I now do accessibility testing. I tested my own blog. I am not impressed.

 

My blog has health care information but it will begin to include what I learn as an accessibility tester. I think I can set the content up with proper heading levels and in a way that is consumable if I have a tool that conforms to WCAG standards.

Unfortunately, I keyboard tested a piece I published and I had too many findings despite the fact that I used heading levels, alt text, etc.

I looked at the company's help pages to see if there was information on making it accessible, a VPAT or ACR or anything about WCAG conformance and got nothing. I am now looking to change the tool I use to publish my website, and remediate my content with a more inclusive design.

The favor I am asking for is which mediums might be able to do that, so I can get down to business and remediate my content, because I can do better.

[Congestive Heart Failure] When the ol' pump ain't what it used to be

This is a repost of my response on Reddit about how someone was going deal with a new sodium and fluid restricted diet after being hospitalized for heart failure. They loved milkshakes and had met with a dietician who really did not have a good therapeutic connection.

Trigger Warning - Below I'm going to talk about what I saw taking care of heart failure patients on a hospital cardiac unit. Someone who has had a heart failure episode may become anxious when I describe the early parts of their admission.

 

This discussion barely scratches the surface of the complexity of this condition. Most people are not admitted every week or two - but the advice I learned to reduce admissions for these patients helped to curate the discussion and education I provided to patients in the clinic and helped them have much more control over their own health and disease.

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Day 1: I have had patients who were admitted about every 10-14 days like clock work. The ER gave them diuretics, the ER would take off 1-2 liters of fluid. By the time they get to my unit, they were still afraid from being short of breath and it being hard to breathe and this was the new and improved version. There is a look in a scared person's eye that doesn't leave you. I know that look from across the room.

Day 2: Less panic, still feeling very drained. We continue to remove fluid.

Day 3-4: Start to perk up, feeling a bit better. Better enough to be irritated with us, and complain about being hungry and don't like the food we're bringing because not enough salt/fluids. Sometimes they ask family to bring food - like fried chicken.

I cannot believe my anecdotes came about because I had so many patients who would come in and say how we didn't take care of their heart failure, but by day 3-4 they were having family bring fried chicken. #ffs #nurselife #we'veseensomeshit

Now let me get to the advice I found worked the best to stop repeat admissions:

Of all the dietary restrictions, salt+fluid can be one of the hardest.

Accept this is a difficult thing. I don't love people who treat it like it is easy like dieting and losing weight. *just* change your diet and the things you eat multiple times a day, every day for the rest of your life. Yeah bud, *just* is a 4-letter word. It is okay to have grief over this.

This person discussed a having dietitian who did not connect well with them: 

If you feel like you and the dietician aren't connecting, consider finding one who has empathy. I have seen great dieticians (they are part of your healthy team and they find ways to help you feel satisfied while having to change something you've been doing your whole life) and ones who just tell a grown adult patient what to do. I have no use for someone telling adults what to do like they are children.

Intake is all choices. You can absolutely eat all the fried chicken and drink all the ice cold milk shakes (or whatever items you love). Be prepared to spend an increasing amount of time in the ED and in the hospital as that taxes a heart that has had an injury.

Basically, the heart is a pump that is with you your whole life. That pump got hurt somehow. Maybe a heart attack or some other type of an injury but at the end of the day, the ol' pump ain't what it used to be. It can't pump like it used to. Your body has tried for a long time to help it - but it just can't do all it used to do. 

What happens when you try to use the pump the same way and it can't do it? These are the chains of events that bring some people to the hospital with a worsening of their heart failure enough to be admitted.

If you are committed to liquid, consider eating foods with less fluid - since the liquids add up you can trade off. Now if less liquid-y foods are dried (e.g. beef jerky) - mind the sodium.

I don't know how you are managing your HF, but daily weight is the gold standard.

Wake up, eliminate any stuff from your body and weigh in the "same clothes" (e.g. naked = same clothes) every day. Write the weight down. If you gain more than 3 pounds in a day or 5 pounds in a week, it is time to call the doctor as that is the best indicator of water weight.

What are the other upsides to daily weights?

Just for a bit of context - our patient often didn't get admitted with a 3 pound weight gain. They were frequently admitted with a 20-30 pound weight gain and often didn't detect it until they were short of breath (height and weight can change these numbers). Watching these numbers lets you know in short order what is going to cause more fluid retention. Daily weights give you insight about your intake from the day before and if it affected you, you can make adjustments.

This is great info for the doctor too. Your doctor can have a much more informed discussion with you over time when you can bring that one bit of data for daily weights to your PCP or Cardiologist.

I don't know your situation, but if you are a Veteran, they actually have a heart failure line where Veterans can call. The line has clinicians who can advise on medication adjustments if needed on the fly. I personally believe it should be an industry standard. The concept is simple, they can manage you at home to reduce admissions. Less cost for them and more convenience and quality of life for you.

The unappreciated choice

 

You have a decision to make. You weigh the options in hopes of making an informed decision (or informed refusal). 

• The decision can be difficult
  
• Maybe you don't like the answer or outcome
  
• Maybe you feel like you don't have enough information to render a decision yet
  

Enter analysis paralysis

Consider this: *Not* deciding is also a decision. 

Why? There will always be an outcome. The absence of a decision is often the unappreciated choice in a scenario.

Consider this when you might come across time when analysis paralysis sets in:

No decision is a decision in and of itself

Why you want to interview a nurse, whether or not you are in the healthcare sector

 

Nurses are limited in their career only by their own imaginations. 

If you are a nurse thinking about changing roles or if you are an employer looking for that next employee to round out your team, let's discuss the things a nurse brings to the table:

1. Nursing is a profession - we teach each other

2. Safety first - Our license is to demonstrate that we know how to keep folks safe - it is a privilege not a right

3. Prioritizing - we have to get ahead of the thing that may kill you first; then we'll get to the second thing that might kill you (see # 2)

4. Learning - evidence based medicine is ever changing, and we have to stay up to date, so we are expert learners (also see # 2)

5. Delegation - we are trained to lead because we know we can't do it all. We learn to leverage the power of a team and the strengths of the many (See # 3)

6. Resourceful - we don't always have everything we need on hand, yet we still manage to get things done (see # 3, # 5)

7. Teachers - we have to teach medications, treatments and healthcare to folks who may not know much about medications, treatments or healthcare (also see # 1, # 3)

8. All comers - we treat everyone because we are everyone <3

9. Compassion - We see people at their absolute worst and we learn to help them maintain their dignity and autonomy as much as possible (see # 2, # 3)

10. Practice - We know how to work toward improving things "That's why we call nursing a practice, not a destination" (See # 2)

11. Pattern recognition - Nursing and healthcare are algorithmic in nature. There is math in humans and we still treat them like humans

12. Soft skills - we are consistently the most trusted profession while doing all of the above things in any given situation (See # 1, # 2, # 3, # 4, # 5, # 6, # 7, # 8, # 9, # 10, # 11)

Universal Truths

 The Distillation Process

 

These things. They happen over and over. They prove themselves at every opportunity. They are Universal Truths.

How do you recognize a Universal Truth? Well - it isn't always easy. Think of distilling a fine spirit. You boil off the impurities and what is left may be the Universal Truth you are seeking.

If something happens over and over - it may be true, from your perspective. Consider though, you are one of over 7 billion people on the planet. What is true for you, may not be true for everyone else. Try to see someone else's perspective. Challenge your own thoughts on the thing. Observe the world around you. Does it change when you changes these variables? If it does, it may not be a Universal Truth. Does it stand the test of challenge? Then you may have a good candidate!

I encourage you when you think it is a Universal Truth - don't declare it, you still may be wrong or the thought may still need further distilling and removing of impurities. Instead, try floating the thought out there, "Wow, this may be a Universal Truth" or "Do you think this could be a Universal Truth?" Have this discussion with folks. Welcome the discussion and challenge. You aren't married to it, you are working on it. 

Some Universal Truths have taken me minutes to find and years to challenge. Others take me years to find and minutes (or seconds) to say...yup...that may be a Universal Truth. I like them because these truths are the things we share with others in life. How we can connect and know each other. How we see eye to eye. How we learn and get better. Remove the impurities, retain the true spirit.

Sit with me by the fire

Imagine you and I are camping. We are sitting around the campfire, you on one side - me on the other. We are discussing things. I am telling you what I see from my perspective. I see the fire, you and the stars. It is beautiful. You, on the other hand see the fire, me and a grizzly bear approaching. 

 Stop time

If you came over to my side of the fire, you would see my perspective and you would not appreciate the danger. 

If I came to your side I would see your perspective and I would see the danger. 

There are at least three hundred and sixty seats around this fire. We may share views, we may not. They are all a little different. 

When we interact with folks, we are at a campfire. I always strive to mentally slide around to their side and try to see where they are coming from so I can understand their perspective.

I also work to help them slide to my side and see what I see. 

This brief stopping of time and mentally putting yourself on the other side of the campfire is the easiest way I know how to explain both perspective and how to promote empathy. 

During a pandemic we are both isolated and we interact in ways that are both social and anti-social. I still remember when working with folks - we all share this campfire.

Walking down the spiral staircase versus jumping off of it

"My blood sugar doesn't like to be less than (200-250) so don't give me that damned insulin!"

Have you ever met that patient? The one who fusses when you get their blood sugar "too low"??

Here is how I teach to that:

First, I have visual printouts of what the symptoms look like for Hyperglycemia (high blood sugar) and Hypoglycemia (low blood sugar). Patients benefit from pictures, not words. I set something like this on the table.

"Here is the deal. Your body likes this state we call "homeostasis." In a nutshell, it means your body wants to be at all times. Sameness. If one thing moves - other things have to move too" I draw this on the whiteboard:

What that looks like: (Pointing to the hyperglycemia chart) "Your blood sugar begins to rise and other systems compensate to keep adapt. Around sugars of 250, your body starts pulling water from here there and everywhere to push that sugar off by your kidneys. You get thirsty, you might be peeing all the time, you may be constantly hungry or you may be tired all the time and feel like you just can't get stuff done."

Patient agrees or disagrees with these statements. I adapt my approach to the ones they identify. 

"Also, you can have trouble seeing things and you might have a small wound that just won't heal - or worse yet gets infected like crazy! Why? Because bacteria like to eat sugar so your body is like Daytona Beach during Spring Break!"

Patient usually laughs - then becomes a bit uncomfortable.

"You didn't get this way over night. You aren't going to have "normal" blood sugars overnight either. We need to walk your blood sugar down, like walking down a spiral staircase to a less dangerous level of blood sugar."

Patient may argue about how their body doesn't like below ___ blood sugar. 

What are we worried about? (Pointing to the hypoglycemia chart) "Your body has gotten USED TO these blood sugars. If we immediately try to bring you down to "normal" your body doesn't have time to adjust. You will have the SYMPTOMS of low blood sugar, even though your blood sugar IS NOT LOW. So, when you hit 250 (down from 500) you feel like crap! You're shaking, your heart is beating, maybe you are sweating and you feel like you're going to fall out. You are starving and ready to chew off your own arm, you have a headache and you are ready to kill the first person who looks sideways at you. Sound familiar?"

Generally the patient is nodding emphatically.

"Well, this is not ACTUALLY hypoglycemia - but it feels that way. If your blood sugar was...say...under 100 - I'd be getting you a full meal together. If your blood sugar is, say 250 and you feel like this - I'd say you are not in immediate danger - but I also know you still feel like crap. For that, I'd get you a small snack, to help you feel better, but not to jack your blood sugar right back up through the roof."

A glimmer of understanding begins to fuel itself. 

So, think about bringing your blood sugar like walking down a spiral staircase. We want to take it one step at a time. You would feel a lot better walking down that staircase, than jumping off of it - wouldn't you?

Planning the new diabetic regimen begins. 

PS: If any of this works for you - please use it! The talk about homeostasis and "feeling" crummy when we overshoot our mark can be adapted to talking to a patient about their hypertension medications as well. 

Why you want to work with the most difficult patient on the unit

I talked about the concept of "othering" and how I would work with this as a nurse or charge nurse on a unit to tighten our team and help us all work together better. The same concepts are true when I apply them to the patients.

First of all, think about the following two questions:

What does the "other"do poorly?

What does the "other" do well? 

Find me a "familiar face" or "frequent flier" and please - oh please - let them be a loud troublemaker! These are so frequently our folks who are misunderstood. Of course, the more loud someone gets, the more I wonder about their underlying motivation, but I usually assume it is some sort of fear. When this loudness is in process, be quiet, listen. You are looking for subtext. Hear the fear, worry, frustration or motivation.

When I hear the subtext, personally, I often find myself tell them how much it sucks or how difficult this all must be. I don't have to agree with them. I don't have to feel that way. I often know I wouldn't necessarily have reacted that way. I just have to hear how they feel at this moment that brought them to this place, and they need to feel that I hear them.

I operate on the precept that when someone is mad 1) you aren't teaching them anything and 2) they can only rage for so long. Acknowledging how difficult this can be for them shifts gears or at least puts their transmission in neutral. This is a great place to be. In neutral, they may need some more time to vent - but you are helping the patient feel heard. The more they feel heard, the more they'll be more likely to tell you the worries on their mind. Don't be surprised if it does or does not perfectly fit your clinical scenario or what you are trying to accomplish - humans aren't always rational but you have to hear this if you want to cease the disruptive behavior.

Next helpful hint: If you really want to de-escalate this quickly, you have to let someone have an easy way to escape the corner they've backed themselves into. A scared, worried, frustrated person can make a real ass of themselves. They can say some nasty stuff. Once they are less screamy and more listeny, my response goes something like this:

"Hey, you were just having a MOMENT. It doesn't define you. This is all pretty stressful and you were upset. Everyone has a MOMENT, including me at times. We're past it now. I don't take it personal. Now let's try to do something that gets us where you are trying to go."

Then I focus helping develop a mutual plan of action. Why? They are engaged and they are open to what we are doing and need to do. I am pretty candid about what we can't do too. Patients don't hear the limits of our treatments, systems or facilities enough, then clinicians wonder why the patients have these unrealistic expectations.  This candid explanation of the limits of the system helps patients be more reasonable - more patient.


Bonus skill: 
Once you learn to speak to what someone does well and what they do poorly you can improve your game with your patients who are as sweet as pie. Why? because pleasant demeanor merely means they haven't gotten sideways of you or everyone else. It does not mean they are having their needs met. They still may not have revealed their fears or frustrations to you. I have learned that actively seeking my patients strengths and weaknesses helps me prepare them in ways that set them up for success and not failure (e.g. no unexpected re-admits).

If you can't say something nice about someone, then you're not done looking

‪On a floor of nursing staff, there will be personalities who conflict. It is not good for the patients or the staff. 

I wanted people to tell me what frustrated them (their barriers). Their feelings about this are real and need to be acknowledged. Often they would tell me something about a coworker that “drove them crazy." I would respond, "Ok, I know what they suck at, now tell me what they do well?" Rarely could they answer it. 

I would point out, this was a skill I had to learn myself but it was very useful. I'll admit, some days it was tough for me to find something nice about someone. I think there is value in having a place to admit that too.  At that point, I could suggest something minor that the "other person" could do well. No matter how minor the good thing was, my hope was it would be undeniable - even for the person complaining. Then I say, "If you can't say something nice about someone, then you are not done looking." 

My challenge to find more is because I've learned there is always more. I promise them if we know what they do well AND what they do poorly, then we can forge a more functional work day with them because we all can play to each others strengths and weaknesses.

I say all this because our team functioned more and more seamlessly on the floor after we all began to practice at this. It gave me some pride to hear the snarkiest of nurses asking another nurse "so, tell me what they do well?" from around the corner. 

This applies to your most difficult of patients. Find out what they do well and what they do poorly. Similarly, for your "sweet as pie" patients, you may find out what they do poorly and also reaffirm what they do well. I have found out this assessment of others resulted in more prepared discharges (read - reduced risk of unplanned re-admit). This whole exercise is one of assessment, and of meeting needs - plus it makes the workday suck less.

Bomb disassembly 101

As the story goes in my husband’s family his brother was sent by his employer Uncle Sam to go help write or edit a bomb disassembly manual. Why? Because he knew nothing about the assembly or disassembly of bombs. He finds himself observing the process of disassembly while trying to follow the manual in its current incarnation. He finds the experts to have missed steps (e.g. disconnect the red wire only after ensuring...) Steps that matter when the expert isn't there to do the thing.

I often think of this when I send patients home with teaching for...whatever. My mind goes to the high risk things. Medication teaching. Wound care. How to know when something is okay versus when to call the clinic versus when to go straight to the ED, do not pass go, do not collect two hundred dollars. If my eyes aren't there, theirs needs to appreciate what is important.