit for about 5 months and I wasn't sure how well I'd do being submersed back in at full force. I was disappointed because part of the reason I took the temporary assignment in the first place because I was feeling burnt out and run down from Med Surg Nursing. Don't let anyone tell you differently, whether you love it or not, Med Surg Nursing after a few years will take a toll on anyone. So going back was terrifying for me. During my absence many new people were hired, some thought I was the new person since they hadn't met me yet. Every turn I made I met someone new! (And 2 months later, I still am!)

Luckily, like a lot of my friends & family figured, jumping back into bedside nursing truly was like riding a bike. Besides a few minor hospital policy changes, or minor unit workflow changes, or a change in where something is located, I picked up everything within a shift or two. 

Our new software change, in my opinion, has made wondrous incredible changes on the nursing frontline. This makes the geek in me extremely excited. The system prompts you to complete all your necessary work that you still have left to complete for a patient, and it is patient individualized, which means not every patient has the same "To-Do" list! We also get alerted if our patient is deteriorating by the system actually watching our patient's vital signs and observing trends. Not just that but there are may workflow changes that have been improved that are now much more efficient. No more double-charting. No more losing charting. No more downtime. There are so many analytics and reports viewable for our patients that it is incredible, it really makes looking at the patients "whole picture" much easier and user-friendly. Communicating with doctors is more efficient, nurse friendly and faster. Reading progress notes from clinicians is no longer a chore or a handwriting-analysis exercise. All notes from every health care clinician or provider including Doctors, Nurses, Therapists, Case Management, etc., are all typed into this software, and of course readable! This way nurses can better understand (and read) the patients actual plan of care and case. There is nothing I don't like about it! I can confidently say that it has made me a better nurse 100%. Also, with this new change we also were able to adapt devices that have this software loaded onto a small device very similar to an i-phone where nurses and aides can take this from to room to room and have all of their patients information loaded in, and they can chart intakes & outputs, vital signs, complete blood work AND even document medications right from this little device. This also makes the nursing workflow incredibly easier and more efficient. This device uploads in real time and no docking required, unless to charge! 

But even though I find myself becoming a better nurse, I find myself feeling burnt out still from the politics of healthcare and Med Surg nursing. I am ready to move on and am so happy to accept a new position of a Clinical Informatics Analyst starting in 2 weeks! In this job I will be on a small team that analyzes how clinicians and IT work together to improve healthcare and technology. We will improve documentation, fix issues or build workflows, innovate new ideas, make new processes, etc. We are the bridge between IT (non healthcare personnel and nursing). This is super exciting for me because I have been raised on computers. My father comes from a long career history of working intensely with computers and has taught his daughter well. I also probably inherited some genes of being very interested in technology. I am always interested in the newest gadgets, how they work and more importantly, how they can improve human life. So now I will be looking at and working with healthcare gadgets, how they work and how they can improve patient's lives! 

So, as you can see- many changes coming in my life & career. So I want to take a moment to reflect back on my bedside nursing experiences and what I expect for the future. 

As a new graduate, I started on a women's health specialty oncology unit. Having only 11 beds and working nightshift with only 1 other nurse, I had to pick up the skill of autonomy very quickly. With high acuity patients, it was a crash course in nursing. I then transferred to a bigger hospital in my network where they I worked on a Med Surg Telemetry unit where I am now. A lot of things changed when I came here, because not only was I transferring campuses, but my old hospital had just been bought out by the hospital network I transferred to but hadn't quite completely integrated all of their changes into my old hospital by the time I left. So even though I was transferring within my network, It felt like I was transferring to a whole different world. I was also crossing state lines, where there was different healthcare rules. In my new hospital, now nurses and aides were responsible for all blood work.The laboratory   only ran tests, no more on the floor phlebotomists. Nursing and aides were also responsible for EKGs, which actually used to be done by respiratory therapists back in the day at my hospital. I also had to quickly adapt to a sicker patient and higher acuity workload on a telemetry unit. At my old hospital, I had the pleasure of having "telemetry techs" that sat in a room and watched every single heart monitor rhythm in the hospital. They simply called me if there were an issue. I am ashamed to say that within my first few months, the tech called me and told me my patient had a few beat run in Vtach, and I remember replying..."oh. Thats bad, right?" Sigh. Whereas in my new hospital there was no tech and I was responsible for not only caring for 7 patients but also keeping an eye on their telemetry heart monitor rhythms too. 0_0 

Needless to say, I survived but not a day went by where I felt like it was easy. It was always challenging and kept me intrigued. But my home life started to wear away as this increased stress load starting eating away at me. I would lie awake at night and wonder if I did something wrong, if I charted everything okay, did I waste every med? Could I have saved that patient? Did I miss something? I started dreading going in to work and my headaches and nausea incidences picked up immensely. I can't even count the amount of times I have been in a shift and thought, "If I can make it through this shift, It will be a miracle. I will be so thankful to be back home and hide under my covers." 

Yes, Its true. And I'm sure every single nurse that you know or that reads this knows exactly what I'm talking about. 

Over the past 4.5 years of nursing, I picked up a lot of skills and I consider myself a mixture of Proficiency and Expert in Patricia Benner's Novice to Expert Nursing Model. However I always was self conscious and thought it to be a weakness of mine that I never really developed a special skill. I was never the "best IV stick" on the floor. Or the "best charge nurse". Or the "best wound care person" ( i never really grasped wound care), or the best person to know X, Y, Z. I rather considered myself a jack of all trades. Or should I say a Jack of all nurses? I felt like even though I never really mastered one skill to its maximum, my "skill" was that I knew a little bit about everything. I had gotten myself involved in a lot of different committees and PI projects and let me tell you, network is KEY to strengthening your career AND your knowledge base. I was always interested in learning and would read nursing books galore and take CE credit courses on my own time or attend nursing conferences. So i knew a lot but mastered none. I always considered this to be a weakness. I always thought to myself, how can I have been through almost 5 years of nursing and I'm still not absolutely great at putting in IVs? How come I never memorize what ABG results mean?? And more. But then I realized that my skill in having multiple trade skills was my super skill! I had the uncanny ability to remember patients information, to organize their care and to stand up for my patient. I had good judgement. I studied their plan of care by reading doctors note after doctors note until I understood everything about the patient. I was able to look at the patient's whole picture and situation and I would honestly take that learned skill over putting in the world's best IV any day. I think this skill has gotten me to exactly where I am today, as I have always had the passion to improve care for patients. Ever since my first day in nursing, I have always thought, "Why are we doing it this way?" I have always thought of imaginary new devices that could be invented to make nurses jobs easier, or new workflows. I have always been able to think out of the box. I know enough to understand the "textbook rules", but have enough judgement to throw most of that away and do whats actually right for the individual patient. When A, B, and C don't work, lets figure out what else will work for the patient. That was my super skill and thats why I think I will do well in informatics. 

Part of me is also terrified to leave the bedside. This time its not temporary, its permanent. I scare myself that I'm only 27 and I'm stepping away from the bedside, something a lot of nurses don't do until they are a lot older or have more experience. I want to stay current in what is going on in nursing and want to maintain my clinical skills. I don't want to get so involved in the IT world that I don't feel like a nurse anymore. I don't want to forget what it was like, so that I can remember how to make it better. 

I don't predict however that this will be the end of my bedside career. If I ever do return, I don't think I can ever realistically return to bedside Med Surg Nursing. It's simply not an option for my soul & heart anymore. If I do return, I am interested in three pathways that actually have nothing to do with each other. Either the NICU, Hospice Nursing, or Emergency or ICU nursing. So maybe that will be where I end up one day. I am not the type of person to stay in one position for forever, I am adaptable, a hard worker and always intend to move up or change positions to learn more or to try something new. 

Whew! I talked about a lot. Sorry. My brain had a lot to say. I am very excited. If you read that all, you are a true fan and a friend of mine. Like I said when I "came back" recently to blogging, I am mostly writing for me. I want to document my endeavors in nursing so I can look back on this in 20 years and see where I was in my career. If you like it and get something out of it, then that is absolutely fabulous! I want to help as many nurses succeed in their career as I can. 

With love, 

A Writer in a Nurses Body 


Wednesday, February 24, 2016

To Code or Not to Code

Hello readers!

So I have a ton of homework to do, which makes me that much better of a blog writer! Hah. No really though, I write better when I'm avoiding doing something else. And I have a good excuse anyway, because this topic has been on my mind for about a month, clawing to get out.

Actually this may even count towards homework because I'm doing research on this for school, so boo yah!

Let me give you the first scenario I have, to slowly dip ya'll into my mindset here.

One month ago, I was assisting/as needed/general help down in our ICU department. After being there for a few, I quickly learned about a case down there. He was an 84 year old gentleman, who had been a code blue (he stopped breathing and no pulse) while on a Med/Surg Floor. He was a "Full Code" at the time, which means we do everything in our possible power to bring a patient back to the living world. We had brought him back to life, and any patient that goes through this automatically gets transferred to the ICU afterwards, no questions asked. There is never a case where we thump on someones chest and shock them and bring them back to life, and then are like, hey- want some apple juice? You seem fine to me! No.

So on he transferred to the ICU, hence where I met up with his case. I heard the ICU nurses talking, their "nursing spidey sense" that I know all too well was all in effect, as they all had a feeling this man was going to die that night again. However, this time his family had decided that this time he would not be a "Full Code". What happens if you aren't a Full Code? You have other options. But in my opinion (and I'll explain this more later) the best option is to pass away peacefully with lots of morphine and silence, and someone holding my hand so I know I'm not alone.

When the ICU nurses noticed his heart rate start to slow down, we knew impending death was soon. Our patient was trying to cross that line and was getting closer. We all agreed to go be with him, as his family had left for the night thinking he would make it overnight and they would say goodbye in the morning. Obviously that wasn't the case. We all stood by him, holding his hand, as we watched at his bedside his alarms going off, his heart rate slowing down dramatically, his breathing erratic. Me, being non-immune to all the alarms in the ICU, only heard the sound of the ventilator (breathing machine) pumping artificial breaths into this man, trying to keep him alive despite higher powers at play.

As sad as this case may seem (if you think that was sad, get your tissues out now), it actually wasn't as bad as it could have been. The reason this man's family didn't want him to be a "full code" in case he passed away again was because they had already seen him code the first time. The general public (hence his family) don't actually know what we mean when we say "Full Code". Doctors ask when you get admitted, usually regardless of your condition, "In the event of your pulse stops or your lungs stop breathing, do you want us to do everything in our power to bring you back?" Given that sentence, that sounds lovely, why yes! Bring me back! At the snap of your finger, or with your magical powerful wand. Bring my loved one back!  However, what most doctors fail to mention is what a Full code really entails. It's not quick. It's not quiet. It's not painless. And its certainly not magical.

For my non-medical readers, let me give you a quick low-down on what happens during a full code on a typical case. Please don't read this paragraph if you get queasy! But I do intend to paint an accurate picture. We automatically begin CPR. You all have seen CPR on TV at some point I'm sure, and the patient always wakes back up within a minute or two.  But have you ever seen CPR in real life? If so, you know that the recommended depth of compressions is 2-2.4" into your chest. Imagine someone right now pushing your ribs in 2", without you backing up. Pushing in 2" while you are laying down, helpless. Yes, ribs are usually broken. We also are doing this at 100 pumps per minute, no less. And we don't stop until the patient does return to life or a family member calls this effort off, or the doctor deems it medically impossible if the code has gone on too long. And that's not all. When we start doing compressions, someone is operating an external airway with whats called an "Ambu" bag, to deliver you 100% oxygen. This is only until we can complete something called "Intubation" where we insert a tube through your mouth and down your throat and into your lungs so that we can hook you up to a ventilator to do the breathing for you. Oh and that's not all.  If you have had anything to eat or drink within the last couple hours, what do you think is going to happen when we are jumping up and down on your chest? Yeah, it's going to come back up! When you're lying on your back unconscious! And we will suction as much out as possible, but it still will be everywhere.

So, that all being said, do you think if Doctors really painted that picture when we asked patients if they want to be a full code, do you think as many patients or patients family members would still want to be a full code? I don't think so. Now I've witnessed hundreds of doctors have this very conversation, and some paint a pretty picture and some don't. However, very very few actually go into detail about what really happens. Why not? Because it seems harsh! It is harsh! That paragraph above is horrible if you imagine it happening to you or your family member. If you get admitted with a broken arm, we still ask you if you want to be a full code. We ask everybody, because you never know what could happen. Life works in mysterious ways. Just a few months ago I remember a case of a man admitted with a UTI (urinary tract infection) but otherwise completely OK. Then BAM, had a massive heart attack while on our floor and coded. You never know.

So if you get admitted with a broken arm or a UTI, and here comes the doctor asking if you want us to save your life if you die? You're automatically going to be like WTF, I have a broken bone- are you not telling me something? Am I dying? If I'm not, why are you asking me this?

Or if the patient does understand the fact that this question is asked of everyone regardless of diagnosis or age, then many patients think that we are "giving up" or "won't treat" the patients condition if they agree to not be a full code. Their logic may be, "well if they aren't going to save my life then whats the point of even being here, or being treated?" Well that simply is completely logical. It is a reasonable way of thinking, but I assure you it is not true. I can say with complete and utter 100% confidence that I have witnessed on so many cases, where the doctors and nurses do so much to help a patient feel better or improve their condition, even if the case is eventually terminal. I promise you, healthcare will never ignore you or not treat you for your current condition as much as possible just because you agree not to be a Full Code if death occurs.

Now don't get me wrong at all, some people should be a Full Code! Absolutely! Let's say you do come in with that broken arm, or are having a heart attack, or a UTI, or whatever- but you are otherwise healthy- You live a happy, meaningful life- You should be a Full Code! You also have the best chance to also survive a full code as your body is healthy besides what is going on now. If we catch your heart stop beating immediately, chances are we will definitely get it back to beating within a very short time frame, especially if your body is remotely healthy. What irks me however is when doctors are unrealistic with those that aren't healthy. Those that come in with terminal cancer. Or have advanced Alzheimer's disease or dementia, or have any end-stage disease (heart disease, kidney disease, lung disease, etc.) Doctor's hit you with what I call a "Double-Positive Whammy", they make you think that death isn't impending soon from your disease, but just in case it is- If you are a full code, we will do everything in our power to bring you back and it will probably be successful! No.

I have been doing a lot of thinking on this and a lot of reflection within myself, my beliefs, my patients, my nursing practice.... and I still firmly believe in what I'm what about to say. I know a lot of people may disagree with me, and I encourage that- Everyone is entitled to their own opinions, especially with ethically situations such as these. I'm entitled to your opinion as are you.

I don't care if you are 18, or if you are 30, 40, 60 or 100.  If you have a disease that is slowly killing you, I see no reason to hold off the inevitable. Now that is a FINE LINE. For example, let's say a healthy person gets diagnosed with cancer. I completely support the notion of undergoing treatment  (surgery, chemo, radiation, etc.) I mean, you were healthy before! But what about after 10 years of treatment after treatment? How is your quality of life doing? Chances are, the patient themself already has a different opinion about their own end-of-life than their family or loved ones do. What I intend to make a point of here, is that regardless of age, if an individual either has a terminal disease, more than three major comorbidities (any major chronic disease that takes a significant toll on your quality of life), or are experiencing a poor quality of life (not eating, not happy, unable to do favorite activities, hobbies, cognitively impaired, etc) then in my honest opinion, they at least deserve the honest picture of what a full code truly means, and then they can decide. I'm not saying it should be mandated that these cases should automatically be a no-code based on an algorithm, that would be unethical. But they at least deserve the honest truth about the decision. The rest is up to them.

The last scenario I would like to share with you (if you are still reading) is a case that really pushed my feelings over the edge. Recently my unit took care of a very sweet elderly lady of the age of 96. She had multiple medical problems and was admitted with anemia (low blood count) due to gastrointestinal bleeding. She was with us for awhile with no events. Sent home. Family brought her right back due to intense abdominal pain. Again she stayed with us for awhile. Her blood counts kept dropping, there was no way to keep up with it. Her internal bleeding was too severe.  Meanwhile, she was absolutely miserable- She couldn't urinate on her own- leading to us straight-cathing her every couple of hours- she was in immeasurable amounts of abdominal pain, and she had a very poor appetite. And yet her daughter was her POA (Power of Attorney) and watched over everything regarding her moms care. And yep, You guessed it! This patient was made a Full Code. Decided by whom? You guessed it! The daughter.

One night, her vital signs started significantly dropping. The bleeding too severe for her body to compensate with. It came time that using our own nursing judgement, being that she was a Full Code, with the vital signs the way they were- she was quickly knocking down deaths door. If she was going to remain a Full code, we needed to treat her like a Full Code and get her to the ICU before she codes, that way she gets more intensive treatment to prevent that from happening. So we called what is known is as an RRT (Rapid Response Team) which is sort of like a pre-code. The patient isn't coding yet, but could be on their way soon if we don't fix the problem now. So of course during a RRT, a lot of healthcare personnel show up. Multiple RNs, Med Surg and ICU, 1-2 Respiratory therapists, a doctor or PA/NP, nursing supervisor, etc. We always draw bloodwork, usually put in a new IV. There's people everywhere and the bright lights are on in your face. Its like a code except you are awake and aware for it all. Well, this sweet lady is terrified and is screaming in pain. She's also crying, "Please, no." "Don't do this to me." "Let me die." "I want to die." "Don't do this." "stop this". And yet, because her daughter has the POA (who happened to be in the room watching this whole scenario unfold), the daughter has the decision on the code status. And despite her mom crying in pain and agony, the daughter demanded we do everything possible to save her. Maybe, maybe not- but if the daughter really knew what a code really meant, would she come to her senses and not want that for her mom?

If a loved one of mine were in the situation, don't get me wrong- Its awful. It's incredibly sad & frightening. But If i knew that my loved ones medical condition had made their life quality so horrible and they didn't want to live anymore, or they were in immense amounts of pain, I would never prolong the inevitable. I would of course want to treat them and care for them, but if the higher powers decide its their turn to go, then all I want for them is to not be alone and to not be in pain as they make that journey. I think that's the best gift I can give them as their own loved one.

Thank you for reading. I know its a hard topic, and a never-ending one. A very ethical one, and I know a lot of people will disagree with me. Chances are, not a lot of nurses will disagree with me, however. Because we see this every day. We see cases like these two every day. We are immune to the sadness, the awfulness of it all. We are trained to do what we have to do. If someone wants to be a full code, then so be it, we will  do everything we can to save your life. Just be sure its really what you want for yourself or your family member.

With love and passion for humanity,

A writer in a nurses body <3 nbsp="" p="">