What follows is an interview with Stephen Lee, RN, BSN, a nurse who started as a volunteer EMT and worked his way up the rungs of the medical ladder to become a flight nurse. His career progression and determination highlight a long road to success.
First off, how are you currently spending your time?
I currently live in Louisiana, a few hours north of New Orleans, and I’m training in a position as a flight nurse. I recently left a position in the cardiac-medical intensive care unit at a regional heart transplant center. I’m part of the forensics team (sexual assaults, domestic violence, simple assault, and burns) and I work PRN in the emergency department (ED) at the only level 1 trauma center in my city. I also volunteer with an urban emergency medical service (EMS) system as a paramedic.
What was your first job in health care?
Several years ago, I started as a volunteer EMT (emergency medical technician), which I affectionately deem to be the bottom rung of the medical ladder. Looking back on those days, I knew close to nothing but was caring for critical patients in unstable environments. I had no idea that I was interested in the medical field until I started as an EMT, but I loved the marriage of critical thinking in a high-pressure environment, and I developed the (very useful) ability to look at life and say, “give me your worst.”
What was it like to be an EMT? Where did you go from there?
I loved being an EMT. I was in a position to interact with critical patients, even if it was with only six drugs. I was taught how to give the best care with very few resources, and the fraternity that I experienced was like nothing I had ever experienced. I spent some time with private ambulances and slowly got more and more interested in the complex tools, patients, and therapies that you can’t really see outside the hospital. I was lucky enough to witness the incredible nursing teams at DC hospitals, and that’s when nursing became my dream.
Where did you go to school, and what did that progression/path look like?
I had earned my Bachelor of Arts degree in a completely unrelated field, so I didn’t have a single science credit when I decided to go back to school for nursing. I got my ADN at Montgomery College, then received the Conway Scholarship from the University of Maryland for my BSN. The UMD School of Nursing and the Conway Foundation have led to so many new opportunities that never would have been possible otherwise, and I’m forever grateful.
So you graduated with an associate’s degree? What was your first job?
After I passed the NCLEX and became an RN, I realized how restricting the ADN was. I wasn’t eligible to work at any magnet hospitals, and all critical care programs require a BSN. I wanted to work in emergency medicine, but I had no ED/ICU practicum experience (community colleges often do not get this opportunity), so it was hard to stand out. Luckily, I had hopped on earlier as an emergency department technician at a smaller DC hospital, and that department hired me as a new grad. I received a full-ride scholarship to earn my BSN a year later.
Tell me about your first job as a new graduate nurse.
I was in a small community ED for my first year as a nurse. It was a nice, gradual introduction to emergency care, and I loved it. It was not a teaching hospital and not a trauma center, but it was like learning within a big family.
Where did you go from there?
After my first year in nursing, I had completed my BSN and ED residency. I was ready to get beat up. I found a position at University Medical Center in New Orleans, the only trauma center in a city with an incredibly high rate of both crime and weirdness. I credit this hospital for building me into the ER nurse that I am. When I realized that I wanted to fly, I knew that I needed more ICU-like critical care experience, because interfacility transports between ICUs are common. I left the ER and worked in the cardiac/medical ICU in New Orleans. I was lucky enough to work with LVADs (left ventricular assist devices), IABPs (intra-aortic balloon pumps), and so many other things that I would never experience in the ER. Forensics is a whole other story that I fell into.
What are your short- and long-term career goals? Where do you see yourself in five years?
I’m living my ultimate dream: flight nursing. Flight nursing requires a combination of the technical finesse of an ICU nurse with the mentality of an ER nurse, all in the prehospital environment where it’s just you and your partner. All of my career moves over the last several years have been toward this goal, and I’m now doing orientation and training. This type of work is the pinnacle of emergency critical care and prehospital care, and I could honestly see myself doing it for the rest of my life.
What advice would you share with anyone who is interested in pursuing flight nursing?
First of all, and quite unfortunately, there are no shortcuts. I meet a lot of people who finish nursing school or get their medic cards and immediately want to be a flight nurse. You need a minimum of 3-5 years of grueling experience, a specialty certification is almost a requirement (CCRN/CEN/CFRN), and be sure to get every smaller certification that you can (ACLS/PALS/NRP/PTLS). Get prepared to be challenged: our training officer likens the first six-month training process to “a firehose to the face.”
If you want to fly, get EMS experience. I can’t stress this enough. Beyond learning about the prehospital environment, you learn how firehouse life works, which a lot of nurses (especially from ICU backgrounds) struggle with. You are not colleagues with your flight team, you’re family—a family that uses curses as terms of endearment and who knows things about you that you never even told your closest friends. Working in that type of environment builds bonds that can never be broken and are instrumental to providing the best care together.
This is very important, even for nurses who don’t want to fly: Learn some of the skills of those around you in the hospital (respiratory therapists, EKG/ECHO techs, IV team), because there’s going to be a time that you’re going to need something done by them and they’re not around (keeping inside your scope, of course). Plus you will learn so much! I’ve come in on my days off to shadow respiratory therapists and IV nurses to see how they do things.
Lastly, be a team player, but never accept help until you really need it. If your patients are settled, then it isn’t time to relax, it’s time to help your coworkers. Avoid accepting a hand just because it’s offered, but take help when you’re drowning. Build a reputation of being self-sufficient but also very helpful to your coworkers, so that when you have that tough assignment and you say “I really need help,” people will jump right in. You’re not going to get far doing this job without a team, and you also won’t get anywhere without hard work.
CBD (cannabidiol) oil is a popular cure-all that you may have seen hyped or scrutinized by the media. But what exactly is it, is it safe, and how is it different from the use of medical marijuana?
THC, CBD, and Hemp
Marijuana comes from the leaves of the Cannabis plant, which produces a variety of active chemical compounds referred to as cannabinoids. There are dozens of cannabinoids; THC (tetrahydrocannabinol) and CBD are two of the more widely studied. THC is the psychoactive compound in marijuana that causes intoxication, or a high, by activating the brain’s reward and pleasure center, causing the release of dopamine. By contrast, CBD is not psychoactive and therefore does not cause a high. It is also not believed to be addictive.
Hemp also derives from Cannabis, but generally refers to plants cultivated for non-drug use. Hemp also contains much higher concentrations of CBD and a much lower concentration of THC (<0.3%). Historically, hemp has been used to make rope, fabrics, or textiles.
Medical marijuana is now legal in 33 states and the District of Columbia. For recreational use, marijuana is legal in 10 US states and in DC. In recent years, the number of patients who are turning to Cannabis for medical treatment is increasing. Marijuana has been a therapeutic treatment for cancer patients; it has been shown to treat pain, nausea, and cachexia. Marijuana is also now used as a treatment for Alzheimer’s disease, chronic pain, Crohn’s disease, and many other conditions.
CBD is generally sold formulated into an oil and has been touted as a solution to pain, insomnia, anxiety, and a wide range of other medical conditions. CBD oil is expected to become a billion-dollar industry in coming years. It is important to note, however, that despite the oil’s growing popularity, it remains largely unstudied and unregulated.
CBD is readily available for purchase online, but it has varying levels of legality in the United States. Although several US states have specific laws regarding CBD, it remains a controlled substance by the Drug Enforcement Agency, and is classified as a Schedule I drug. This designation remains despite the passage of the 2018 Farm Bill (which legalized the broad cultivation of hemp, under outlined restrictions).
There is a lack of high-quality, large-population studies on CBD use in humans. Large-scale, randomized clinical trials are needed, but it has been proposed as a potential therapy for a range of conditions, including anxiety, Parkinson’s, chronic pain, schizophrenia, and multiple sclerosis. Many users anecdotally claim it has pain-relieving benefits and use it as a treatment for muscle aches, inflammation, and pain. Other people use it to ease anxiety and insomnia.
There currently exists only one FDA approved medication that contains CBD: a seizure medication called Epidiolex, which is used to treat two particularly severe seizure disorders in children.
CBD is most commonly available in the form of an oil or drops. It may also be formulated into a balm, patch, or topical. There are also edible formulations, such as chewing gum, gummies, cookies, and brownies.
It is not likely that a patient will mention the use of CBD oil during a medication reconciliation, so it is important to ask patients about all products they use, including herbs, supplements, and oils. Patients should know that CBD oil may interact with other medications (such as blood thinners), and it could potentially increase the level of certain drugs in the bloodstream. Although side effects are anecdotally infrequent, it may cause sedation, fatigue, or nausea or diarrhea.
Patients should be informed that the concentrations of CBD oil vary widely, not just from product to product but also from bottle to bottle. A 2017 study published in JAMA found that of 84 different CBD oils purchased through online retailers, 18 actually contained THC. Moreover, 43% of the products were underlabeled (that is, the concentrations of CBD were lower than listed on the product), and 26% were overlabeled (the concentration was higher than listed).
Additionally, because there have been no large-scale studies of CBD in humans, there are no recommended safe or effective dosages.
Nursing is a vocation rife with occupational hazards. On a daily basis, nurses come into contact with sick patients, infectious agents, teratogenic chemicals, and radiation, to name a few environmental risks. Additionally, nurses are constantly on their feet, walking several thousand steps per shift. They are expected to help lift, move, and transfer patients several times per day, and face many potential musculoskeletal injuries from strenuous physical labor.
It is not surprising, then, that many nurses worry about the risks inherent in their daily job descriptions once they are expecting. Many nurses are women of childbearing age, and a pregnant nurse has to take certain precautions to keep herself and her growing baby safe. Below are some of the hazards pregnant nurses may face and suggestions for mitigating those risks.
Infection. Perhaps one of the most obvious risks to a pregnant woman and her fetus is infection. A nurse in the emergency department (ED), for example, may encounter patients sick with potential pathogens, from strep throat to tuberculosis to the flu. A pregnant nurse should follow standard precautions with all patients, and may also wish to wear a surgical mask around patients with a fever or suspected respiratory illness. A pregnant ED nurse may also wish to limit exposure to pathogens by reducing time spent in triage, if possible. Pregnant nurses may wish to avoid taking care of patients with active shingles or varicella zoster infections, as well as patients on airborne precautions.
Pregnant nurses should be immunized against influenza; the vaccine is safe for women in all stages of pregnancy. The live attenuated flu vaccine is unsafe for pregnant women. As an added benefit, flu antibodies are also passed to the fetus. If a pregnant nurse cares for a patient with influenza and later suspects she may have contracted the flu, she should speak with occupational health at her hospital to possibly receive a prescription for Tamiflu. Tamiflu works best when taken within 48 hours of symptom onset.
Drugs and chemotherapeutic agents. Because several drugs and pharmaceutical agents have known fetotoxicity, great care should be taken by the pregnant nurse when administering those and any medications to patients. Medication preparation is risky, and pregnant nurses may be exposed to hazardous drugs through skin absorption, inhalation, accidental contact, or needle-stick injuries. Sometimes while drawing up medication, the liquid can splash or make contact with the skin. Nurses should at the very least wear gloves while drawing up any medications or handling drugs, and at the most, should avoid handling known chemotherapeutic agents such as methotrexate.
Nurses should also weigh the risks and benefits of continuing their particular field of nursing while pregnant. Cancer treatment drugs, for example, have known effects of infertility, miscarriage, birth defects, and low birth weights.
Ionizing radiation. Radiation for diagnostic imaging is common in nearly all hospital departments, and nurses are at risk not just of background radiation but also of direct ionizing radiation. Nuclear medicine departments in particular are of high risk to a pregnant woman. Effects of radiation on a fetus depend in part on the dosage of radiation and on the baby’s gestational age. The thresholds of safe exposures are not well investigated, but research has demonstrated an “all or none” effect; that is, significant exposures cause either no effect or a fetal loss. Although dosimeters are used in areas where high radiation exposure is expected, other areas of high ionizing radiation (e.g., the emergency department) are rarely monitored. Expectant nurses should be very aware of their surroundings.
Stress, physical labor, and shift work. It may be necessary for nurses later in pregnancy to modify their shift schedule or behaviors to help accommodate their needs. Nursing is already a physically rigorous vocation, but add in the fatigue of pregnancy and it can be extremely physiologically demanding. In the first trimester, many women experience morning sickness, which to the pregnant nurse can be debilitating. Later in pregnancy, back pain and sciatica can also interfere with nurses’ ability to continue working until their baby is full term. Additionally, the 12-hour shifts typical for most hospital nurses become more taxing later in pregnancy, and it may be necessary for the pregnant nurse to request a modification to shorter shifts or part-time hours. The best solutions for pregnant nurses are to enlist colleagues for help when possible, to always use safe-lift equipment when available, and to speak up when requiring assistance.
If you are pregnant and struggling to perform your duties, certain pregnancy complications are covered by the Pregnancy Discrimination Act. Pregnant nurses should also be familiar with their state and employer’s Family Medical Leave Act policies and eligibility requirements.
For more information about the hazards to pregnant health care workers, you can browse the National Institute for Occupational Safety and Health’s website about the effects of workplace hazards on female reproductive health.
On February 15, 2018, the newest safe nurse staffing bill was introduced to the U.S. Congress. The bill (H.R.5052 and S.2446) has bipartisan support, and is championed by Reps. David Joyce (R-OH), Suzan DelBene (D-WA), Suzanne Bonamici (D-OR), and Tulsi Gabbard (D-HI), as well as Sen. Jeff Merkley (D-OR).
In the past, several safe staffing bills have been presented in previous Congresses but have failed to pass committee. This bill, the Safe Staffing for Nurse and Patient Safety Act of 2018, is slightly different than previous iterations. Under this staffing legislation, Medicare-participating hospitals would be required to form committees that would create and implement unit specific, nurse-to-patient ratio staffing plans. At least half of each committee must comprise direct care nurses.
“It is so important for nurses on the front lines to be able to have a say in what they believe is safe staffing,” says Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, the president of the American Nurses Association (ANA). “This bill benefits bedside nurses by giving them decision-making power, control, and the ability to influence the delivery of safe care,” Cipriano continues.
A committee made of staff nurses—who would make staffing decisions that directly affect their own units—is so important because it is nurses who can best assess patient needs and the resources required to provide safe patient care. Staffing committees would be able to address the unique needs of specific units and patient populations by involving specialty nurses in the decisions, and would have the ability to modify the hospital safety plans as needed.
Overwhelmingly, research supports adequate nurse staffing. Over the last several decades, literature has demonstrated a decrease in patient morbidity and mortality and an increase in patient safety when units are well staffed. “With adequate amounts of staffing we see mortality go down and patient complications can be prevented or diminished,” Cipriano says. “It is important for nurses to have sufficient resources to care for patients, because nurses experience moral distress when they cannot provide the care they know a patient needs.”
Short-changing patients also contributes to nurse burnout, and low nursing retention is expensive. Additionally, adequate nurse staffing leads to reduced health care costs, as a result of fewer hospital readmissions, hospital-acquired infections, medical errors, and other significant measurable patient outcomes. “Patients deserve to have the right care,” Cipriano says. “They need to be kept safe, and the best way to prevent problems and complications is to have the right nurse staffing.”
Is there hope that this bill will pass, when so many previous iterations have not? “It may be difficult to pass the legislation, even this time around,” Cipriano admits. “But the most important impact is that every time we have an opportunity to have this legislation discussed, it’s another opportunity to educate another decision maker. Whether it is congresspeople, their staff, or other leaders in their communities, it gives us the opportunity to continue to reinforce why it is so important to have the right nursing care.”
It is ethically challenging when a nurse is asked to take staffing assignments that do not feel safe. On many units, nurses are expected to care for several acute and critically ill patients at a time, and are given patient loads that stretch them far beyond their reasonable care delivery capabilities. What should a nurse do when faced with an unsafe assignment? Nurses should raise immediate concerns by following the chain of command, and talking with immediate supervisors to express that they believe the situation is unsafe. “The first obligation is to make sure that no patient is left uncared for,” Cipriano says. “Short term, use the chain of command and do everything you can within in your power to make sure that you’re providing at least the minimum care the patient needs.” Longer-term, if nurses truly believe that their organization is not supporting the right staffing ratios, the ANA encourages an active dialogue with leadership, such as a conversation with responsible nursing leaders, quality directors, or patient care committees or councils to focus attention to the issue.
“Nursing care is like a medication,” Cipriano says. “You wouldn’t withhold a life-saving medication, so why would you withhold the right amount or right dose of nursing care?”
If you are passionate about safe staffing laws, consider calling or writing your congressperson and encourage them to support the Safe Staffing for Nurse and Patient Safety Act of 2018.
As most nurses certainly are aware, this year’s flu season is exceptional. It has surged earlier than in previous years and as of mid-January is widespread across all 50 states. There has been a significant wave of flu cases in doctor’s offices and hospitals across the country, affecting everyone from children to the elderly. Emergency rooms (ERs) are inundated with flu patients, and in many cases patients line the hallways in overcrowded facilities without space or beds available due to additional patient volume. Patients are boarding and holding for inpatient beds in the ERs, which exposes additional patients, visitors, and staff to the flu.
Below are some friendly flu reminders, tips, and tricks to keeping yourself and your patients healthy and safe this season and beyond.
Hand hygiene is the most effective way to stop the transmission of the flu. Flu spreads via droplets coughed or sneezed by infected persons onto shared surfaces. Washing your hands thoroughly and frequently and using alcohol-based gel sanitizers is an effective way to prevent flu. But one thing we often forget about is our patients’ hands. Especially when I work in triage, I’ve started asking my patients and their visitors to use hand sanitizer before triage and before they enter their patient rooms as well.
If your hands are feeling the burn after so much vigorous washing and sanitizing, reach out to your infectious disease department to see if it can provide some hospital-approved pump-style lotions for your cracked hands. At home, try using Bag Balm or deep healing lotions and placing mittens on before bed to help salves and creams absorb overnight.
If you have flu symptoms, you should stay home from work. Not all employers have the same regulations regarding sick leave and doctor’s notes, and some are certainly more rigid than others. But the best thing you can do for yourself, your patients, and your colleagues when feeling under the weather is to stay home. This doesn’t just help you get better faster, but also prevents you from endangering your fellow nurses. The flu can spread so rapidly through a department that it can quickly decimate staff numbers and leave no one else to care for other ill patients.
You should feel empowered to communicate with visitors about the flu. It is imperative that nurses educate family members and patient visitors about their role in flu prevention. If your facility hasn’t already done so, consider limiting visitors to your patient rooms, especially children. It is wise to limit visitors under the age of 12 to protect this vulnerable age group from germs. You should feel empowered to ask ill-appearing visitors not to enter a patient’s room if you are concerned for their health. The safety of patients is the utmost priority.
Tamiflu is not for everyone. Most cases of the flu do not require treatment with antiviral medication such as Tamiflu. Clinical judgment will determine whether a patient fits criteria for treatment with antivirals. In most cases, treatment is most effective if given within 48 hours of symptom onset. If you have cared for influenza patients and are starting to see symptoms in yourself, reach out to your employee or occupational health department as soon as possible. In some cases it may be taken prophylactically.
It’s not too late to vaccinate. Make sure to teach patients that even though the flu vaccine has been less effective this year, it still helps save lives by reducing the severity and duration of the influenza virus. Remind patients that it is not too late to receive their flu shot. Everyone six months and older should get the flu shot, especially children, the elderly, and pregnant women.
Mask yourself, mask your patients. If you suspect someone has the flu, you should immediately begin droplet precautions. Place a mask on the patient in triage or when leaving his or her room, and keep yourself protected with a mask and gloves at all times. Remind patients to cover their coughs to help keep you safe.
Resort to basic teaching. Effective discharge teaching can help prevent repeat doctor’s office or ER visits and can help patients stay healthy. Remind patients that the best place for them to be if they are feeling sick is at home. Most people who get the flu will have a mild illness that does not require hospitalization. Fluids, rest, and over-the-counter antipyretics are effective in treating most cases of illness. People with suspected flu should stay home until at least 24 hours after their fever has gone away. Emergency symptoms that require immediate evaluation in an ER include shortness of breath, difficulty breathing, sudden dizziness or confusion, severe or persistent vomiting or diarrhea, or pain or pressure in the chest or abdomen. In children or infants, watch for signs of dehydration, fast breathing, lethargy, and rash.
Keep yourself as healthy as possible. In addition to washing your hands frequently (while at work and not), you should also try to boost your immune system by eating nutritious foods, including fruits and vegetables; staying hydrated; and getting exercise and sleep. Staying well rested and well hydrated can help keep your immune system in good shape to combat this flu season.