Waiting over, now real work begins

The time seemed to pass so slowly leading up to my boy’s surgery, and then the last two days flew by so fast! We spent last Thursday doing preoperative requirements–blood draw, chest X-ray, physical with the surgical team. All day long I was counting down in my mind: “In 24 hours, they will be wheeling him into the operating room. In 12 hours, we will be leaving for the hospital.” Thursday evening was pretty laid back, with visits from friends and time spent just being together. I let him pick his favorite for dinner, so we dined on soft-shell tacos and watermelon!

The morning of surgery, we headed for the hospital early, and things moved quickly from then on. Our pastor was there waiting for us, as well as my college roommate. (Yes, we both settled in this area, a thousand miles from Indiana where we met.) After some quiet time together, it was time for them to wheel my little boy away. That was the hardest part. I kept it together until he couldn’t see me anymore and then gave into a couple of tears. Even knowing he was in good hands, it was hard to watch him go. But the staff was wonderful, and we were updated several times during the procedure. I shed a few tears again—this time, tears of joy when we got word he was off bypass, and everything was working great. Five short—but very long—hours after he was wheeled away, we were at his bedside in the cardiac intensive care unit.

I didn’t recognize him at first; he was just so small in that big bed with all the monitors and IVs. Thankfully, he was extubated already and breathing well on his own. Throughout the rest of the day, he woke up occasionally, but it wasn't until Saturday that he really started to make progress. His chest tubes were removed that morning and, by afternoon, his central lines were pulled as well. He was up in a chair and sipping water before we knew it. And, surprisingly, he moved to the step-down unit that evening. Sunday was spent with visitors and coaxing my already picky eater to eat. Nothing sounded good on his upset tummy—poor boy—but, by Sunday evening, he was nibbling on strawberries and bread and, by Monday, was willing to eat some yogurt.

I was shocked on Monday when the staff wrote discharge orders. My first thought was, “There is no way I am ready to have this kid at home!” But they felt he would eat better and we would both rest better at home. (I had been sleeping at his bedside every night with just a few short breaks each day to get some fresh air.) I think I drove 10 miles under the speed limit the whole way home; my cargo just seemed so much more precious to me!

And now, two days later, he is eating better and walking almost like his normal self. (He has lost at least four pounds, though, and looks skeletal.) He is also getting sassy, a sure sign he is feeling better. I am still watching him like a hawk. As I write this, I am sitting in the same room he is, and I confess I slept the last two nights on the trundle bed in his room. I continue to entice him with all the foods I can think of—How long can a boy live on Otter Pops?—and we even ventured outside to water the flowers together this morning. Now I fear he is feeling too good, and it will be tough to keep him calm the next couple weeks. Already, he misses riding his bike and doing jumps on his scooter!

Wonderful friends and having my parents here has been instrumental in his quick healing. We have been wrapped in prayer, well fed, and his sister has been entertained, if you call soccer camp in 100-degree weather entertained! Thank you all for the support. We couldn't have made it this far this fast without each and every one of you!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. 

Boys will be boys!

“Mommy! Mommy!” I could hear my boy screaming, but couldn’t see him. Just seconds before, he had been swinging in a friend’s swing while we grown-ups relaxed on the patio. I looked at my friend. “Where is he?” I asked as we both stood up—and there he was, lying under the swing, on his belly with his arms folded under his body.

Apparently, his friend had dared him to jump out of the swing—on the back swing. (His sister also broke her arm while swinging. She was attempting to tie her shoe—another hard-learned lesson in gravity.) We ran over, brushed him off and all appeared fine. His left arm hurt all over, but he could move it, and there was no swelling, no apparent broken bones, We set him up on the couch with some ice and went back to relaxing.

The next day was pretty busy—church most of the morning and a Cub Scout barbecue in the afternoon. He was favoring the arm but not really complaining of pain, and it still wasn’t swollen. At the barbecue, the boys were to work on their athlete badges. Sit-ups, push-ups, a long jump and some running was involved.

My boy did great on everything but push-ups. He refused to put weight on his arm. So, off to Urgent Care we went, 30 minutes before they closed and—surprise—discovered the poor boy had a buckle fracture of his left radius. The good news? It wasn’t displaced, so surgery wasn’t needed and, once the arm was splinted, he really had no pain. The bad news? We were just 12 days out from his open-heart surgery!

Monday morning, I spoke to his surgical team, and we agreed that surgery could go as scheduled. If he has significant body swelling afterward, we can just have the cast removed. We also arranged to have the arm casted, and he is now sporting a purple “Rockies” cast. I have struggled to keep him grounded over the last week but, in typical boy fashion, he has tried to ride his bike, has been cruising the street on his scooter and has even hit baseballs. Maybe this is a sign of how his post-op recovery will go, and he will just bounce back to being the active little boy he’s always been!

The irony of this story: Last week, I was on call for our clinic, which involves being available for medical advice and approving all urgent-care requests. We are pretty cognizant of not providing care to our own family members. (It can be bad medicine, as providers sometimes lack objectivity when caring for those they love.) So, on Monday morning, I joked with our medical director: “If my kid breaks his arm while I’m on call, can I enter his urgent care referral?"

Yep, boys will be boys!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

I did it!

I run for many reasons. I run because I have to. (The Air Force requires a biannual assessment of fitness, part of which is a 1.5-mile run.) I run because it is easy. (All I need is a good pair of shoes, some music 30 minutes of spare time, and my workout is done.) I run for stress relief. (I miss those endorphins if I skip more than a day or two.) I run to spend time with friends. (When time is limited and both a workout and a chat are needed, a run is a great way to accomplish both at once.) And I run because I am competitive and enjoy accomplishing a goal, beating my last time or achieving a new distance.

But even with all that, I never wanted to run in races. The thought of all those people, the adrenaline that comes with a race and doing “my” run on someone else’s schedule just never appealed to me.

In January, my running partner at work suggested we do a half marathon. I gave the excuses listed above and said, “No, thank you.” But, shortly afterward, when my sister and her son completed their first half marathon and loved it, my mind opened to the possibilities. Besides, my runs had started getting a little stale, the stressors at work had started piling up and I needed a new challenge. So I acquiesced, and my running partner and I signed up for the Colfax Half Marathon—three months away at the time—and started training.

Friends who had done marathons and half marathons gave advice—one sent a training plan— and we fit runs into our afternoons as much as possible. Even with the plan, it was tough to fit too much distance into my week. Between, homework and ski season, there was little time for long runs. And, with my boy’s recent health concerns, I didn’t relish the idea of running on weekend mornings and leaving the kiddos home for very long. Another friend was kind enough to find a few afternoons free, and we managed an eight-mile loop around a local reservoir, my longest runs leading up to race day.

Race day actually started in what I normally consider the middle of the night–4 a.m! With a 6 a.m. start, I needed to be at a friend’s house by 5:15 to walk to the start. Yes, we walked two miles to the start of the 13.1 mile course, ran the race, and then walked the two miles back to our cars. Crazy! But, it all culminated in a great morning. Although the crowd was big, it was part of the experience and, with friends around. it wasn’t nearly as intimidating as I had feared. I finished in 2:07, running a sub 10-minute mile the entire way. The sense of accomplishment is still with me a week later.

I think our next half will be the Rock and Roll in late September, with a few shorter races—and maybe even one of those mud runs — before that, as well. It is true: Once you do one, you’re hooked!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

A second opinion, and life goes on

It is hard to believe it has been just a month since we discovered my boy has two heart defects that will require surgery to repair. Life continues to fly by with science fair projects, end-of-year school performances and wrap-up of our spring sports schedule. Sometimes, I can even forget we have this major event staring us in the face!

Not so, last Monday. My boy and I met with a cardiologist for a second opinion and a repeat echocardiogram. Not surprisingly, the second opinion was the same as the first. Yes, there are two large defects that need to be repaired to prevent further compromise of my son’s heart function. Knowing that I’m a nurse practitioner, this cardiologist even took the time to do the echo himself, walking me through the pictures and showing me the defects and altered blood flow. He also included me in the assessment, putting my hand on my boy’s chest so I could feel the force of his heart beating against his ribs, not a typical assessment finding!

We talked about how healthy my son seems, and the doctor explained that because my boy is always working at an increased effort, he has less reserve. Light bulb moment! That explains why he struggles more than I would expect to peddle up a mountain on his mountain bike and why I’ve twice had to carry him the last 100 yards up Mt. Evans, a 14,000-foot mountain you can drive up most of the way. I would frequently get frustrated with him during these times. Often, the biking was at his request, and then he “refused” to keep up, often throwing a fit when the rest of us peddled on ahead. Pile on the “mommy guilt!”

Although I really appreciated the second physician’s time and patience with us, I will stick with the original doctor’s office. It is more convenient and is associated with one of the best children’s hospitals in the country. So, surgery is scheduled for the third week of June with the chief of the cardiothoracic department. He comes highly recommended and he has an NP as his assistant. (He can’t be all bad!)

Years ago, I worked in an adult ICU doing open-heart recovery and was the lead on the balloon-pump program. The up side is, I am prepared for the surgery, knowing what to expect. The down side is, I keep remembering all the complications, all the times people returned to the unit still “open,” the times I rushed to the OR with the balloon pump praying for a miracle, the times I sat with families after passing along the news that “things are not going well.” I keep holding to the truth that my boy is healthy and strong, and that this is corrective and planned surgery—not an emergent response to an ailing heart with blocked blood flow.

In the meantime, life goes on with Cub Scouts and camping trips that were planned prior to surgery, together with baseball practice and building of bike ramps, using construction debris scavenged from around our cul-de-sac—typical, active boy fun.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

From practitioner to parent of a patient

Seems I always start a post with a statement of how long it has been since I have managed to write or how busy life tends to become. It seems I blink, and time just flies past—between school projects, spring sports, a big inspection at work and training for a half marathon, there is barely time to breathe some days.

But summer is just around the corner and, thanks to a fluke episode, my boy is ensuring that we will slow down over the school break. He just turned 9 and is an active, typical little boy—playing baseball and riding his bike over any jump he can find. A few weeks ago, he had what appeared to be a minor viral illness but then suffered what is now being termed a fainting episode. Because it mimicked seizure activity, off to the ER we went.

A routine ECG turned up some thickening of the right side of his heart, so we saw a cardiologist a few days later. A long afternoon spent in the cardiologist’s office ended up in a surprise diagnosis of two congenital heart defects that could result in significant damage if we don’t repair them. Needless to say, I was in shock and still am two weeks later. My healthy, typically wild but extremely kind-hearted boy is shunting oxygenated blood back into his right heart with every beat!

Yes, we are getting a second opinion in a week but, because I have confidence in the diagnosis, the surgery is scheduled for the middle of June—a week after school ends. He will spend the summer being spoiled rotten, and the goal is to be back in school when it starts in mid-August. The cardiologist even said we could sign up for fall baseball. I think he is as optimistic as I am about all this, something I really appreciate.

In the meantime, my son has no activity restrictions, so we are pressing on with life. We fill our free time with baseball and soccer, bike rides and yard work, Cub Scouts and Girl Scouts. We have tickets to see the Rapids and the Rockies and hope to throw a big presurgery party in June. I firmly believe attitude can affect outcome, and we will enter this with the best attitudes we can muster! I will do my best to keep this site updated with our progress on this new adventure in life and know we are wrapped in prayer every day by so many people, something I am very thankful for and believe is contributing to my calm emotions.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Inevitable change ... continued

Why is it I seem to find time to blog only when the clouds roll in and gloominess invades? Maybe because on the sunny, blue-sky days we are on the go—skiing, hiking, exploring!

What a whirlwind December it was! Between school and scout programs, church activities and ski lessons, our evenings and weekends have been packed. The kids took a series of skiing and ski boarding lessons that really paid off. In the last week, we managed to have some days on the mountain together and they were racing down the hill with me, hitting little trails through the trees. We even ventured into the terrain park for one run!

My boy is a daredevil on his board, and he was thrilled to tackle a small table/jump. He almost landed it! The down slope on the landing surprised him a little; he’ll get it next time. My girl switched to skis this year and is very happy with the change. She is flying past her brother, leading the way through the trees. It’s a big change from last year, when she boarded well but was a little fearful.

Work is ... work! The only constant is that change continues to occur and should just be accepted as fact. We continue to plan for our big move to our new space, but that appears to have been pushed back a few weeks or months. The space isn’t finished yet. One concern is that it was developed three or four years ago when we were much smaller. With the current floor plan, we will be short on exam rooms, so are attempting to creatively plan for this challenge. The space also appears to limit efficiency with provider offices segregated from the exam rooms. Technology may save us on this. There’s talk of tablets and more mobile computing.

I am sure more change will happen with the new year. It’s inevitable and, if you know me well, you know that change is something I don’t enjoy. My personal goal for the coming year is to embrace change better for the opportunity it provides. We will see how that works out!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. 

Time flies and change is inevitable.

Why are my posts so often about time or the lack thereof? Are you ever amazed at how fast time really does fly? I know it is early for a “year-end wrap-up,” but I just seem to be in the mood for reflection on this gloomy day after Thanksgiving.

There is enough research out there about adjustment after a move (and even more about how long it takes to feel “normal” after a divorce) that I shouldn’t be surprised at how much difference a year makes. Most experts agree that it takes a year to feel settled after a move, to see the “new” place as your place and for that feeling of being a stranger to go away. And the good news is, it has!

I no longer say things at work such as “You guys do things strange here,” and I have accepted many of the quirks as normal. I have also taken a more active role in bringing about change for the better and not just to make things more like where I came from. I do, however, continue to fight silliness and am the first to speak up when wacky decisions are made that don’t really seem to be for the good of the group.

One battle I recently lost was a decision to rearrange our primary-care teams. It seems my MD “partner” and I are too efficient and need to be split up to balance another team. We have access within a few days. In fact, I saw people last week for follow-up the day after an emergency room visit, something unheard of at many military clinics. We even have days where we have appointments that go unbooked, and we receive very few patient complaints.

How do you reward that kind of access? You split us up, of course! So, as of the first of the year, I will be switched to a different MD partner, one who is very meticulous, kind and thorough, but tends to have less convenient access. I fear that, for me, it will translate to more crossbooking and more difficulty for my enrollees to get in to see me as easily as they do now. Only time will tell! The good news? I’m able to keep working with the same technician. She does a great job of keeping me on schedule and has taken over some of the paperwork the nurse used to do.

A battle still to be waged is improving communication between public health and primary care with respect to deploying members, something that is a bit convoluted right now. We will also be moving our whole clinic this winter, which will tax the patience of staff members and patients alike. The move also puts us back on the list for a visit from the national accreditation agency, which always creates extra “spin” in an organization. It’s all part of the life lesson that life never settles down and change is inevitable!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Follow the red tape to New Beginning!

I work for one of the largest bureaucracies in the world and have for 18 years. So, when confronted by red tape, I am not surprised and usually find a way to cut through it rather than work around it. It drives my dad crazy. As a retiree from a large corporation, he knows red tape and tries to redirect my efforts to working within the system, rather than fighting it. I figure it is a little bit of the rebel in me that wants to set things “right,” to have things “make sense,” that drives me in moments like this.

My nursing license was due for renewal at the end of October. Normally, it’s not a big deal. I log onto my computer, answer some questions about whether I’ve been arrested or had action taken against my license—I responded “no” to both, in case you’re wondering—and enter my credit card information. Before long, I’m notified that my status has been updated and am informed of my next license expiration date, two years hence. My chosen state of licensure doesn’t issue a special practitioner license, but I do declare myself as an advanced practice nurse on the renewal form. The Air Force then logs onto the online verification system and—surprise—I am current for another two years.

Not so this year! It seems the Air Force has issued new guidelines (obviously written by someone not familiar with all state licensing requirements) that require APNs to have a nursing license that identifies them, in some way, as an APN. (If memory of my first year of graduate school is correct, I don’t always need a license as an APN, just a registered nurse license and APN certification.) When I pointed this out at the local level, I was told, “But that isn’t what the regulation says.” At the consultant level, I was told: “Don’t worry about it. Have your local level call other bases. It’s fine!”

So, in an effort to do this “the easy way,” I called my state of licensure (it’s a large midwestern state spelled with more than four letters) to request a letter that simply states they are aware of my APN status but do not issue an additional license for this higher level of practice. They agreed this is true, but said: “We are a state; the federal government can’t require us to do anything. If we write you a letter, everyone will want one!” Really? How many APNs, do you think, carry a license in your state? And, if you keep that letter on file, just change the names!

I finally got though to an assistant director, who agreed to discuss my situation with the director of the board, who has never e-mailed me back or returned phone messages. So, I guess this is the way this state wants to “support the troops,” which is what frustrates me more than anything. They request my military stories to share for Nurses Week or 9-11 anniversaries, but when I need something, it boils down to red tape and closed doors.

So, where does this leave me, besides disappointed, frustrated and out the money I paid to renew my license in the state where I have been an active RN for almost 20 years?

I will now have to research the law for the state in which I currently reside and pay the several hundred dollars required to get a license here. (It is the state where APNs started, and where we are so respected, we can open a private practice.) I will need a license here eventually, anyway, as I plan to stay in the area once I retire. (That’s also my dad’s rationale; just get one here rather than argue the issue.)

So, I will spend a vacation day this week doing the research and finding all the necessary paperwork. And, I will cease my relationship with that old state and, here in our new home state, call it a New Beginning!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Juggling glass balls

Have you heard the story of the many balls we juggle? Some balls are made of rubber and bounce, while others are made of glass and will shatter, if dropped. Each of us determines the balls we juggle and some of them change, depending on a day’s priorities. Often, when I walk in the door of my clinic, my “family” ball changes from glass to rubber, because my kids are well cared for and safe for the day at school, but my “work” ball suddenly becomes glass. Some days, that glass ball stays in the air with what seems like little effort. Other days, I feel as though I should be wearing protective gear as I dive repeatedly to the floor in an attempt to catch my ball before it shatters.

There are many ways the Air Force is ahead of the times (or at least keeping pace). We utilize “mid-levels” to the fullest extent of their education; we embraced the electronic medical record long before our civilian peers; and we are constantly evolving in practice theory with a mindset of patients first.

Where do we fail? In managing our people and, often, the day-to-day running of our clinics. We put nurses or providers into mid-level management roles, and the position of “Group Practice Manager” is handed off like a hot potato to the most junior administrative lieutenant. The result? Often a poorly managed clinic, with constant errors in schedule templates and lots of scrambling to keep up to date on performance reports and award packages.

Have I seen it work? Yes, there are nurses or providers out there who are excellent managers, whose calling is more toward leading people, who display great juggling talent as they keep those glass balls in the air with apparent ease (or they just work 60-hour work weeks to make it all “look easy”). And I have seen group practice managers, with prior experience in running large civilian clinics, calm the chaos and facilitate better provider efficiency.

Why this discussion today? I spent the last week filling in for the nurse who normally performs our middle-management role, while I continued to see a clinic full of patients every day. I have said all along that both are full-time jobs and, when trying to do both, neither is done well. This week proved it. (As glass shattered all around me, I definitely needed protective gear!) 

I was consistently a few patients behind and frequently had a line of people out my door who wanted to update me on personnel issues or get paperwork signed. I missed my usual lunch catch-up time, spending it instead in meetings where my attendance was required but my input not needed. The saving grace? I was not on call, so I didn’t have that added stress.

The lesson I learned? I am a provider, and pretty good at it, but middle management is not where I want to spend my time! I am so thankful for those who do enjoy that role. It allows me to stay where I thrive, immersed in patient care and, most days, easily keeping the balls in the air and not surrounded by shattered glass!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

National day of remembrance

Like so many Americans, it is hard for me to believe it has been 10 years since the day that so changed all our lives.

Every U.S. generation has “that moment”—the one that forever defines for members of that generation where they were when “it” happened. For some, it is the beginning or end of a war, for others the day President Kennedy was shot. For younger generations, it seems there are several moments: The day President Reagan was shot and the two times we lost a space shuttle certainly qualify, but the biggest one was the attacks of 9-11.

Where were you on September 11, 2001? What is your story? How has your life changed?

For me, I was sitting in my favorite chair, nursing my now 10-year-old and enjoying a rare solo visit from my father. My mom was in North Carolina, awaiting the arrival of my sister’s third child. We were living in Las Vegas and had turned on the TV to check the weather for our planned outing to Mt. Charleston, for a day of hiking and a picnic. At first, as the weather report filled most of the screen, a list of airport closings and shutdowns scrolled across the bottom. It didn’t make sense. When we changed channels and saw pictures of what was happening in New York, Washington, D.C. and Pennsylvania, the situation came into focus—at least as much as anything could come into focus that day. It took awhile for the shock and reality to sink in.

We called Mom and then pressed on with our plans to spend the day on Mt. Charleston. There was nothing we could do, and our need to escape and try to be as normal as possible was strong. But as we hiked, we were a little on edge, wondering if anything else was happening or what surprises awaited us when we returned to town and the constant media coverage.

Has life changed? Sure, especially when it comes to travel and security. As a military member, I have deployed in support of the global war on terror. My kids now live with the knowledge that our borders are not as safe and secure as we believed them to be when we were young. But our lives have also changed in positive ways. There seems to be more support of those who spend their days protecting America: policemen, firemen, soldiers, sailors and airmen. Ordinary citizens seem to better grasp the service-before-self concept that these people display every day they’re on duty. The stories of public servants entering the doomed twin towers, or the daily scenes played out at airports all over the country as military members deploy or return in support of the mission, remind Americans everywhere of those who serve.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. 

'Forever friends'

Do you have “forever friends”? You know the ones—people who have known you since high school or even elementary school, people who know you better than your spouse does, the people you reach for in those life moments when you need to cry or celebrate. Not that, when you first meet someone, you actually define them as a “friend for now” or a “friend forever,” but you often know pretty quickly if this is someone who will fade away when the circumstance that brought you together is history.

I recently saw on Facebook a post that occasionally circulates, the one about people who touch your life and either stay or move on. Many posts also comment on military friends, those people who are brought into your world because of an assignment or deployment and become a forever friend. Whether it is a circumstance or common culture, shared events or true connection, these people are the ones you invite to your promotion or retirement, the ones you travel cross-country to visit, or celebrate with when your paths cross again, perhaps to spend another assignment or tour together.

We have had a busy summer, and I was lucky enough to spend a few days connecting with a few of my forever friends. There are five of us from college who still keep in close touch, who shift schedules and move mountains to spend a short weekend together every year. Some years, the mountains won’t move and someone has to miss—in my case, “Uncle Sam” sometimes has a different plan—but we continue to make the effort.

This year, I was the lucky host and the girls spent a short 48 hours in my new house, sharing stories of kids and significant others, tears over the same and sightseeing around these beautiful mountains. We decided two days is not nearly enough; that once we get the youngest off to college, we will spend an entire week together, soaking our toes in the sand somewhere. And we were reminded that, although 363 days may pass before we get together again, because life is full and we rarely have time to connect, there will always be those two days when time stands still and we can surround ourselves with those who know us best.

Thank you to all my forever friends!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. 

A REAL doctor!

I had one of those experiences last week that I know is not specific to military medicine. I am sure it happens to our civilian counterparts, to other NPs and PAs. And I know it happens on a near daily basis at military treatment facilities worldwide. As I walked into the exam room and introduced myself as a nurse practitioner, the patient announced she was “forced” to come to our clinic and “wasn't allowed to see a real doctor” downtown. I was slightly taken aback. Here I was, running on time, in a pretty good mood and ready to assess and treat to the best of my abilities, and then WHAM. I took a deep breath and realized she wasn’t slamming NPs; she had a grudge against military providers, regardless of education background.

Some people think we are on active duty because we can’t cut it in the “real world,” that we are somehow subpar when compared to our civilian peers. And, people do sense a lack of control, since they have to enroll with a provider at a military clinic, requirements put in place by TRICARE (basically, our military HMO/PPO/insurance provider, depending on current terminology). In reality, we are all credentialed and/or certified in our specialty and really have two specialties to maintain, our civilian requirements and our military ones. I honestly believe military medicine should be it’s own specialty, since we have to know how various military-specific careers affect disease processes. And don’t even get me started on deployment medicine—who needs malaria prophylaxis, who is more resilient and able to tolerate the stress of deployment, etc. I could go on and on!

So, what did I say to that patient that day? Basically, a toned-down version of the above. That she is actually lucky, that we are a unified practice of providers all credentialed in our fields, who “get” the difficulties of being a military family. Then I asked, “What can I do for you today?” and we progressed on with the visit. I hope it was a positive experience for her and she won’t be so opposed to military providers in the future. Time will tell.

As NPs, that is all we can do; try to show the world—a patient at a time—what we bring to the table and what we have to offer. And, to hope that, over time, the response won’t be, “I wasn’t able to see a real doctor” but that patients become more accepting and some will even prefer to see us for what we have to offer!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Patient Centered Medical Home

If you stick around the military long enough, you will experience change, which may come as a surprise to people, since we are known as one of the biggest bureaucracies in the world! Since I have been on active duty, we have changed the names of our units (remember Strategic Air Command?), added new units (Space Command is a great example) and closed multiple bases. In the medical service, we have tried multiple ways to provide consistent, quality care to our patients (Primary Care Optimization and Primary Care Management, to name two) and now, we are changing again.

A few years ago, we started hearing more about something termed Family Health Initiative (FHI), and most of us feared it was just another attempt at putting a shine on what was quickly becoming a failing mission. We were undermanned, overdeployed and, in many cases, overenrolled. A case in point, before leaving Texas for Afghanistan, I was assigned more than 2,000 patients, well over the suggested cap of 1,500. But, we had a couple unfilled provider positions, and the patients needed a provider, so we muddled through as best we could. And, when I deployed, the sole primary-care physician who remained carried a load two to three times that until replacements arrived.

With that kind of workload, we had very little control over schedules, and a frequent complaint was the feeling of “running on a hamster wheel,” as we tried to meet the rising demands. I don’t think this was an issue specific to our little corner of the world; it was a frustration voiced by providers at many military treatment facilities and likely echoed the struggles of our civilian counterparts, who experience their own provider shortages.

So, we spent a few days last week learning more about FHI (now renamed Patient Centered Medical Home) and making plans for implementing this philosophy over the next few months. This is not a military-specific patient care theory, but a model being executed in the civilian community in an effort to maximize available providers and contain health care costs. For us, it will involve a change in staffing ratios and a decrease in maximum enrollment numbers. We will be shifted into teams of eight, composed of a physician, a mid-level (a term I still don’t love), a nurse and five medical technicians. (That’s the ideal composition. When we continue to deploy and our staffing is already below expectations, we will aim for three technicians per team.) We will be responsible for 2,500 patients (1,250 per provider) and be given more freedom to creatively meet patient demand through improved template management.

I honestly can’t yet say that I am 100 percent on board with the change. Part of me still sees it as a name change with lots of empty promises. One concern: Even though there is a strict cap placed on enrollment, as well as “cross booking” between providers, there are still requirements to see patients who are promised care and, after dividing those between our available providers, we are again back to 1,500 patients each. Also, there is an expectation to meet the needs of our patients on a daily basis. So, if there is a spike in viral illness and a need for more acute or walk-in visits, we are expected to do it. This can wreak havoc when my leaving work on time is necessary to make our usually maxed-out, kid-centered evenings work as planned! Between homework and sports, there is little room for overtime at work!

I would love to become a convert to anything that will provide consistent care to our patients. I know they are tired of seeing a new provider every visit and “starting over” every time. Rumor has it that, after the first few months of working out the kinks, most providers really enjoy the new model. I’ll keep you posted on the transition.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Some nurses still eating their young

First of all, somehow, in just two months, I’ve managed to precept an adult health NP student for more than 135 hours! It was her first semester, and it reminded me so much of how things were five years ago when I did my first adult health rotation!

I attended graduate school at Uniformed Services University of the Health Sciences (USU). The military’s own graduate-level university, USU has both medical and nursing programs. USU Graduate School of Nursing offers a doctoral program as well as master’s degrees for family nurse practitioner, anesthesia and perioperative clinical nurse specialist.

Within the first few days, six of us gravitated toward each other and we were just as tight when we graduated two years later. We studied together, laughed together—sometimes cried together—and, in our free time, got our families together. We were an incredible support group for each other, and we all stay in contact today. Four of us are still on active duty, one has left the Air Force to start medical school and one, fulfilling a lifelong dream, is is providing health care in India.

I remember those first few days, thinking I knew so much, then walking into clinical, terrified, trying to just remember my own name. Now, five years later, it was a great experience to support another NP through those first scary patient interactions. First, we would talk about the questions to ask and the assessment to do, and then I would turn her loose. She quickly took to the whole process and I watched her confidence grow as she formulated her own style in the exam room. Simply talking through disease processes and looking up current research has done much to reinvigorate my own practice. I look forward to spending more time together over the next year as she works through her program.

Contrast that with another experience I’ve had recently. I conducted a medical legal review for a pending case against another practitioner. I won’t go into details, but it was interesting to read the case files and to read the detailed notes made by the specialist reviewer. She even went so far as to conduct a literature review of the standard of care that was in evidence 10 years ago when the initial incident occurred! My frustration? Another NP reviwer, in seeking to build a case against the person in question, used research that wasn’t even published 10 years ago. It frustrated me that, as nurses, we sometimes still have the “eat our young” mentality.

I wonder if there is any way to remove that from our collective culture. Maybe in precepting a new generation of practitioners, we can take away this outdated belief that we have to step on each other to get ahead. I think there are enough opportunities in this world for all of us to succeed without using our peers as stepping stones!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

The speed bump that became a high spot

Friday was one of those days that will linger in my mind for quite awhile.

It was the end of a long week. Sick children, life stressors, work demands—all the typical things that pile up in the face of an approaching weeklong vacation. I thought I had the week pretty well planned in advance—a few days of “sick call” and a wide-open Friday afternoon to ensure a few quiet, patient-free hours to tie up loose ends before leaving the nurse in charge. (I hate leaving too much for my covering physician to deal with. He has his own daily demands and, as we all know, covering for another provider can destroy your week.)

Then, as only the military can do, a huge speed bump was put in the middle of my well-planned road! In response to the events occurring in Japan—the earthquake, the tsunami and, now, a nuclear threat—the military was offering voluntary evacuations to family members located in that country. The evacuees—mainly women and children—were being routed through various cities, and our location was chosen to support this mission. The request was for a provider to be on site at all times to provide acute care and address any medical concerns that might arise as the families were routed to final destinations elsewhere in the United States.

I scrambled to find someone to come to the house in the early morning hours and get the kids off to school. A few good friends have made the offer to “call anytime,” so I took one up on it, and he was quick to say yes. (Proof that the week wasn’t all that bad is that it reminded me of the wonderful friends I have made here in a short six months!)

When I arrived at the site, I was pleasantly surprised to see how organized the event was. The USO and Red Cross were there with food, hygiene items and a bank of computers and phones for the evacuees to utilize. The support staff had established play areas for the various aged children (everything from playpens to a bounce house to Wii) and staff to supervise them. They even had military members in place to walk the animals that were accompanying the families.

As the evacuees arrived, it was awesome to watch young soldiers, sailors and airmen assist the travel-weary women by carrying their baggage, pushing strollers and cleaning up after pets. The women were free to complete all the necessary paperwork and arrange their follow-on travel, knowing that everything else was covered, and the kids—and pets—were able to spend all their stored-up energy in a safe environment.

Except for treating some nausea and hypertension and handing out lots of Band-Aids, I provided very little patient care. In the course of the day, eight to 10 new moms and their babies came through—one just 6 days old—and I touched base with most of them to ensure they were doing OK and didn't need additional support. In general, I just watched and was so proud to be a part of this organization that sometimes can frustrate me to no end but, at the end of the day, can put together an operation to support our own that is second to none.

Although the evacuation initially added stress to an already stressful week, I am so glad I had the opportunity to assist in this massive undertaking, talk to these people, hear their stories and provide what little relief I could. It may have started as a road bump in my busy life, but it ended up being one of those experiences that will stick with me as a highlight of my time in the military.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

The search continues

I am still looking for our “forever” house. My military friends will understand this.

We live in many places while serving our country. Most members of the military move every 3 to 4 years. We adapt to new communities, new cultures, new norms. Our kids adjust to new schools, new friends, new sports teams. And, through it all, we live in dorms or base housing, apartments or rental homes, and we occasionally purchase homes, usually knowing it is only for the duration of our relatively short stay in that community.

When we buy we look for something that will “do” for those few years, with a relatively short commute, safe in case we have to leave our spouse and children there alone during a deployment, something in which we can acquire some sweat equity, something with good resale potential.

Now, with a relatively short time remaining for me in the Air Force, I am considering the option of staying put in this community, allowing my hoodlums to finish high school with friends with whom they attend elementary school. The decision is tough but, when my retirement rolls around, they will be in middle school, a tough time in any child’s life and a tough time to start over.

So, we spend our weekends looking for “the one,” the house that won't just “do” for the duration of the assignment but maybe “forever” (or at least until the boy child finishes high school). We have found a few that are OK, that meet our basic needs. But we haven’t found anything yet that is on a quiet street, has enough beds and bathrooms to accommodate my parents’ frequent visits, has a backyard big enough for impromptu soccer games but not too much for me to keep mowed and a reasonable price that enables me to keep the kids in their current elementary school! Do you think I am asking too much?

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Simple pleasures

Today is one of those days I initially railed against when the school calendar was released. It’s a “non-contact” day, as they call it in this district, a day set aside for conferences but not a federal holiday. Thus, it’s a day I am forced to either take leave from work or enroll the kids in all-day care at the school. I chose this school for its quality before-and-after school care program as well as the all-day care it makes available on breaks. They do a ton of activities, and the kids have grown very attached to the staff members, but I feel that, if my children have a day off from school, they should get a day of freedom—a day to sleep in, watch bad TV before breakfast and maybe hit the skate park when the “big kids” are still in school.

So, I was frustrated that I would have to “burn” a day of leave to stay home with the kids. Now that the day has rolled around, I’m loving my break from clinic. I had a long day Monday, saw 25 patients in 3.5 hours of sick call, followed by my first experience of precepting an NP student.

So, today, I slept in and got in a workout before the kids woke up. Then, the best part of the day so far, my girl child delivered one of those notes we parents are so familiar with: “Dear Mom: Come downstairs and take a seat.” I honestly had no idea what to expect. A story request, maybe a “show” she had choreographed, a made-up play? What I found was a clean room with the bed made and her table pulled into the middle, all set for tea! We enjoyed a rare chance to just sit together and visit. We talked about her artwork that she has displayed in her room and about the colors she would like to paint her room, once we find that house.

So many days are spent running from activity to activity, task to task. We go to school and work, come home and complete homework, cook diner, and then hurry through showers so we have time to read before bed. This morning provided that rare opportunity to just sit and enjoy my girl’s company without worries about the day. So, my thanks to the school district for this wonderful opportunity to enjoy an unstructured day with my babies! And tomorrow? I have another of these “forced” days off, a day we’re looking forward to spending on the slopes with friends!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Keepin' on bloggin'

Maintaining this blog often competes with other priorities—cleaning house and grocery-shopping, to name two. I am so thankful to Sigma Theta Tau International for providing this forum and for Jim Mattson, editor of Reflections on Nursing Leadership (RNL), who ensures that what I say makes sense and helps keep me on track. A couple times, he has sent an e-mail asking if I plan to continue posting, a very polite way of encouraging me to get typing!

So, recently, in the midst of a rare Saturday morning without my children, I managed to write three posts and even looked over the blog design and statistics. I had no idea there was a way to see how many people had accessed the site and where they were from. I was pleasantly surprised to see there have been more than a thousand hits since my blog was created almost two years ago. Now, I realize that really isn't much when compared to many others out there, but it gave me a little lift to think of all those people reading what I write.

What was fascinating to me was all the foreign countries where people access my blog: Malta, South Africa, China. What do those people think when they look at what I write? Why did they land on this page? Are they nurses? Are they looking for information on Afghanistan? Are they Americans living abroad or are they native to those places?

I also took time to update the “blogs I am following” link (click on "Lori" under "Contributors" in the right-hand column) and was a little sad to see that some people had stopped posting blog entries. One of the soldiers on the team we replaced had stopped updating his blog when he returned home from Afghanistan, in the summer of 2009. I enjoyed his writing and hope he has returned to the “peace-loving lifestyle” he was so looking forward to.

I also added a favorite website—“The Pioneer Woman.” If you’ve never visited the site, I encourage you to check it out. Several months had passed since I had last viewed it but, after receiving her cookbook for Christmas, I plan to become a regular again. Her humorous reflections on farm living always lift my spirits. I also—finally—updated the link to Meg’s blog, “Soup is not a finger food.” Meg is an old friend who frequently has a sassy way to state the obvious. Reading her posts brings a smile to my face, as I remember the days I spent hanging out in the ’hood.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Greener pastures

Many of us who spend the majority of our time in military medicine see private practice as so much better. No inspector general visits, no “working for the man” and no threat of deployment. We often feel as though, with meeting access demands, completing medical evaluation boards and fulfilling all the required military training (frequently on our own time because of patient care demands) with no end in sight, we are on a hamster wheel.. But, as two of my good friends have discovered, the grass is not always greener!

One of my friends, a physician, left the military to join a large group practice connected to a large hospital. He enjoys the time off, choosing his own hours, and the increased time he haswith his family, but he is considering rejoining the Air Force, because he senses something is missing. There is no camaraderie within the practice, and he misses feeling that he is serving a greater purpose. He still has pressure to see patients and sees changes to insurance reimbursement limits as potentially detrimental to private practice. He also realizes the impact of walking away from the retirement money. As he puts it, “I still work for the man; it is just a different man and I get to choose the clothes I wear to work!”

Another friend left the military just a few years short of retirement. She was dissatisfied with future assignment opportunities and wanted her spouse to have stability in his non-military career. After a recent move, she struggled to find a job. Medical-provider positions are not typically listed in a newspaper and she almost resorted to going door-to-door or hiring a headhunter. Now, working in a practice she enjoys, she can still tell stories that would make most of us military medical members’ toes curl! She discovered the medical assistant wasn’t wiping her exam tables after every patient, and my friend recently returned to work after a vacation to discover she was double booked and, because a colleague unexpectedly needed time off, had been volunteered to take on that provider’s schedule.

So, on those days when I feel like the hamster wheel is more challenging than usual, I remind myself that the grass is not always greener. When it comes to medicine, you can change the clothes you wear to work or the “man” you work for, but that elusive “perfect” job or practice may not exist. Sometimes, you have to find the “perfect” where you are and focus on that; and hope you don't fall off the wheel!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International (STTI).