The Holiday Heart: Improving the Patient Experience During the Holidays

Our hospital president posted a poignant holiday message for the staff this week. He talked about the melancholy in Joni Mitchell’s song “River”. He wrote that “the song paints the picture of the season, but it juxtaposes against that backdrop a sense of melancholy that is not usually associated with the end of year festivities… One of the extraordinary blessings of delivering care is that, for a period of time, we are our patients' families. We are their loved ones. We are their company when no one comes to visit. We are their comfort when the outcome of their stay with us is uncertain.”

That post resonated with me. My first job here in the United States was in a long-term facility. The patients were long abandoned by their families; left under a stranger’s care. The nursing staff held their hands and listened to the nostalgic remembrances of their loved ones. I sometimes stayed past my shift just to listen. We became their family. The nurses dried their tears just as we dried our own tears of being away from home. We were their daughters and granddaughters.

The three years I spent in that hospital shaped me to be a better nurse. I emerged to be more compassionate and empathetic to the patients. The pangs of homesickness were better dealt with when amongst the patients who needed our care. I gave my patients an extra dose of care and attention during the holidays. The staff tried to cheer up the patients and to provide distraction when their families forgot to care. I remember holding the hand of one trache-dependent ALS patient as he waited for the visit that never came. He could not verbalize his disappointment but I saw his eyes react sadly whenever the other patients in the 4-bedded room received their own visitors.

In the merriment of the season, hospitals see a lot of patients overcome with depression. Those who are medically sick sometimes spend the holidays with the staff who had to leave their families to take care of their patients. In the emergency department, we continue to get patients who choose to binge drink to fight their loneliness and ended up with Holiday Heart syndrome.

One New Year’s eve several years ago, I stayed with one lonely 70 y/o patient as we watched on tv for the Times Square crystal ball to drop. She was waiting for her family to pick her up. She was teary-eyed, confused at the babble of voices in our crowded ED, unable to understand the language. But she smiled when I brought her food and counted down with her during the ball drop. As I hugged her, I was reminded of my mom, miles away in the Philippines. The patient eased my homesickness as I comforted her. Mrs. Chen bowed to me and said "Xie-xie" (Thank you in Mandarin).

During the holiday season when families spend time together, someone out there is looking for some love and attention. Like the woman from Oklahoma who posted on Craigslist, “Anybody needs a grandma for Christmas? I’ll even bring food and gifts for the kids! I have nobody and it really hurts.” This post went viral and illustrated the stark reality that many of our elderly population are isolated from their families. Actually, not just the elderly; there are many lonely people in the world.

Thank you to all of those who work during the holidays. At a time when all others celebrate the holidays in the comfort of their homes with their loved ones, it is a blessing to bring some kind of comfort and peace to those who need them the most. During the holidays, the ED is not always crowded so there is always a chance to spread some cheer around. A little touch, a little smile, and some time to just listen go a long way to ease a lonely heart.


"River" by Joni Mitchell




"River" by Sarah McLachlan



Holiday Heart Syndrome
In 1978, Philip Ettinger described "Holiday heart syndrome" (HHS) for the first time, as the occurrence, in healthy people without heart disease known to cause arrhythmia, of an acute cardiac rhythm disturbance, most frequently atrial fibrillation, after binge drinking. The name is derived from the fact that episodes were initially observed more frequently after weekends or public holidays.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3998158/

When One of Our Own Is the Patient: Anna's Story

“Trauma notification coming in”…

It was not just any other trauma patient, not just a stranger. The woman on the EMS gurney groaned in pain. Her face was bloodied and disfigured, her hair matted with drying blood, the face almost beyond recognition, until I saw the nurse’s uniform. Just like my own.

“Anna”, I whispered her name but it sounded loud in a room suddenly rendered quiet by the shared recognition. Anna was one of the senior nurses in the ED, and she was well-loved by all of us. Even the surgeons respected her. She was the ED’s toughest nurse, and we were all proud of her.

There was just one muffled curse then the trauma chief’s voice spurred everyone into action. We listened as we moved Anna to the stretcher. The EMS paramedic’s voice quavered with the report. “We got the call about the assault from about two streets away from the hospital. She was assaulted by her ex-husband. She’s breathing and moving all extremities. She’s awake, alert, and oriented but she cannot talk much because of her swollen face.”

The other paramedic chimed in, “And her ex was arrested by the cops. A few construction men came to her aid, but I think they beat him up too.”. I hoped that he was beaten up bad too. I was also relieved that the police did not bring that evil man to our ED.

As I cut her scrubs, I felt my eyes sting with the tears, which I had to blink away. My heart was in my throat. My hands were shaking. I locked my knees and leaned into the stretcher to prevent myself from falling. Damn it, I had to be strong because I better be the best trauma nurse there is for Anna.

I saw the fear in the staff's eyes. It was surreal to be taking care of one of our own. Anna was the trauma nurse for the day; she just went out for her lunch break and now she was lying down on the same stretcher that she just prepared.

Just like the professionals that we were, the team went to work. The other nurses looked as determined as I was as we all took our positions and did exactly what she taught us to do. Our trauma team worked in sync. The patient was one of our very own.

The ED doctors and the surgeons methodically did their assessments, Airway good, breathing on her own, no pneumothorax, vitals good. FAST was negative. As soon as the IVs were inserted, the tetanus and the antibiotics were given, we had Anna readied for the CT scans. I scooted around to her side and held her hand. Anna squeezed my hand tightly, and I said “We got you.”.

As we passed through the trauma door, several hands reached out to move the stretcher, a few “I love you" from the staff followed Anna into the CT scan. I think everybody held their breaths as we waited for the test results.

The rest of the staff had to return to their own assignments, each one held their emotions in check as they braced against the onslaught of patients demanding their pain medications and complaining about what took the staff too long to attend to their needs. One of our own was hurt, I wanted to yell at the intoxicated patient who called out for more turkey sandwiches.

The results came back. All were negative except for one broken finger when Anna punched back in defense. That’s our Anna. It seemed that the department heaved a collective sigh of relief. We admitted then to our ourselves that we feared the worst, and so we were all thankful and hugged each other.

Anna stayed out only for two weeks, but time was not enough to recover from the emotional trauma. Although she came back physically healthy, her heart was broken. After another month of showing up to work with a forced smile, she finally said her goodbyes. She relocated with her son to California, away from her husband who was in jail, to be with her mother and the rest of the family.

The last I heard, she was back to her old self, a no-nonsense nurse who intimidated the residents and the surgeons in her new hospital. Anna was back.

Making a Difference as an ED Nurse #IMakeADifference

HAPPY EMERGENCY NURSES WEEK!!!!!

This could be you. This could be any nurse (ED or not) who makes a difference every single day. With humility, I acknowledge the privilege of touching somebody's life. That is why I am proud to be a nurse, more specifically an ED nurse.



As a STAFF NURSE in the Emergency Department, I made a difference when…
- I was the IV nurse to go to for the smallest and most difficult-to-access veins, long before those fancy vein-finder devices ever made it to production
- I volunteered to work another shift of overtime, even after a few hours of sleep from partying with friends
- I could last longer doing CPR than some of my co-workers who huffed and puffed after just three cycles
- I sang and danced to calm down a Down syndrome patient who was having a meltdown in the midst of a noisy ER
- I multi-tasked to cover another nurse who needed a little time to recover from a bad trauma case
- I helped out a tech who was busy elsewhere and did the EKG myself for a patient with an atypical presentation of chest pain (she had an MI)
- I intervened to prevent a fight between two intoxicated patients (I was almost hit by an errant left hook)
- I cross-checked the new nurse’s drug calculations and prevented a medication error.
- I triaged a quiet, stoic elderly man who sat patiently for his turn before a loud, obnoxious female who complained of having an asthma attack (while speaking in full sentences and clutching a bag of chips). He turned out to be in sepsis.
- I held my dying patient's hand so he didn't die alone.

And many more to mention…. I miss those good ole days.


As a NURSE EDUCATOR in the Emergency Department, I made a difference when…
- I taught the nurses how to triage, to use across-the-room-assessments, and to trust their instinct, and to not be intimidated when the doctors questioned their judgments.
- I watched like a hawk and did not let the nurses pass competency until they can demonstrate setting up chest tubes and rapid infusers to my satisfaction
- I failed a nurse’s orientation because she did not meet her milestones, but most especially, she had the nastiest attitude toward her patients.
- I patiently counseled an earnest novice nurse who had the potential to become better but just needed a little guidance to boost her self-esteem
- I “saw” the “light bulb” in my students’ eyes when I taught them how to read the EKG
- I gave feedback with respect
- I challenged the nurses' minds so they would not accept things just because they're used to doing them
- I encouraged the nurses' aides and techs to study for their nursing degree
- I engaged my students in my class to participate in robust discussions
- I prepared specialty certification materials for the nurses and pushed them to go for advanced degrees.

I felt validated when I meet former students/nurses who told me that they learned so much from me.


As a NURSE LEADER in the Emergency Department, I am making a difference when…
- I closed the vacancy gaps and improved the unit’s staffing (I must say that this is a work in progress due to increased patient admission boarders)
- I promote nurse engagement, to improve retention and satisfaction; when they feel proud of being part of the work-family
- I collaborate with the interdisciplinary staff to improve unit processes and patient workflow
- I manage my budget but will always choose patient safety over not approving overtime when the ED is in a surge
- I manage up or acknowledge the staff when they are doing great or when they do a Great Catch (catching a near-miss or potential error). I will always find a way to nominate them for a Nurse Excellence Award or for a DAISY.
- I encourage advancement in the nurses’ practice by using evidence-based care
- I practice Just Culture when staff makes unintentional errors and still hold shared accountability when needed
- I listen with an open mind and do not cast judgments until I hear all sides.
- I give honest but constructive feedback but make sure that my expectations are clear and will be followed up
- I am fair, tough but compassionate.
- I care. I only want the best for the unit, for the patients, and for the staff.
- I still intervene during difficult patient interactions.
- I do not condone workplace violence. I am an advocate for patient AND staff safety,
- I sometimes cry with the nurse, when she/he needs a shoulder to cry on.

I am still learning…. My difference may not be as exciting and full of action as when I was on the front line, but I'm hoping that I make a difference to make life easier for those in the trenches of providing care. 

Work Family Love

The ‘Hurst has become a second home to me. That’s where I started my career in Emergency Nursing, where I learned and grew alongside a group of kind-hearted and dedicated people and I am proud to call them my work family. Even after I left in 2011, I craved news about my beloved ‘Hurst. I am the nurse that I am today because I survived the ‘Hurst. It will always be a home to me, and will always be in my heart.

And so, I wait eagerly for Rich’s narratives of his crazy night shifts with trauma and cardiac arrests, and in his own words, “The joint was jumping, 45 pts on A, 46 on B .. 8 in CT.. 26 in FT ... standing orders for 5:2 was not enough ... even visiting resident said, " how can anyone yell at Dr. Kim 💔.“ And yet, there will always be a time to bond over Jollibee and mango pie, bahn mi and salami, and birthday cakes galore. Haven’t we bonded over picnics, holiday parties, graduations, baby showers, and any other excuse for a party? So much love and camaraderie among the work family.

I share with you all the grief, the profound sadness, and the sense of loss of two strong women, Caryn and Johanna who made a difference in those they touched with their kindness. They have inspired us with their strength. In a world of wonderful people, Caryn and Johanna are prime and shining examples of the phenomenal caregivers we have in our midst. I can only imagine how you are all reeling from the shock, and yet you all continue to swallow the lump in your throat and wipe the tears from your face as you care for the patients who come to the ‘Hurst.

Before Caryn and Johanna, we lost Ruthie, Beckley, Neil, Angel, Kathy, Jennifer, Phyllis, Arlene, Bob, Kettly, Ana, Julie, Rowe, and Angela. And the list goes on. Nurses, doctors, PAs, techs, clerks. All members of the work family. We have fond memories of them, as we shared short-staffed and heavy-volume shifts. They left their footprints in our hearts. There was also an ER resident who took his life, Derek who battled depression, Brad who died tragically, and a new nurse who was stalked and killed by her husband. I felt guilty then because we did not recognize they needed help.

I remember one nurse who was triaging a patient with tears streaming down her face the patient actually forgot that she was in pain and came around to comfort the nurse. I still feel remorse that I had to cancel a dinner date with Phyllis because of a work emergency, only to lose her after a week. I remember Neil hugging me when he saw me break down in tears after I ran around to comfort each nurse after Beckley died. And that’s what we do, even when our hearts are breaking, we try to hold our emotions together because we need to be strong in order to help others. We are resilient in the face of loss.

This work family has to carry on. As you struggle to resuscitate the pulseless patient, as you hold back a negative response when a patient curses at you, as you hold a family member’s hand to tell them the bad news, as you keep your heads above water, as you have each other's back in times of crisis, you are strengthened as a work family. You are a team.

Let us hold their memories in our hearts and celebrate the gift of knowing them.

"Papi"

“Papi!”.

The wail came from the child strapped on the EMS guerney. The Emergency Department was at its busiest with its usual din of alarms, and conversations between staff and patients, but that single word stopped me in my tracks. I could hardly see the patient with the crowd gathered around him, but I could hear the anguish and desperation from that single word. The child was shouting for his father. He was hoarse, his voice cracking.

Two men in black shirts emblazoned with the word ICE stood silent but watched everybody with eagle eyes. Their stern faces as they stood next to the patient did not invite any questions. A social worker from the detention shelter presented herself to the triage nurse. “We need a Psychiatric consult for the kid, he tried to bang his head on the floor after he was caught running away… again.”

As the triage nurse reached out to put the blood pressure cuff on the boy, he cowered in fear and started screaming unintelligibly. The only word that we understood was "Papi". He repeated it over and over again, as if such repetition will conjure the man. His voice was hoarse, probably from hours of screaming. The social worker spoke in Spanish to the boy and tried to calm him down. The boy clung to the social worker, the person most familiar to him. His lips quivered and his beautiful brown eyes spoke of the terror he felt surrounded by strangers.

The patient was a 7-year-old from Guatemala who was separated from his father at the Immigration Center. He lost his mother two years ago from a violent attack by a drug gang in his city. Father and son were caught trying to cross the border to America, to seek asylum, anything to escape what was a living hell for them. At this moment, the boy is trapped in a nightmare that no child should ever be in.

As part of the ‘zero tolerance” policy against illegal immigration, the father was whisked away to the detention center and the boy was brought into the processing center with hundreds of other migrant children, also kept apart from their parents. Countless other kids who learned early on that America is not the haven that their parents thought it would be.

The pediatrician shooed everybody from the room except for the nurse and the social worker. The ICE men stood guard outside the room. The charge nurse called for the psychiatric doctor to examine the child. Until then, the staff could only try to calm him down and prevent him from bolting out of the door. He was sitting on the bed, refusing to speak with anyone else; his arms clutching a teddy bear that the nurse gave him.

It was difficult walking away from the terrified little boy. There was nothing I can do at that moment. But I will do something to share my voice to stop this cruelty to the vulnerable victims of a xenophobic law.

I do not condone illegal immigration, but is it really necessary to separate the children from their parents? This is emotional blackmail and it hurts the kids the most. Are we risking the children's mental well-being just to enforce the rules?

How much heartache could a 7-year old take? How did it come to this that a child is taken away from his “Papi”? How did it all come down to "zero humanity"?

My Human

I am a service animal. My human is who I am loyal to. Please do not make fun of him because he is disabled. He is trying to make the most of what he’s got. I am the only one who can understand him. I go with him everywhere, even to the hospitals. As long as I behave, I can stay at the bedside.

I am his seeing-eye dog. He can see shapes with his right eye. He lost his left eye several years ago in Afghanistan. As he walks by my side, he feels for the tug of my leash to warn him of danger in the path ahead. He responds to my subtle moves. Step to the left, step to the right. When I stop, he stops. After four years together, he trusts me. I once saved us both when I warned him of a car who whizzed by without regard to the blind man and his dog.

Yesterday, my human had to go to the hospital. The security officer tried to block me from coming into the emergency department and wanted me chained to a corner. I did not growl at him, but I was tempted to. It's good that the nurse came right on time to lecture the security officer of my human's rights.

I guess the officer was just too eager. There are a few people who try to pass off their pets as service animal. If the dog is just for emotional support, that is not enough to qualify as a service dog. My human told me of Mrs. Harris, our next-door neighbor, who tried to smuggle Rosita into the hospital. That chihuahua could not stay quiet at all. She even tried to bite the nurse. Ahem, then there is Senor Diaz, his pet ferret is not a service animal even though he claims he need Chester for emotional support.

My human suffers from what he calls PTSD. When there are these loud things in the distance that he calls “damn fireworks”, he cowers in the corner, just like me. We hold each other, and I try to calm myself so that he can stop shaking.

My human said that the American with Disabilities Act protects his rights as a disabled person. The public cannot discriminate against a person with a disability. He said that nobody can demand proof that I am a service dog especially since it’s obvious that he is disabled. I don’t have to have a license or a certificate. Sometimes, I wear my special vest except during the hot summer months.

When my human meets up with his old friends from his old platoon, that is when I also bond with the other service dogs. One German shepherd barks when his human’s blood sugar is getting low. A golden Labrador warns his human before he gets a seizure. I am a beagle and I am the most experienced dog in my group.

Oh, have you heard that miniature horses can also serve as service animals? I would love to meet one someday.




ADDENDUM: 2/7/18
An artist was prevented from boarding a United Airlines flight with her "emotional support" animal. Not a dog or a miniature pony as allowed by the American Disabilities Act. She tried to bring a PEACOCK on the plane. Really?

Nurse, Can You Tell My Story?

I write about Nursing because I am proud of the difference we make in our patients' lives. This is a profession that is definitely and infinitesimally life-affirming and emotionally rewarding. Then, on Thanksgiving day in 2015, I received an email from a patient. His story is unforgettable and inspiring. I will call him Mike to protect his privacy.



11/26/15

Hi Ms. Cerrudo,

On this Thanksgiving, I write to simply say "thank you'. I randomly come across your blog. I'm not in the medical field, but I know it well - as a patient. A few years ago, I was taken into surgery for an emergent surgery. The doctors discovered several masses. Unfortunately, the hepatic artery was nicked during the case, and I began bleeding profusely- I subsequently coded twice during the case, and it was a very skilled RN who helped perform open cardiac massage. After several weeks of intense recovery, I made it home.

I now face a second major surgery in a month to attempt to repair a thoracoabdominal aortic aneurysm that is pressuring both the spinal cord and diaphragm. Additionally, they will attempt to remove some metastatic lesions on the upper and lower GI tract. They have estimated a 16-hour case with a 70% intraop mortality rate.

I write to thank you for sharing all of your stories, which exemplify how important nurses are in the direst of situations. I was able to obtain authorization for an observer during my upcoming surgery and was wondering if you might want to observe. I think so much good could come out of you sharing my story and re-emphasizing that medicine is a balance of technical skill, compassion, and humanity. I could think of nobody better to tell that story.



11/27/15

Hi Mike,

My heart goes out to you. Despite all that you have gone through, you still managed to recognize the contribution of nurses to your care. I have never received a request from a patient for me to share their story. It will be an honor and a privilege to assist you in any way I can.

Let me know how I can help. When is your surgery? I will be leaving for a 3-week vacation in January. I hope I can see you before then. I would really like to meet you.


11/29/15

Hi Jocelyn,

Thank you for getting back to me. Would you be open to talking to me very soon? I would love to tell you of the many ways that the nurses made a difference in my care and how they comforted me when I was anxious or just needed someone to talk to. Can I send you my case study?


12/6/15
Hi Mike,

I read your case study. Words fail me because I cannot imagine how difficult it is for you and your family. If you want to discuss this with me, I am available this Saturday before the holiday rush. In mid-January, I will be out of the country on vacation. I want to speak to you by phone or in person if you're up to it. Your story needs to be told.


(In truth, I was so touched by Mike's trust in sharing his case study. He's not even thirty yet and has gone through a lot. The doctors removed some lesions on his gastrointestinal tract. The names of the OR staff were redacted in the operative report. The case details chronicled the whole session. The assisting surgeon prayed for spiritual guidance for the OR staff. She also prayed for the patient- for his comfort and peace of mind so that he would feel the “hedge of angels surrounding" him. She also prayed that the lessons from this case study will benefit others in the future.

Except for a month’s stint in the operating room as a nursing student, I have not known much about how stressful it is to work in the OR setting, how tenuous life is, and how, in one instant, the patient can bleed out from a ruptured artery. The attending surgeon stepped out twice to inform Mike's parents of complications during surgery. Each time, the attending returned with the family’s decision for a full code. The OR surgeons, physician assistants, nurses, and scrub techs all rooted for Mike, and he survived. No neurological complication from the two episodes of cardiac arrest- one from ventricular fibrillation and one from an asystolic rhythm.

He wants me to write about how the nurses cared for him. I should write about how he inspired me. I cried after reading Mike's OR report. I hoped and prayed that his upcoming surgery would be a success. With all that he went through, he still wanted to honor the nurses. I may not know him personally, but I wanted to reach out and hug him.)



12/10/15

Hi Jocelyn,

Was there anything particular about my case that resonated with you? Have you ever had to perform compressions on the table during a non-emergent case, both external and internal?


12/11/15

Dear Mike,

Several things that resonated with me about your case:
1. Your resilience. Your strength comes through loud and clear. The operative report was graphic and detailed, especially in the resuscitation efforts. Everything was so surreal.

2. Your spirituality. I did not even know that prayers are in the OR.

I have been an ER nurse for about 25 years. I spent the last 12 years as an educator. I have done my fair share of external cardiac compressions. When I was still doing trauma, I had assisted in cardiac resuscitation using the internal defibrillation paddles, but I have not done an internal cardiac massage. The closest I have ever come to seeing this was when the trauma surgeons opened up an eight-year-old boy who was hit by a baseball in his chest. To this day, I still get goosebumps when I remember the day the boy came back to the ED several weeks later, alive and well. I have never been so happy seeing the healed scar on his chest.


(In fact, I wanted to tell Mike how grateful I am that we could talk over the phone. I felt emotional hearing his voice, especially since I realized that his impending surgery was complicated. He expressed optimism, but I sensed that he was resigned to the fact that he might not make it this time. With the 70% intraop mortality rate, the odds are against him.

When I asked him why he wanted me to specifically thank the nurses, he said, "I thanked the doctors enough, but the nurses don't get enough credit."

He was not able to expound on his experience with the nurses. He was getting tired, so I suggested that we can just make another appointment to talk again. We did not have a chance to speak again since he was busy with more tests).


1/12/16

Mike,

In a few days’ time, you will undergo surgery again. I am sorry that I will not be able to be there for you because I am boarding the plane to see my family. I will pray for you. Would you email me back when you have recovered? Be strong.



1/20/16

Mike, I pray that the operation was a success. Please email me back.

(I called him from overseas. The phone just rang and rang, and I prayed that he was busy recovering.)



2/26/16

Hi Mike,

This is Jocelyn. It has been a while since we corresponded. I am not sure what has happened since then. Can you please e-mail me back?



3/8/16

Mike, are you there? I tried to call your phone, but it was not in service. I also tried to google your name for any news.


11/26/16

Mike, it has been a year since you e-mailed me. I fear it is not good news since I haven't heard from you. I do not want to intrude on your family's privacy, so although I know your real name, I couldn't contact your family. Are they even aware that you want your story shared with the world? I do not know you personally, but I am convinced that for whatever little time you have on earth (I feared the worst), you have enriched the lives of those around you.

I am humbled that you chose me to tell your story. You wanted to honor the nurses. Instead, I honor you.

Mike’s requested scripture readings before the surgery:

He heals the brokenhearted and binds up their wounds.—Psalm 147:3

Fear not, for I am with you; be not dismayed, for I am your God; I will strengthen you, I will help you, I will uphold you with my righteous right hand.—Isaiah 41:10

For I will restore health to you, and your wounds I will heal, declares the Lord, because they have called you an outcast: 'It is Zion, for whom no one cares- Jeremiah 30:17