Here’s a Sunday post: Musing about miso soup and it’s role in my battle with the pandemic. If you’re here for data, clinical informatics, and health system thinking, you can leave now.
When I was the age of my youngest niece (okay, my only niece), I remember telling my mother who had just served me a bowl of home-made soup, with a sprinkling of goldfish crackers:
THIS SOUP IS SO YUMMY. I think it must be the goldfish I put in there. Goldfish are the perfect food, and I think I’m going to make a soup just from goldfish crackers and hot water. Mom, can I have some hot water?
Of course I wasn’t watching my mother’s face at the time, I was so sure of my world-shattering upcoming invention: Delicious hot water-and-goldfish soup.
I stood by, as she boiled some hot water for me on the stove. I had carefully selected a big handful of goldfish, and was cautiously resisting eating them, KNOWING that the soup was going to be TOTALLY WORTH THE WAIT. I was bouncing with excitement.
At last, hot water, in a cup on the kitchen table. =Plt-phtl-tlthtpl-plthth-ppth!= I slid all my goldfish from my sweaty palm into the cup, gave it a big stir,
…paused for a drawn-out moment to let the flavors swirl…
And took a big sip.
What did I think? It gradually dawned on me, as my face twisted into a surprised grimace, that the soup was not good … AT ALL. Just a bunch of semi-soggy flavor-less crackers and hot water.
I tried to fix it: added salt and pepper. Even some “Accent” (packaged MSG salt; hey it was the 1970’s! anything goes). Nope. Nope. And Nope.
I finally looked at my mom, who was silently watching, smiling and shaking her head at me. It was a lesson, I suppose, that her son had to learn for himself. Good soup was just not going to be that easy.
FLASH-FORWARD, present day.
I have always been obsessed with soup. Almost every restaurant we go to (or, used to go to), I would scour the soup offerings for candidates. I did let go of my soup-inventing dreams, but have lately been punching out Instant Pot – powered soups like Rosemary Cauliflower and Ginger Carrot, to some pretty good family reviews. But of course, they realize it’s Dad cooking, so the critic-grading-scale is set pretty low and forgiving to start.
Night-times are for miso soup, though. I’m a night owl and do some of my best thinking and working at night, and give me 1 teaspoon of Marukame Boy brand Miso paste, a cup from the hot-water pot, a sprinkling of scallions (pre-sliced and saved in a container in the fridge), and maybe some … GOLDFISH CRACKERS from a huge Costco bag. Heaven.
And, what do you know? Miso soup, consumed daily is supposed to have ability to FIGHT INFECTIONS! Hey! Who needs vaccines or treatments? Daily miso soup for EVERYONE, that’s the ticket. Okay, whatever, no.
Turns out, if my pre-teen self had just known SOMETHING about miso paste, I might have been a chef instead. Happy Sunday, everyone. Hi, Natalie!
These are our healthcare heroes at work: From ICU rounds at Poudre Valley Hospital, part of UCHealth: Starting from the left standing we have Respiratory Therapy, Palliative Care PA, and Chaplain. Sitting from the left are RN, intensivist MD and Charge RN. In front of the intensivist (in green scrubs) is a telephone on the desk. The telephone is on ‘speaker’ and dialed in to a conference line. Also dialed in are: Pharmacist working remotely, Nurse Communication Liaison working remotely, Social Work.
So many great things going on here: Social distancing as much as practical (too much further and you can’t hear each other over the din of electronic alerts across the ICU), N95 masks (all day every day), reviewing data together from so many disciplines, discussing each patient in detail and taking immediate actions (placing orders, creating consensus on medical decisions, dividing tasks for rapid action).
In times of pandemic, the hospital follows infection prevention protocol and isolates very sick, very infectious patients. In this case, we have grouped and isolated all Covid-19 patients into a distinct unit, away from non-Covid patients. AND, in most cases, patients are not allowed to have visitors.
This is both good medical practice, and heartbreaking to families who cannot be present at a patient’s most desperate hour.
Out of this swirl of confusion, Julie Griffin, Nurse Manager of Care Management, thought: we have highly qualified nurses on-leave at home (orthopedic unit nurses with no post-op surgical patients; pregnant nurses for whom Covid infection would be particularly dangerous); how might they help share the burden of patient care with bedside nurses, and still minimize risk of contagion and exposure?
And so was born: Nurse Communication Liaison. Nurses from home, helping keep families connected, and reducing the burden on bedside nurses. We haven nurses helping with med/surg units as well as ICU’s. As described by ICU nurse Molly:
7AM: My day starts at 7: I review the Epic EHR chart from home for patients in the ICU. I read the notes from the nurses and the doctors overnight in our 12 bed unit. By the way, our unit has moved to double occupancy, and we’ve expanded to be a 23 bed unit. So much has changed, we’re so much busier.
8-10AM: I start receiving calls from family members and I give them updates on their loved ones, that I can, based on what I know. I am using Epic secure chat (a HIPAA-compliant text message service) to communicate with the ICU bedside nurses, social worker, respiratory therapy to get and give updates. I LOVE secure chat because it means the bedside nurse: who is gowned, gloved, doesn’t have to scrub out to answer another nuisance phone call interruption; they can catch up with chat-messages when there’s a break in the action.
10-11AM: Daily ICU rounds (picture above), where the team discusses every patient and I’m on the conference phone. It is a complete team with everyone pitching in.
11AM-430PM: We have designated ONE main contact family member for each ICU patient. We have found it can be overwhelming to have many family members calling each day for updates. I am so happy to be able to serve as the main contact for these family members and unburden our extremely busy bedside nurses to focus on their patients.
Some great unexpected moments:
Jamie: “Bedside nurses often spend 15 minutes on the phone with family. Multiply that by 5 patients and it becomes a big part of your day. We all wish we had more time to talk to families, but we’re often too busy caring for patients. I love helping connect with families and reassuring them.”
Jamie: “One gentleman was was not doing well. He was very quiet on the phone, and would never ask for anything. I spoke with his close friend at home, who noted that he was Jewish, and might appreciate a visit from a Rabbi or the Chaplain. I was able to arrange that.”
Jamie: “Being an ortho nurse on a medical unit, I was anxious at first. But communicating with the bedside nurses by secure chat and occasionally the phone, I found that even if I couldn’t answer families’ questions, I could always find out. Families are always so appreciative of the extra communication. I love this role. It is really awesome.”
Dawn: “The difference with this role is: There’s only the person on the phone. It is quiet at my home on my end. Normally when I’m at the bedside, I’m always trying to ‘wrap up the conversation’ with family: there are so many other things needing my attention. I can really feel good about being focused, connecting with family, and freeing up the bedside nurse to do their jobs.”
Dawn: “I was on the phone with the husband of a Covid patient. I noticed he would occasionally grunt, while we were talking about his wife. I had to ask him: ‘Are you okay?’ He told me he had had a fall, and had to pull on his pant-legs to go up the stairs. I recognized the signs of a major injury. It took some convincing, but I finally got him to call his doctor. Turns out the next day he was admitted and had emergency surgery himself.” As an ortho nurse, she was probably the perfect person to help.
Davida: “Sometimes you can remind the bedside nurse by secure chat: ‘his daughter would like to see his face today. Can you get the tablet in there for a Zoom visit?'”
Davida: “I feel really useful, being able to connect with PT, social work, bedside nurse all by non-interruptive but efficient Secure Chat, and then calling to make sure the family stays informed.”
Molly: “It is completely weird not to be an ICU bedside nurse right now. I think I will be better at charting in the future. Not being able to see the patient lets me understand what families want to know, that I rarely wrote down before: how do they look? are they following commands? can they squeeze? How scary this is for the family, and although it is a tricky role for us, it feels great to be helping.”
CMIO’s take? Thank you to our amazing UCHealth nurses: Lisa Claypool, Julie Griffin, Jamie Deschler, Davida Landgraf, Molly Carrell, Dawn Velandra for their experiences and stories.
I’m so proud to be part of a multi-disciplinary, talented group of clinicians. Our Department of Psychiatry is gearing up for what may become the second surge of our pandemic, as we relax the stay-at-home orders in Colorado:
Mental Illness. Depression. PTSD. Panic. Suicide.
These terms must no longer carry the stigma they do. There is no shame in reaching out for help. Appropriate and timely treatment can aid a person’s innate resilience and return him or her to health.
We have not experienced a pandemic of this scope for more than a century … We are psychologically inexperienced.
C. Neill Epperson MD
Read more of Dr. Epperson’s ideas and initiatives in this fight for mental health and the major investments UCHealth will be committing to improve the well-being of all residents of the State of Colorado. Welcome to the fight!
Thanks to the hard work of our outstanding nurses, staff, and physicians, many patients with Covid-19 are pulling through. Here’s a particularly poignant story from UCHealth’s own reporter, Katie McCrimmon. Have your tissues ready.
I had the pleasure of being interviewed by Mile Hi Magazine last week in regards to questions about how patients can cope with Covid-19 at home.
I responded to such questions as:
So many people contract but recover, is this what our body is designed to do?
Can people determine whether they have the virus without a test on symptoms alone?
When contracted, quarantine is the first step. What’s next in terms for two weeks – nutrition, special foods to eat to help the immune system fight?
Any special foods we should be eating now to be in top immune condition should we contract?
Any over-the-counter medicine to take for the fever or diarrhea?
Should people change out bed linen during the two-three weeks period?
Once fever breaks, is this a key sign that its over?
Should people exercise while body is fighting the infection?
Once over, should person we wait a couple days to ensure no symptoms return?
If Covid-19 is a flu strain, will it mutate into another strain as flu does each season for next winter?
Anything else you feel is pertinent to help people feel they can get over it if infected.
I made one particular point at the end of the interview. I shared our family’s strategy for coping with the anxiety and stress during this pandemic:
Exercise every day
Play or make music every day
Limit yourself to 30 minutes of news or social media daily
Three Good Things. At dinner each of us discusses THREE THINGS we are grateful for, today. INSTEAD of our natural tendency to focus on the negative, this exercise helps us reframe our day in a positive light.
CMIO’s take? I challenge all of us to do THREE GOOD THINGS with our loved ones at dinner every night.
My name is Guy Ristoff. I work for the EPIC IT Team at UCHealth (Colorado) as an Analyst. I also have a 3D printer. A few weeks ago, I started seeing a bunch of people posting in 3D printer Facebook groups about ear guards to use with surgical masks. I thought it was a great idea for me to explore here at UCHealth.
I contacted a unit I have done some EPIC build for and asked if they would want some. I created my first 10, delivered them to the hospital, and hoped they liked them. I then contacted Gwen Martinez from the Clinical Informatics team and she sent an email blast to a group of people about the ear guards. Within 20 minutes, we started to get responses. It was amazing! The first few “orders” were coming from the Northern Region. My brother lives in Wellington and has 3D printer as well. I called and asked him if he would be interested in donating ear guards to the Poudre Valley and MCR. He was excited to help! His kiddos even got in on the fun by making thank you cards for the staff.
As for production, I can make 17 of them per batch, which takes about 4 hours. It is not a super-fast process, but it is a lot of fun making something that helps people be more comfortable. My brother has made and dropped off 80 of them. I have created 122 of them for the AMC and MHC campus so far. I am dropping those in the mail and at the hospital today! I will keep up production, so keep the orders coming. I am just happy to be able to help!
CMIO’s take? Thanks to all our creative Epic/IT team members like Guy, to step up and help in every way that they can. –CT Lin MD
Executive Summary: We have a global pandemic, daily policy changes, we work from home, have new video tech, and we are learning to communicate and build relationships in new ways. It is easy to forget that there may be a scared patient on the other end, counting on us. How might we improve the patient experience? Some ideas:
Secure Chat with your MA
Scrub your schedule together, days ahead for patients more appropriate for telehealth vs in-person visits, med rec, troubleshooting, visit focus
Arrange your room, self
See tipsheet in Epic “Demonstrate Professionalism.“ How is: your room, your light, your clothing?
Eye Contactand, put a sticky note on PC cam to “LOOK HERE!”
Arrange the camera at eye level if possible. For some, looking down = frowning? Eye contact on video visits is EVEN MORE important. “If I look away it is because I’m looking at information in your chart”.
Avoid running late
If you DO, inform your MA by Epic secure chat & they can inform patient
Greet the patient
I like to raise my arms in surprise when we connect: every human connection now, is amazing. Maybe thank them for connecting with you. Ask if they’re in a safe private spot (eg: advise patient NOT to be driving!)
Talk, human to human
Ask: how are you coping (aside from medical concern)? Scared? Worried?
Even more important now in this time of anxiety. You can reflect or say back Data, Ideas, Feelings, Values. It strengthens connection: for example DATA: “It has been 5 days of worse symptoms?” IDEAS: “so you think it might be gout?” FEELINGS: “you’re worried about work? Hmm.” VALUES: “so, what’s important to you is your family.”
Some clinicians may have taken the Excellence in Communication course. The PEARLS acronym can also be helpful. Some examples: Partnership: “We’ll get through this together.” Empathy: (reflective listening, as above) Apology: “I’m really sorry that happened.” “I’m sorry for my part in it.” Respect: “You have worked really hard on this.” Legitimization: “Anyone in your situation would feel that way.” Support: “My team and I are here for you. We aren’t going anywhere.”
Physical Exam creativity
Teach them to take a pulse “say beep when you feel it” and YOU can count. Patients may have a BP cuff, Pulse ox, flashlight, thermometer.
Ask for help from family
Others may help add to history or exam findings
They may ask about YOU as a human
“How are YOU doctor? Are you staying safe?” So many surprising comments from patients worried about their doc. Thank them!
Brief LIFE advice
During pandemic, consider: A) Limit news/social media to 30 min/day. B) Exercise daily. C) THREE GOOD THINGS exercise: proven to reduce depression, anxiety if done consistently “What 3 things are you grateful for today?” Can become a great family habit at dinner.
AVS, Open Notes
From My Health Connection, they can see your AVS (after visit summary) and your Progress note (called Clinical Note) to remind them of details of your visit. Maybe at end of visit, ask: “Sometimes I don’t explain myself well. Can you tell me what you’ve heard, so we’re on the same page?”
Reassurance and Hope
“We’re going to get through this!” “Stay in touch with your loved ones.”
Ending the visit
Consider: a handwave OR palms together, nod OR thumbs up OR “You Got This!” Forecast next steps or if your MA will call them after.
Secure chat with your MA
Handoff any items after visit for continuity (referral, next visit, lab, etc)