Nursing

A Note on CPR ***Triggering re- CPR and death.

I don’t watch football. It irks me for many reasons. 1- Doctors and nurses save lives every day and we will never make millions of dollars per shift. While I do not fault pro players for working hard and pursuing something incredibly difficult, I do no think it is worth the millions they are paid. 2- When I see people riding motorcycles without helmets I have a visceral response because I think wow. You just want to die don’t you? And/or you are a complete idiot. Playing football…sort of the same reaction. I worked in a pedi-ED for 7 years and the worst injuries were football, hockey, and skiing/snowboarding, and the surprising fourth place would be cheerleading. These were kids. Sustaining serious injuries. The fact that we KNOW that long term head injuries causes chronic traumatic encephalopathy and yet people still PAY to see these men literally cause brain damage to themselves…well it’s sick and fucking twisted in my opinion.

So when I heard about a football player falling down cold and requiring CPR mid-field and the subsequent fallout. I’ve had a lot of feelings about that. I think people having the most feelings are people who have performed CPR. You can’t see me, but I’m raising my hand. I’m that person. I’ve performed CPR. And honestly, I lost count of how many times I have done it.

The feelings I’ve seen from my fellow critical care healthcare providers on social media are a mix of things including but not limited to: we are not paid enough for what we do and it’s ironic that the million dollar employees on that football field had no ability to save their teammate and it was the 20$/hour EMT’s who saved him. The NFL and the world has taken a pause after being traumatized by watching CPR performed. There is acknowledgement that watching and performing CPR is traumatic. I can tell you, of the several times I performed CPR or rescue breaths I never got a break afterward. In fact I would be reprimanded if I tried to take one because “Everyone is feeling it and they are all back covering patients. Pull it together.” Was said to me when I was found crying in the med room after the unsuccessful resuscitation of an 11 year old. Unsuccessful resuscitation sounds too pretty though. This is what really happened.

I straddled a kid and pushed in and out on his chest with sweat pouring off of me, no gloves, no mask, no idea why he was here, he was carried in by screaming parents and me and another nurse threw him on the stretcher. She started breaths. I started compressions. She and I passed glances as the rest of the team surrounded the bed. I could feel his ribs bend under my hands, and I had to keep a fast pace. It was the end of night shift and we were all fucking beat. We were also short staffed. I also had three patients who were freaking ill that I knew needed me but here I was. Pushing on a chest praying this heart would start. But there’s a particular smell of a dead body. You learn it after working critical care. We all knew it. We all smelled it. He wasn’t long dead, and young enough we may get a heartbeat back, but he was gone. The heart beat would be so the parents could have time to wrap their minds around organ donation and brain death. I knew it. The nurse at the head knew it. The doc knew it. But there I sat. Pushing on his ribs, hearing the parents scream and cry, and after fifteen minutes, three rounds of epinephrine the doc called it. You ever hear parents when a doc calls their kid dead? It’s about as awful as you can possibly imagine. There was a thud as the Dad fell to the floor. The mom keened a sound like a horribly wounded and dying animal. And I slowly climbed down trying not to look at the kid because I knew I had three more waiting for me outside the door.

I wiped a stray tear and walked past the dead child and the grief stricken parents. I walked into a room with a kid with pneumonia. I looked at her chest. Rolled my eyes and said “Fuck.”

Grabbed the bag and started pushing air into her lungs. She was on the monitor but for some reason it didn’t pick up that she wasn’t breathing. Her oxygen level was still perfect so it must have just happened. She was warm and pink, but definitely not breathing. The doc walked by saw me bagging and said “Oh!” and helped me roll them into our resuscitation room. I bagged her until she was intubated and brought up to the ICU. Then I went to try and give report to the day shift nurse who was pissed I hadn’t hung the antibiotics for the other patient.

I could barely even speak. I remember just rubbing my head and saying I’m sorry and going to get the antibiotics and hanging them and going home. That night was Christmas Eve.

I went to my family’s traditional get together and pasted on a happy face and pretended I hadn’t had a horrendous shift that involved CPR.

So you see. That was one time. One time out of many. Healthcare professionals are not given the support, the time, the space, or any ability to not be traumatized doing our work. I didn’t get a bonus when I saved people’s lives. In fact my clinical skills had absolutely no bearing on my raise each year. It was based on patient reviews and emergency department numbers and benchmarks. So if anything comes from this very public display of CPR I hope it’s 1- Respect for the goddamn skill that critical care healthcare workers possess. Because I’ll say it- we are a fucked up little bunch of people- but damn we know how to save lives. 2- Acknowledge that football is fucked up. 3- Healthcare providers NEED and should be REQUIRED to have access to the time, space, and resources to heal after a traumatic work event which SHOULD include any and every time we perform CPR.

To any Healthcare Providers reading this- for your own knowledge- after I left the ED I saw a therapist for about two years and did a lot of EMDR therapy with him. It changed my life and allowed me to heal from all the trauma of the ED. Our focus was on my memories from working in the emergency department as those were quite traumatic for me, but I did not even realize it until after I left how messed up I was. When you are functioning in chaos it’s hard to see how heavy it is until you are out of it. Exposure therapy and I think any kind of therapy can be scary for critical care workers- I know we are a tight little bunch who don’t trust outsiders to be able to hold our shit. Because it’s heavy. But I promise you there are mental health providers out there (Myself included!) who treat first responders and are not intimidated by our shit. Do not let yourself go untreated because you think we can’t handle it. We can. Hospitals will never prioritize your mental health- you’re going to have to take the steps on your own. And for that I am sorry. I am sorry we work within systems designed to demoralize us. But I see you, and I appreciate you, because I am you.

Nursing · politics

A B*&$H About Benzo’s

I watched Xanax on Netflix. It’s a documentary about anxiety and Xanax.

I had a lot of feelings come up as a prescriber.

I think the commentary on the mental health system and race was good and certainly accurate. I think the commentary on why we as a society are anxious is also good/accurate. But it misses why Xanax is a problem.

Benzodiazepines are meant to be used short term. The psychiatrist does say this. She does not go into why though people end up on them long term.

There are a number of reasons; starting with there is a shortage of mental health prescribers. Primary care physicians and APRNs end up bridging this gap. They are comfortable starting some one on Xanax because they are actually taught to do this in school. The line they give is “I’m going to prescribe you a 7 day supply, and give you time to find a mental health prescriber.” Now, it takes more than a week to get an appointment. At my practice we are booking out 2-6 weeks depending on provider. The prescriptions then may get extended and by the time a patient lands in front of me they have been taking Xanax daily for six weeks. As prescribed by their primary.

This is not meant to knock PCPs. They are doing the best they can in the system we exist in. But there is no education about it. There is likely no discussion about what will happen when they see a mental health provider- aka we are not going to continue it daily and we are going to recommend a daily antidepressant medication. And once you’ve had xanax- well Prozac just does not feel as nice. Thus begins a person chasing the “calm” aka “high” that Xanax induces and being really angry at the mental health prescriber who won’t give it to them.

The documentary then spent less than ten seconds on the pressure on prescribers to do what the patient wants. And at the end of the day- that’s what matters- because without that pressure prescribers would have the balls to prescribe safely and ethically. I had to leave a top hospital in our country system to prescribe safely and ethically. Let that sink in. I had to leave a top hospital in the country to be a good and ethical prescriber.

Here’s why.

You ever hear about Press Ganey? It’s a company that puts out those nice little surveys all patients get after a hospital stay. My raise and reimbursement and ability to advance in the corporation was dependent on my Press Ganey scores. Yes, much of my present and future career at the hospital was based on feedback from patients. I worked on an inpatient psychiatric unit and usually half my caseload were hospitalized involuntarily. Then about 1/8 of those people had to be medicated involuntarily through a hearing with a probate judge.

Guess how many of my patients gave me and my team good reviews? Potentially half. The other half, well I was lucky to not be sued by them; which was threatened daily.

Let me tell you a story. Patient X is on Methadone 120 mg, Xanax 1 mg TID, Quetiapine 800 mg nightly, and Lithium 450 mg ER BID. Patient X is admitted on this regimen for depression and suicidal ideation. They are noted at the table in the morning eating breakfast falling asleep. Legitimately falling asleep. Food falling out of their mouth mid-chew.

They are now a choking risk. And within six months of me starting I had some one on Methadone choke, and need to be resuscitated due to their airway being completely blocked. It’s a real thing that happens.

Me being the responsible APRN I am, consult with my Attending MD, they agree, we need to lower their sedating medication especially AM dosing when they are eating right after. We also review the EKG, shows significantly prolonged QT interval- due to Methadone/Quetiapine combination- prolonged QT interval can lead to Torsades which leads to sudden cardiac death. Again- kind of a big deal.

We go sit with the sedated patient, who barely responds to us verbally, and tell them we are going to start tapering their Xanax and Methadone. VERY SLOWLY. We will not put patient into withdrawal but it is unsafe how incredibly sedated they are. Patient mumbles as food falls out of their mouth.

Next day. I walk onto unit. Patient screaming about doses being lowered. Thus begins a very unhappy week for myself and our team and our patient. But. They did not die, they did not have any observable or measurable withdrawal symptoms. And they were able to actually be awake for mental health treatment by 10 AM and engage in groups and therapy. They left on lowered doses of Methadone and Xanax with a lower QT interval and not a choking risk. But they gave me a complete crap review and wrote a novel about how we sucked.

I had to have a sit down with my manager about that case not because of the inappropriate prescribing done by their outpatient team, or the good job in looking out for their respiratory and cardiac health- and preventing another preventable choking potentially fatal situation on our unit- but because I got a bad review. I had to review the chart with my manager and go over the case step by step defending my actions along the way. Amen for my stellar documentation, the withdrawal measures (which were all negative), and the objective data provided by group leaders, EKGs, vital signs, etc. that showed patient had a decrease in depression, decrease in SI, and increase in attentiveness, concentration, and ability to engage in treatment.

My manager wanted me to sign a form saying that basically we had spoken about my negative review. I declined. I requested a meeting with HR. So the cycle began. I provide safe care in conjunction with the treatment team including an MD. I get a negative review. I have a meeting with my manager then with HR. This is not unique to me. This is common among any prescriber working for a corporation that favors patient satisfaction over safe and ethical treatment.

This is not the only reason hospitals cannot retain good doctors and APRN’s. But is definitely in the top three reasons. At least it was for me, and for many of my colleagues.

It is not safe to be a competent and ethical prescriber when working for a healthcare corporation that measures my present and future success by patient reviews- especially when working in psychiatry and addiction medicine.

This does not just apply to inpatient work. It applies to outpatient centers also. My pay being directly linked to patient satisfaction is a problem and the reason I do not work for a hospital corporation any longer. Because working with patients who ran out of their Xanax early, their outpatient prescriber says they are going to be cut off, now I have to forcibly taper them off of it- doesn’t go well for me in my reviews. But that’s part of the work inpatient, and it’s part of being a prescriber. Making tough calls, and especially inpatient working within a team of clinicians to do right by the patient.

So me being ethical and legal…didn’t go so well. And that’s what the documentary failed to expound on. Not only are there these patient reviews- but these patient reviews dictate how much money we make, our performance reviews, and how and if we can advance…and that, my friends, is a fucked up system that invites prescribers to make bad decisions to advance their pay and their careers.

I still get negative reviews on Google for my practice. And they still irk me. But they do not impact my ability to advance my practice or myself. I also can look at them objectively and say, well that patient didn’t get the 3 mg of Xanax they wanted, and got mad, pulled a knife on me- and then wrote a Google review. True story. The google reviews don’t bother me because they do not impact my career and to date they have all been reactive to me setting boundaries and prescribing ethically and legally.

I still have a full caseload, a growing practice, and rock solid clinicians who work for me who know I have their back to be good, ethical, competent clinicians and that I will not let a bad review by an angry patient who we held a boundary with impact their pay or merit or my respect for them.

I agree with the psychiatrist in the documentary when she says benzodiazepines have a place and a time and I am incredibly grateful for these drugs to have been invented and utilized by clients who need them. Because I do prescribe them when appropriate with a lot of education, a urine drug screen, an informed consent form with risks/benefits that the client must sign, and what the expectation will be going forward in terms of treatment.

I have full control over my caseload whereas before I did not. Until our healthcare system changes from a for profit, patient satisfaction oriented system- there will be more irresponsible prescribing and irresponsible treatment. There will also be a lack of retention of prescribers in areas they are needed most such as mental health and addiction psychiatry. The two are linked and need to be addressed nationwide.

*****This blog post covers a very small portion of the issues and dangers of benzodiazepines and is not meant to be fully comprehensive of every issue prescribers face in relation to benzodiazepine prescribing.

Nursing

“Tilt When You Should Withdraw”

You know you’re a millennial when…the movies of the late 90’s and early 2000’s still define who I am as a person. And they are grossly underrated by all these twats coming after us. You know I’ve met multiple people (mostly my clients in their early to mid-20’s) who have never see Lethal Weapon or Bad Boys? To be fair Lethal Weapon was 80’s but Bad Boys?! None of them! Do you know how many times I’ve referenced a line and they stare at me blankly or worse like I’m old?!

Despicable. But the worst is if they have not seen A Knight’s Tale. Not only is Heath Ledger probably one of the best actors to live (and die far too young) but it’s hilarious, sad, poignant, and action packed.

It’s also historically relevant because it’s loosely based on Chaucer’s A Knights Tale. There are many parts of this movie that speak to me, essentially the whole movie. Because it’s an underdog story of a young man being told he can’t. But then he does. I have always felt that. As a girl I was told I was too smart, too loud, too opinionated, as a woman I’ve been told the same.

All William wants to do is joust. And he’s rather good at it. He builds a team ultimately who believe in him and who stand in front of him in the stocks to block the rotten food being thrown at him. That’s when Prince Edward unveils himself and steps up to William who is dirty and weak and bent in the stocks.

Prince Edward (who is also kind of hot) leans over and says “What a pair we make huh? Both trying to hide who we are, both unable to do so. Your men love you. If I knew nothing else about you, that would be enough. But you also tilt when you should withdraw…and that is knightly, too.”

Tilting exposing a knight’s face and leaves them vulnerable to injury but it also gives them the most advantage in striking their opponent.

That scene gets me every time. I’m usually crying by the time he pulls William out of the stocks and he shakily kneels in front of the prince.

It’s quite a thing to be seen. To truly be seen. If you think about it there are very few people we come across in life who see our true selves for all that we are. Who have the patience, the insight, and the ability to see who you are.

That scene gave me hope as a teenager that I could be something more. That I could “change my stars” and along the way I would meet people who truly do see me.

I had to grow into a person I was proud to have people truly see. It was hard in nursing as a confident, smart, and direct woman. The feedback was mostly negative. And the message was to do my job and not question management even when nurses were being assaulted and abused. God forbid I ask for mental health services after a major assault or updated TdAp vaccines for the entire staff after two pertussis exposures to me personally and twenty other staff members.

It took distance and time and therapy for me to realize that what I sought was not wrong. I’m allowed to take up space and ask for reasonable accommodations, help, and support from my employer especially when working in high acuity and dangerous areas.

People seemed to listen when I spoke. I was told by a manager after I became an APRN that I was an “unofficial leader” because they knew everyone would listen to me but that I was not actually in charge. That surprised me. I didn’t realize people paid attention to me honestly.

That conversation opened the door for me to open my own practice. I was not wrong to be smart and confident and direct. I was not wrong to expect a safe work environment. And I could get that. But I’d have to do it on my own.

Five years later I am safe and I’m surrounded by people who truly see me and appreciate me personally and professionally.

It’s been validating to be in business for myself and treat employees the way I wanted to be treated and to see their appreciation and the loyalty that it builds. I’m not perfect. I’m still too direct. And I am impatient sometimes. And maybe too patient other times. I also tilt when I should withdraw- I fight the fight for clients, employees, I fight insurers, and my favorite line is “I’ve got nothing but time,” whenever I’m told that something is not possible…I make it possible. And my friends, family, and co-workers see this.

They see me and finally that what were perceived as negative traits are actually positive and have helped me grow a business and expand mental health services for the Queer community.

I’d like to think if I was in the stocks I’d have some people who would stand up to block the rotting vegetables from hitting me.

That’s a good feeling actually. Knowing I have people who see me and who think I’m worth protecting. They also would probably make very sarcastic remarks and jokes to work off their anxiety in the moment but they’d be there. (You know who you are;)

Because that is what’s important right? To have people who would block the rotten vegetables from you.

And every Gen Z-er reading this…this is why you are missing out. You don’t even know one of the life goals you are supposed to have. Lord have mercy.

#COVID-19 · Nursing

The Grim Reaper & A Nurse

Contrary to my normal procrastination I bought tickets to a haunted attraction way back in the beginning of September. I was determined to get there. Last year I bought tickets and it got rained out. A few years before COVID we went on a night to something you couldn’t pre-buy tickets to, and the night we went it was closed. Then COVID.

Needless to say I was frantically stalking the weather all week, and very excited the night came with no rain in sight and no global illness causing mass lockdowns…we were good to go!

When we got there we had to wait for our turn to go through as they send people through in small groups. We were a group of four, my three friends and I, and while we are all in our mid-late 30’s, and tough as nails psych nurses and a therapist, of course none of us wanted to go first or last. Finally the therapist went first and the three nurses followed. I doth my hat to our therapist friend of course.

We screamed and held onto each others vests and coats in a train of four excited and terrified friends.

We came upon our first ghouls who spoke to us and instructed one of us to reach a hand into a bucket of water and pull out two syringes. One of us may have freaked out about touching syringes to the point that the grim reaper asked “Are you nurses?” in a growl, and we nodded “Yes, three nurses and a therapist,” and the grim reaper in his grim reaper voice bowed his head a bit and said, “Thank you for your service,” and the scary baby-doll with face paint reminiscent of Frankenstein agreed in her creepy baby doll voice, “Yes, thank you.”

And there we were. In a haunted house with a grim reaper and a creepy baby-doll tipping their heads to us in thanks.

They still made my friend grab the syringes.

And on went the show.

It was followed by another grim reaper who did not speak motioning me to push a button on a wall. Well I was pushing the damn button and nothing was happening. He made a down motion with his scythe(?) and I pushed down and it fell off the wall. He’s growling at me and I can almost hear him sighing at my stupidity and my three friends are a mixture of laughter and screaming each time he waves the scythe at me telling me to just push the button. And they are yelling at me “Just push the button” and I’m like duh I would if I could, but it’s dark and there’s grim reaper growling at me, I grab it and stick it back on the wall.

If you’ve not had a grim reaper shake his head at you in complete frustration and disbelief at how stupid you can be….it’s an experience.

As I stick it on the wall the thing lights up. Finally. I pushed the button somewhere. He lets us past and follows us, the whole time pointing his scythe at me. He did not need words. Even through a full coverage mask his message was clear. You are too stupid to live and I will end you.

My friends thought it was hysterical and then of course later we did get lost and the same grim reaper popped out and had to growl and herd us back on track.

It didn’t hit me until we got out though and we were back in the car. That moment with the first grim reaper and the ghoulish baby doll. It was surreal and kind and even though it broke the scary haunted house thrill for a moment to be brought so forcefully back to reality, it felt more authentic and more real than any of the hundreds of pizza parties the hospital I worked for thought were ‘good enough’ of a thanks.

What healthcare providers- not just nurses- psychotherapists, doctors, techs, etc. have been through from 2020 to present, is inexplicable to people outside of healthcare. It’s been constant chaos and tragedy and feeling invalidated and not good enough and underlying it a deep and true terror. Terror that we would catch an illness and spread it to our loved ones. Terror that our patients would die. Terror that going to work would lead to our deaths. And on top of that dealing with the irritability and anger that has permeated seemingly every human interaction. People are angry and they are taking it out on healthcare providers and practices.

So for a random grim reaper and haunted baby doll to acknowledge us in the throes of a terror inspiring activity- it felt so wrong and yet so right.

To the ghouls at Evidence of Evil- we had a great time, and you made three nurses and a therapist feel seen and appreciated. Thank-you.

Mental Health Stigma Suicide · Nursing

My Thoughts on Treating Murderers signed: a nurse.

Working in private practice people sometimes make the assumption I only treat the “worried well”. Every prospective employee I interview I tell them- while there are serious perks to private practice including total control of your schedule and fully remote work…we still treat sick people. You may get an easy straightforward anxiety…but you likely will have some serious cases that will push you.

For me, I’ve treated…a lot. I’ve treated sexual abuse victims, incest victims, victims of DV, and many other incredibly intense cases over the years.

What has been surprising for me, and what no one ever discussed when I attended school and training- were treating patients who committed murder. Working both inpatient and outpatient I’ve treated roughly 40-50 patients who have committed murder in some capacity.

There are many different kinds- negligent homicide is something like a drunk driver who hits a car and some one in the other car dies- basically an unintentional homicide but caused by the person’s negligence. There are homicides that are intentional, or perhaps just witnessed but the witness is held responsible for not stopping it or for contributing to it, and the saddest are probably the murders committed by people in a psychotic state such as with postpartum psychosis- those are probably the most publicized in the media.

We learn a lot about transference and counter-transference in school- and we do talk about how it would feel to treat a perpetrator of a sex crime but for some reason we never touched on treating some one who commits a murder.

But it’s an important conversation to have.

Working in mental health has caused me to take stock of my values, ethics, and core belief systems…and made me re-evaluate all of those things repeatedly at a very visceral level.

I remember working in the pediatric emergency department. There was a certain coldness projected toward the parents that overtook all of our demeanors when we realized the child we were treating was the victim of abuse- whether sexual or physical. At some point the truth always comes out. And I did treat some children who died of their injuries. And if you could have bottled the rage in the room from the healthcare providers…well that would be some potent nuclear energy.

So I had that background going into mental healthcare.

Then I sat across from my first patient who committed a homicide. I did not have that rage encompass me though. I still do not. I think they expect it. But as the mental health provider treating the perpetrator of a crime, well they are still my patient, and I treat all my patient’s the same. With respect and I try to come from a place of empathy and understanding.

In reflecting on murderers I’ve thought of my Dad. Was he a murderer? Not by my our standards I suppose. But he did kill people when he fought in Vietnam. He was a gunner on a helicopter- one of the big ones where the sides are open…hopefully you’ve seen enough war movies you know what I mean. I asked him one day when I was old enough to realize what a “gunner” meant “Dad does that mean you killed people” and in typical Dad fashion he said, “Well I killed more cows than people hon,” and that was that. My Dad was excellent at non-answers. Especially about Vietnam.

So I suppose the first “murderer” I sat across from at a table was my Dad.

So you can see why I have a stronger response to pedophiles than to murderers? Murder I’ve had to assimilate and rationalize because I grew up the daughter of a combat veteran. There ain’t no assimilating or rationalizing pedophilia though. That’s never okay. Not even in war.

I am speaking somewhat facetiously because the double standard is absurd. Murder is never okay. Pedophilia is never okay. But we live in a society that is more okay with murder than any other type of crime. As evidenced by the lack of gun legislation in America after the first mass school shooting. We receive the message from the highest level of politicians and courts that murder is justified as long as it’s with a gun that you should be free to carry.

We also live in a society with combat veterans who have committed legal murders. And we praise them, respect them, salute them. I am not saying we shouldn’t do all of that. I am grateful for all the people who have served and continue to serve our country because I see the sacrifices they’ve made in my work every day in the veterans I treat who carry such shame, guilt, and trauma.

I used to be very black and white in my thinking. Back when I was 22 and thought I could be part of the solution in saving the world. I’m 37 now. I’ve seen children die at the hands of their parents- intentionally and unintentionally. I’ve treated men and women who have been raped and who have killed.

I also grew up with a Dad who was a Vietnam veteran and deeply committed to the love of his country.

Through all of this I’ve come to realize there cannot be a black and white version of myself or of mental health treatment. I’ve treated rapists who I did trauma work with who were deeply wounded humans perpetrating in the cycle of their own traumas. I’ve treated incredibly brave and resilient victims and supported them through court proceedings to bring their perpetrator to justice. I’ve treated murderers who carried the deep wound of taking a life. And I’ve treated murderers whose murders were legal in the face of battle but who have to make the decision to live every day because the incredible wounds they feel internally drive them so close to suicide.

There is no black and white and there is no right or wrong. What I’ve discovered in myself is that I have to present myself with empathy, understanding, and I have to listen to my gut and bodies responses. If my body is telling me that there is no remorse here, and potentially sociopathy, our consultation appointment is just that. A consult. And I will not be following up with them.

But those are rare. More common is the person who is just a person. Trying to survive. Who was thrust or who put themselves into unthinkable circumstances and who are spending the rest of their lives trying to not be defined by that one moment. There is grief for the person they once were, compassion for who they are in this moment- vulnerable and seeking a non-judgmental space- and hope for the person they can become.

Fifteen years in and I still love being a nurse. I love this field, I love that it pushes me to see beyond society’s expectations and norms. I love that it makes me examine my own weaknesses and prejudices and challenges me to do better and be better. In these cases it’s pushed me to examine my beliefs about “murderers” and what I found is they are just people with a story. Stories that deserve to be told and to be heard.

p.s. #banguns #fucktheNRA

p.p.s. For all those asshats saying you should have the choice to not treat people who are LGBTQ…you are assholes. If you continue in that vein for your “religious freedom” shouldn’t you also not treat adulterers, murderers, pedophiles…etc? How come you can decide to not treat one population of people but not all the rest? How come you are more comfortable treating a heterosexual murderer than a law abiding non-rapist and non-murdering lesbian? Y’all need to have a Come to Jesus moment. Cuz you make no sense. Just own it and say you are homophobic and transphobic.

Nursing · politics

As Roe Falls- Reflections on being Pro-Choice.

This June marks my fifteenth year as a nurse. Fifteen years. Nuts. I’ve worked in emergency departments, inpatient psychiatry, outpatient psychiatry, as a COVID-19 vaccinator, and as a school nurse. Those I think were all of my “official” nurse positions. Unofficially I have nursed many people in many more settings including but not limited to my Dad, my kids, recently my dog, and many other friends and family members and strangers.

When I was 19 I took a bus to Washington D.C. on a whim with women I didn’t know, for the March for Women during the tenure of Bush. It was before I went into nursing school. It was when I didn’t even know why I supported being pro-choice. I was raised in a church that was pro-life. And my family didn’t really ever discuss it. But I felt in my gut that women should be able to choose for themselves at a very young and naive age.

I am still pro-choice but I can formulate coherent sentences around why now.

What I struggle with is that I know I personally, could never get an abortion. Well, I say that, but I have never been in the situations I have witnessed with friends and clients and patients. So I guess I will say, I do not think I could get an abortion- especially after my experience with IVF and pregnancy. Because I remember feeling the first flutter. And I remember thinking, ‘Wow, I could never get rid of this.’ But as I said, I worked hard for those boys. I wanted them with all my heart and soul. I have never had a pregnancy that I feared.

In my work as a nurse I’ve seen and been told some pretty horrible abortion stories. I have never counseled a patient to have or not have an abortion. It is a time of complete neutrality for me as a healthcare provider. I am essentially a wall for them to talk at. I have treated young teenagers who sought abortions, I have treated women in their 40’s homeless, addicted to substances, seeking later term abortions, I have treated women days, months, and years after obtaining abortions. It is always a part of their narrative. It is often a part of themselves that is sad, shamed, unresolved, and takes a great deal of courage to disclose.

I have treated women who had to walk through protestors, who couldn’t tell their families, who went to classes or work still bleeding, still in pain, and “powered through” because they didn’t want any one to know or ask or suspect.

Abortion is like mental illness- it doesn’t discriminate. Women have sex. Women get pregnant- often on birth control, using condoms, or some other method of birth control. It is often very unintentional. And the decision to have an abortion has never been made lightly. Literally. I have never met a woman who didn’t have feelings around having an abortion. Who hadn’t put significant thought and emotion into the decision.

I was pro-choice when I was 19 because I was a naive and passionate woman who believed completely in the liberal agenda. I am pro-choice at age 37 after 15 years of nursing because I have seen women make the choice. I have supported them, held their hands, given hugs, sat watching them cry and holding space for their pain, and I have been the only one in the world outside of the OB-GYN who they have told. I am pro-choice now because I have never known a woman who has made that choice without losing a part of herself. Abortion leaves a palpable scar and women seem to know going in that it will be there and they do it anyway because it’s right for them.

I am pro-choice at 37 because I have carried my own babies and I know the incredible journey of pregnancy and parenthood. I also know that for a woman to not be ready for either journey should be up to her.

I have never known a woman to take the advice of an outside party over their own intuition.

We trust women to raise our babies. Why do we not trust them to decide if they are not able to raise them?

Please note I have not stated any woman’s reason for obtaining an abortion- just that they did. Because it’s no one’s damn business why they do or do not obtain an abortion. Incest. Rape. Substance abuse. Homelessness. Fetal abnormalities. Teenage pregnancy. There are countless reasons a woman obtains an abortion. Literally none of them are your business or your right to know.

I was never surrounded by people who were pro-choice growing up. It was not something we discussed. I certainly was not surrounded by pro-choice people in my undergraduate in a conservative area in upstate New York. I just knew in my gut that women deserve autonomy, privacy, and respect. I saw a poster almost completely covered on a bulletin board at my college. It was a flyer for the Women’s March. I ripped a piece off the bottom with a phone number. I called the phone number. I was screened to ensure I was not a pro-lifer trying to infiltrate. Then I met a bus in a parking lot around 11 PM and got on board. I went alone. I do not even know if I told my parents. I was 19. I remember sitting on a full bus. We drove over night and made it to D.C. We disembarked, and made the plan to meet up at the bus later that day.

I do not even remember any one’s name that was there. We didn’t talk much. All these women and I. We had nothing in common except a belief so strong that we took a bus with strangers to march on a rather warm day on the Mall. I listened to Hillary Clinton speak. I remember the protestors barely made a sound because the numbers of women in the march was so overwhelming. I remember it was actually very quiet. There was the sound of footsteps and breathing, and our signs. I remember the looks on our faces. There was a quiet resolute determination. There were women in their 70’s, 60’s, 50’s, 40’s, and so on. I remember thinking never had I seen so many different women all in one place all for common belief in one right.

I can’t tell you the sadness I feel now knowing those marches will have to continue. That more than marches the Democratic party needs to be as well oiled, organized, and funded as the GOP. The Democratic party acts shocked and appalled with each move of the GOP, but it should not be a surprise. Their plan dating back to my 19 year old brain was very clear. Take away rights for women and the LGBTQ community and any and all minority that are not straight cis white men. They play the long game.

The difference now is I’m 37 and trying to survive as a single parent and business owner. I do not have the bandwidth and time and energy for marches. Political activism is a privilege. That unfortunately at this time I do not have. It’s a shit feeling. That powerlessness watching as our rights are stripped away.

Nursing

What it’s like being “the nurse friend”

  1. I receive random pictures of skin rashes. At all times of day, night, and with NO trigger warnings. EVER. Then I give an educated guess and get the response, “Nah I think it’s…xyz…because that’s what google said.” (I’m usually right…not google for the record)
  2. I am told far more detailed information about people’s medical maladies than I ever care to know often at funerals, weddings, and any other inappropriate time where I’m trying my damndest to not be a nurse.
  3. I get calls asking for referrals. At least weekly some random person from my past or present life DM’s me or texts me or calls me asking for referral options (this only became a thing after I opened my private practice).
  4. I get asked for advice. Then I give it. Then I am told, “No I mean, like your real advice, like professional advice.” “So you want me to tell you what I’d say if I was your therapist or prescriber?” “Yes.” Then I sort of rub my chin and say, “Tell me how that made you feel.” Then they get mad that I won’t therapize my friend.
  5. People tell medical stories. Then they look at me for validation or something? Then I stare blankly back. Then they say, “Well what do you think?” And I say, “Dude you just told me a long ass story about your dad’s prostate. I don’t know how many times I have to tell you. I worked in pediatric emergency medicine then psychiatry! I don’t know ANYTHING about prostates.” (as an aside I know far more about prostates than I ever thought I would because I cannot tell you the number of men who seek psychiatric care before, during or after prostate cancer because of the emotional and physical sequelae…it’s a whole thing…but I don’t want to discuss any one’s prostate unless I’m getting paid to do so honestly.)
  6. On the off chance some one has an experience that I can actually have an opinion about…I usually want to keep it to myself. Like my friend called me hysterical on her way to the ED, and I said in my head ‘sounds like her appendix is rupturing.’ I said out loud, “Hope you feel better,” and then her appendix was removed. Do I want to be the one to tell a very good friend that her appendix needs to come out? Uh nope. I want to be the supportive friend. When my niece was born, we went and visited her in the NICU. I could see her labored breathing, and honestly she looked unwell. I looked at my wife at the time and whispered, “She’s gonna be intubated by midnight.” I hugged my sister and told them both Congratulations and we are here for you. She was tubed by 6 pm I think. It’s a curse sometimes. Knowing critical care. Knowing who’s hours away from intubation. It was scary. I knew she was incredibly ill, and could do nothing but wait.
  7. At parties if there are injuries people look for me. Expecting me to assess. I learned never to have more than a drink, max two at parties with kids. Because inevitably I will have a bleeding kid thrust in front of me. I know you think I’m exaggerating. But I’m not. Every party…bleeding kid. The worst was a dog bite.
  8. On airplanes I keep my mouth shut. Because it’s either a heart attack, stroke, or childbirth. I want nothing to do with any of those things. I also have warned people I’ve flown with to keep their mouths shut. When I’m on a plane I’m anxious as all hell and not in the mood to be a nurse. Especially for an adult or even worse for a birthing adult.

In some ways being a nurse is a blessing. People trust me and I’m ethical and smart so I’m not a bad person to trust. Those qualities help when, you know, I’m at work. It sucks when I know too much. When I know some one’s parent just received a death sentence but it hasn’t quite been spelled out for my friend. Or when I know what’s coming next for my close friends and family and can do nothing to stop it, and just live with the knowledge myself.

I’ve learned to keep my own counsel. I’ve learned to not be brutally honest when people ask me to be (my friends are shaking their head like no, she’s never not been brutally honest, but I swear I haven’t been around medical stuff). I’ve learned restraint. I’ve learned how to be somewhat solitary in moments when other people are leaning hard on me. When my dad was alive and struggling with multiple medical issues it was hard to balance being the nurse and being the daughter.

I remember crying on the shoulder of an LCSW who I worked with. But in that moment he was the social worker taking care of my demented and dying dad and I was just a grieving daughter. I knew every time my dad had surgeries in the last ten or so years of his life that he may not make it through them. I could read between the lines of what the surgeons were saying in ways my Mom and sister didn’t. It can be a lonely road with the knowledge.

My nurse friends and I joke about the rash texts we all receive. It’s not unique to me. Apparently if you are a nurse your friends just send you pics of their rashes. We don’t joke about holding the knowledge though. We never have joked about that. Because it’s not funny. It’s a burden.

So as my favorite man on television Monk would say, “It’s a blessing…and a curse.”

#COVID-19 · mom of boys · Nursing

Shut your piehole KK

A few months ago I hired some one to take over the billing for me. I had been doing the billing every waking hour that I wasn’t seeing clients…mostly between the hours of 8p-11p nightly. But I could see that either I’d have to give up my caseload of patients- which was not an option- or give in and hire some one. She already did my Quickbooks and happened to be in need of full time work. It worked out. She had no knowledge of medical billing.

But she is meticulous and could learn. I had no knowledge of medical billing until I owned a practice and taught myself.

The first month was a lot of questions that I answered and that she then would ask, “Okay where can I find that though?” and I’d smile or wince and say, “In my head,”. After a month and after the hundredth time I said that she laughed and said, “I literally cannot believe how much you remember in that brain.”

Can’t find my keys on the daily but I can remember the different sliding scales we offer for a hundred different people, and who has a payment plan on which days and who we have to call the Mom for, and who we have to call the Dad for payment, and who we have to email the Mom and the secret code words…lol. I mean it’s a whole thing. “I can’t find her in the system, is this another one whose Aunt or Grandma or Mom or Dad pays?” Was a question. And I knew the Grandma’s name and email. And it’s not my patient, it’s some one else’s in the practice. What about this one? “Aha, that’s a partner of x, x sees Rory and pays with this card, Y sees Alana and pays with this card,” “Why is the name different in both systems for both of them?” me “Yeah just accept that’s how it is and move on for this one, it’s too long to explain.”

“This one the transactions look…odd…is this one that we only bill on the 15th because that’s when they get paid?” I mean she picked up quick on the patterns at least. I told her part of her job is sleuthing because she’ll have to figure out the inner workings of my brain. Which is a scary place to go.

She’d ask about random Cigna plans and carve outs of Aetna plans and a NY based UMR plan that carves out to Cigna…and all the things. And it was all just in my brain.

Then after a month she was picking it up and I could back off and I suddenly had these hours FREE at night after the boys went to bed. I had these images and dreams of me being so productive, writing that blog post, folding the laundry, when in reality for the last month or so of free evenings I’ve stared mindlessly at the television watching episodes of Blacklist (I could do without the girl, James Spader is my favorite), murder docs like Murder in the Middle & I’ll be Gone in the Dark, and I went to bed. Many nights.

It was like that meme “My plans for my day off” “Me on my day off”. In the midst of the last month I also opened a second location which has resulted in many many days of moving and building furniture. And still seeing clients. And single mom-ing it. I planned out my Summer for childcare. A whole freaking expensive thing. I hate this country and our lack of support for working parents.

But I digress. I felt guilty the first few nights. Guilty that I had two hours to sit and stare at Blacklist episodes and snuggle with my dog. Then I thought. Fuck that. I get no time to myself. I’ve worked my ass off to get here and I was still working my ass off every day. What is wrong with me that I feel guilty for sitting for two hours and not being productive? When I saw clients this week I actually felt engaged and refreshed and not exhausted and burned out.

I literally thought to myself- this is odd- why do I not feel burned out and exhausted right now? Oh that’s right because I can actually go to bed. And snuggle with my dog. And think about things other than work for two hours a day. I still log in and do work. But I logged in the other day and there wasn’t anything for me to do. It was the weirdest freaking thing.

Within a month it was a forty hour position. I was doing a forty hour position on top of my 32 hours of clients and 8 hours of employee managing. That’s not okay.

I recognize now that was not okay. And I’m incredibly grateful that I took this step.

The best part of my week so far though was reading and watching Kim Kardashian’s comment that women need to work their ass off and no one wants to work these days.

I’m sure you can hear my eyes rolling. To speak as a billionaire who started life in a family with millions…yeah that falls a little flat.

We want to work. We are working. If you don’t start life with millions though it’s a little hard to work hard and still get ahead. Not for nothing but as some one born in 1985 I will never see a pension, I will never have fully covered health insurance with low co-pays and no deductible, I may never get rid of student debt if I decide to go back for my doctorate- if I stay with my master’s I may have it paid off in 5-10 years. I entered the workforce during the “worst economic disaster in history” in 2007. I didn’t get a raise my first three years as a nurse. I am parenting and working during a pandemic- again a “once in a lifetime event”. My clients who are going hungry do not have access to food. I love when a Boomer says, “Well they just need to access the resources, or apply to the state,” yeah that doesn’t exist. There are food stamps- they are extremely difficult to qualify for. There are no state programs that offer housing and food to any one who makes over 18k a year. You can’t live on 19k a year in this state. You go hungry. Like my clients.

But I digress onto a rather large soap box.

My point to this rambling. I work my ass off. Our society dictates we work our asses off. When all is said and done it will take three full time positions to take over all the administrative tasks I do for my practice. I do not want a medal. But I would appreciate a billionaire who was handed millions…to not make a gross judgment about women in a capitalistic male dominated society.

Stay strong. Work hard. Binge watch Blacklist or whatever you like and don’t feel guilty though. Because we all deserve a freaking break.

And yeah. Shut your piehole Kim.

#COVID-19 · Nursing

Hospitals and Nurses

I usually write a fiery, steamy, infuriated, depressing, crying, first draft of a blog post depending on the topic and my mood. Then I leave it for a night. Then I come back and completely erase and/or heavily edit it. Last night, I may have accidentally published the fiery, infuriated first draft. In my defense. It was late. The publish button is close to the preview button, and I was trying to figure out the picture size. Then all the sudden I got 5 views in maybe three seconds…and thought “hmmm”…immediately replaced by “shit fuck holy shit. Delete Delete Delete.” Of course not before my subscribers got the emailed copy.

So I get a call from my friend who subscribes and says, so…yeah. Maybe not a great idea to publish a rather thinly veiled expose. Fair. I agree. Picture me waiting for the lightening to strike.

I feel like that sums up my life. Letting out the emotional side before I make it PC and having to then backtrack and attempt to censor myself. Which, in all honesty, I should be censored at times. I fully own that.

However, the point of my blog post, even in all it’s fire-y-ness was to address the fact that hospital ferociously protect even bad doctors. Really bad ones. And if they put a fraction of that energy into protecting their nurses…there would not be a shortage.

That hospitals are advocating for legislature to cap travel nurses salaries instead of advocating for legislature to protect nurses aka: automatic felony for assaulting a nurse, student loan forgiveness, tuition caps for furthering nursing education, patient/RN ratios, safe staffing ratios…etc. To name a few. It’s freaking insulting. Not just a little insulting. But fiery steamy infuriated first draft blog post insulting.

Nurses are the lifeblood of hospitals. We see all. We know all. If every nurse let loose publicly the biggest secret they know about their hospital system…that would be, well, epic. But for hospitals…it would be literally a liability and natural disaster. So I just don’t understand why they keep pushing the very population of people who can whistleblow the crap out of them.

But here we are.

Hospitals are messed up places. Any one who has worked in one is emphatically nodding their head, smiling to themselves thinking of the most messed up thing they have seen. And I’m not talking with patients. I’m talking with staff. Because there’s a lot of both. Grey’s Anatomy…I mean I’ve never made it through more than ten minutes but I think real life would have it beat. Big time.

Hospital systems should maybe consider the true power nurses hold. In our knowledge…of everything. They should then consider supporting appropriate legislation to protect nurses. Protect nurses with the same furor and energy that you protect doctors and maybe you’d actually retain them.

My employees know that I have their back. When they are wrong I tell them. But, I never undermine them to clients or to other employees. They also tell me when I’m wrong. As I think they should. I am protective of them. They know that. We all have scars from working for larger corporations, mostly hospitals, where we were not valued or protected and even if we were right…we were always wrong. That sticks with you, and it completely destroys peoples confidence and sense of self. As an employer I feel like I worked to create a space where we can all just be ourselves and not be scared to be right or wrong and to always feel valued.

COVID sucks. But what it did was force healthcare to face the chasms that exist. It forced nurses to acknowledge they are treated as second class citizens. It forced families to discuss masks, health decisions, testing, vaccines and so much more. Could I have done without COVID? Yes. But I am not sad about the discussions it has brought forth. I am also not sad that it has finally publicly unveiled the lengths hospitals go to in order to not protect, not reward, and not promote their most valuable assets- nurses.

#COVID-19 · Nursing

Why America Cried At Steve Burns

I can’t be the only one who wiped at tears at the end of Steve from Blue’s Clues recent video that was posted to Twitter…? In every FB group I’m in from medical based, to illness based, to therapist based, to even a Harry Potter fans group….they erupted with Steve memes, with hearts linked to Steve’s video, and many many of my individual friends posted a tribute to Steve and his video.

Let’s break this down.

America literally lost its shit when a former childhood show star posted a vulnerable, truthful, completely unremarkable video.

It is quiet. He is soft spoken. There is no tension build-up. There is no comedy and no time when he is purposely trying to make us feel angry or sad or anything. So why? Why did an unremarkable video hit our hearts in a way that makes it completely remarkable?

I have some guesses and because I feel like I’m smart and Steve told me I look great I’m going to go a step further and say it’s an educated guess. Below is a rough quote of the video that I re-watched three times and typed while listening to it in order to get the words down.

“We were younger and we used to run around and find clues and do all the fun stuff…and we didn’t see each other for like a really long time. Can we just talk about that? (Pause) Great. I realize that was kind of abrupt. I just kind of got up and went to college. And that was really challenging by the way but great. Because I got to use my mind and take one step at a time. And now I’m doing many of the things I wanted to do. And then look at you, and look at all you have done, and all you have accomplished in all of that time. And it’s just so amazing. I mean we started out with clues and now it’s what? Now it’s what student loans and jobs and families. And some of it has been kind of hard. You know? I know you know. (Pause) And I wanted to tell you, I really could not have done all of that without your help…and in fact all the help that you helped me with when you were younger is still helping me today, and that’s super cool. I guess that I just wanted to say after all these years I never forgot you. Ever. And I’m super glad we are still friends. You look great by the way. Whatever it is your doing. It’s working.”

Reading the words does not have the same impact as watching the video. They fall somewhat flat with Steve’s vulnerable and honest voice and earnest eyes slicing through the horrible bouncy background music.

When I do therapy, as in when I am in the therapist chair, there are moments when I can see I hit the vulnerable spot in a client’s defensive armor. It’s in the moment when I say something that to me can feel like a shot in the dark but I know I hit it when their eyes well up as we maintain eye contact and they nod without speaking and I just named something that let them know, “I see you.”

Steve Burns literally just did that to every kid who grew up watching Blue’s Clues. Even if you hated the show. That two minute video he said, “I see you, and it’s hard, and you’re great.” In a way that we yearn for every day but often lack in receiving. Steve saw us. He let us know with sincerity that he sees us because he is us. He has student loans too. He went to college and gets to use his mind and do all the things every day he wanted to do. And he did it with us, for us, because of us. He says you helped me accomplish things and you still do and I’m grateful for you.

He called us friends still. And told us we look great.

Why did America lose it’s mind? Why did this bring tears to our eyes? Because we lack validation in our every day lives. Especially in the last year and a half. Our lives have been thrust into complete uncertainty. As a parent we don’t know if our children are safe anywhere. We don’t know if we are remote or in person for work, appointments, and school. We don’t know if we should go to the grocery store. We can’t see our families and our friends. We are isolated. Nothing feels right. Everything feels scary.

Steve came in and in two minutes let us know that he gets it. He gets that things are scary. But look at all we’ve done already. Look what we are capable of! Look! Because I am looking and I SEE YOU! Why is Steve Burns the first and only person who has been able to penetrate the “scary” of the last 18 months and provide validation, acceptance, and reassurance in ways that brought us all to tears?

Because he gave us what we yearn for. He gave us non-judgmental acceptance of our choices.

He gave us positive feedback.

He bolstered us to be able to keep moving forward with the same greatness with which we had arrived in the moment to watch his video. Why do we not get this validation from our jobs? Partners? Families? Friends? Some of us, probably do. Some of us have supportive and positive people surrounding us. But so many of us, clearly, are lacking in this area because it was painfully obvious we had not received any of this for a long time by our extra reactions to his video.

His voice was calming, unifying, and his message was of appreciation and hope. Hope. We all are craving the elusive ray of hope that crept out of his video. Are there other people who didn’t forget me? Do I really look great? Other people struggle with student loans too? He spoke directly to the viewer. It felt like sitting down with an old friend. He paused at the right time and the inflection in his voice was always to add calm not uncertainty. It was the least anxious two minute video I’ve ever seen. And if there is anything over the last 18 months it has been a steady influx of anxiety.

This is important because it shows what America lacks. Empathy, validation, and understanding from authority figures- employers, family, friends, etc. It’s important because it shouldn’t take one video to unravel us and that it did shows that we all need to be in therapy if we are not already because we are all raw, so raw. You cried because your emotions are bubbling so close to the surface it took one person to say- I see you. Your feelings are valid. I’ve felt them too. I see you.- to have you in tears. He did that therapy move that I do. He took a shot in the dark to say what we all needed to hear and he landed acutely on our weak spot in our defenses.

Why did we cry? Because we felt seen. Because we felt connected in a time of isolation. Because an old friend greeted us warmly without judgement and told us we are good enough as we are and that he is proud of us. It seems so simple yet we cannot find this validation, connections, and positive reinforcement in our every day life. We cried because we needed to cry; we needed a release valve.

I am grateful to Steve for his video. I am grateful it brought catharsis and relief to so many people. I am saddened that so much of America feels unseen. I can tell you as a healthcare provider and as a mental health provider for many other healthcare providers the most important unvalidated person walking America is the healthcare worker. We are tired. We are dying- from suicide, substance use, and damnit from COVID. We are sick of the horrific deaths. We are sick of the ignorance. We are burned out in a way that no one else outside of healthcare can even begin to comprehend. It’s making us resent the patients. It’s making ICU nurses refuse to turn their unconscious unvaccinated COVID vented patients, leading to more pressure ulcers, more black eyes from being prone and not having their cheeks turned. It’s making the fifteen respiratory therapists who can do ECMO in one hospital system think about quitting. All 15. If all 15 quit ECMO can’t function. I don’t think Americans grasp the devastating consequences COVID-19’s ongoing toll it taking on our healthcare workers. We are going to lose them all. There will be none left to care for us if we don’t get our shit together.

Get your shit together America. That moment that made you feel tears when Steve Burns breached your defenses…make healthcare workers feel that moment. Make them know that you see them. That you hear them. Get the freaking vaccine. Wear freaking masks. Stop saying science isn’t real. Because science doesn’t give a shit when you are drowning in the fluid in your unvaccinated lungs. Your going to die regardless.

This is a plea. One human to another. Think. Feel. Change. Because if you don’t we are looking at devastating consequences for our healthcare workers.

To my nurses I see you. I am you. I feel you. I understand if you leave. I truly do. I thank you from the bottom of my heart for the blood, sweat, tears you’ve already given. I can’t ask you to give more than you’ve given. We all hit our walls at different moments. If you’ve hit yours. Step away. Know it doesn’t make you less. I know you are not abandoning us. I know you have to take care of you in this moment and I will never fault you for that and if any one does- tune them out. They don’t know what we’ve seen and been through.

If you are still fighting the fight- rock on, stay strong, and take care of yourself in a way that no one else will. “You look great by the way. Whatever you’re doing. Keep doing it.”