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Tuesday, July 28, 2015

When Life Changes on a Dime




We have all been there--one minute you're fine, and the next, you’re not.  In my case, my disruption came in the form of a serious medical issue that interrupted my life completely. In this week’s posting, I want to talk about the experience that has changed me. I will also share some of the tips and resources that helped during some of my darkest times dealing with brain cancer.

I have always been a very active person, and I have always kept myself healthy.  I have had many wonderful experiences both personally and professionally throughout my life and probably took my good fortune for granted, as most of us do until there is an event that changes our lives.
As a nurse, I have had the opportunity and privilege to work with professionals in a team setting, in which we provided quality care to patients. I, however, never really tested our health care system personally. I always knew problems existed, but it wasn't until late November of 2014 that I had the opportunity to experience it all firsthand.

On November 24, 2014, I was diagnosed with a central nervous system brain tumor. The only symptom I had prior to diagnosis was blurry vision, which I attributed to new glasses. I went to my ophthalmologist to address this, and the doctor assured me the glasses were fine and I probably just needed to get used to them. Leaving the appointment, though, I hit the curb with my car. As a result, I got a flat tire and called my husband as I was unable to drive the car. When he arrived, he said I looked confused and was not acting like myself, so he took me to the hospital. Hours later, a CAT scan revealed the tumor in my brain. 

This diagnosis thrust me into the complex world of healthcare. I was admitted to a small community hospital where I received various tests to determine if the brain tumor was the primary site, or if it had metastasized. I was lucky, or as lucky as you can be with a brain tumor, that all of the tests were negative and the brain was the primary site.

After the testing was completed, the neurosurgeon recommended I go to another neurosurgeon at the University of Miami for further treatment. This was a relief, as I did not want to receive care for such a serious condition at a small hospital but preferred an academic setting. But getting an appointment with a specialist at a large teaching hospital is not easy. One of my colleagues called a few people and was able to secure an appointment the next day with the neurosurgeon. I was evaluated by the neurosurgeon and admitted to the hospital for a biopsy. We learned that the tumor was inoperable so chemotherapy was going to be the course of treatment. I was seen by an expert team coordinated by the Neurosurgeon. The hematologist/oncologist he referred me to specializes in the tumor type I had. He was able to see me right away, admit me and begin treatment. I truly believe that the expedited care I received from this expert team saved my life.  

As most of the early days of my journey are blurry to me, I turned to my husband for information. He pointed to four large binders that he built that detailed my course of care. Having a system to keep track of the medical records and all of the professionals who treated me was critical.  The binders also contained business cards with information for important contacts that he communicated with along the way. The information in the binder detailed the dates when we saw the various physicians/providers, what they said and what the treatment plan was. The binders went with us to every appointment so that if there were questions we could produce a discharge summary, doctor’s notes, or my husband notes on the visit to help clarify the plan of care.

It is important to keep in mind that, as a patient with a serious medical condition, you are the only constant in your care, so having a way to maintain the history and the course of care is critical. The plan of care can become confused as new players enter the picture.

Another tool that helped in unanticipated ways was our cell phones.  My husband showed me a few of the videos he took with his cell when I was having trouble communicating. The videos and the documentation in the binders were eye-opening to me, as they showed how sick I was and how lucky I am to have come as far as I have in a few months. He also used these videos to explain to the medical team what he was seeing at home and how my personality changed as a result of the tumor.

I attribute my recovery to the medical team, nurses, and pharmacists at Sylvester Comprehensive Cancer Hospital at the University of Miami. Because of their expertise and close supervision, I am here today. And through my husband’s love, patience and support, I have been safe and cared for. I had several friends who assisted us and untangled many of the roadblocks that often hinder care. I also had a very good support system made up of family and friends, who prayed for me and kept in touch, providing intangible support in times of isolation.  Having an advocate when you enter the hospital is very important. The advocate can be a significant other, a family member, a friend, or a professional.

Today, there are professionals such as nurse case managers and professional patient advocates with whom you can contract with privately to help you and your family navigate the complex health care system. These professionals can be a godsend for the family and the patient during a difficult and confusing time.

In the midst of overwhelming and complex treatments and developments, communication can be difficult. To help with keeping friends and family updated, my husband set up a CaringBridge site.  CaringBridge is a free service where people can set up individual web pages to update others on progress or challenges a loved one is facing. Family and friends can leave comments and well wishes. The site was a help for my husband; it alleviated the stress of making repeated phone calls with updates.  After each doctor’s appointment and hospitalization, my husband would update the site. I gained comfort in reading the comments, as they showed the support I had behind me. It was very uplifting.

My husband was able to take off from work and visit with me daily, sometimes twice a day at the hospital. This was a blessing. Due to the type of chemotherapy, I was admitted to the hospital every two weeks, usually for 5 to 7 days at a time. His presence and assistance carried me through a very challenging time.  He was a help to me when the nurses were busy and I needed a cup of ice or a soda. Since he was the only relative in the area, I depended on him for everything.

In order to ensure a similar type of support system, it is important to plan.  Families that have other members in the same area need to make a visitation schedule to make the most of the patient’s time and to provide support to the primary caregiver. If possible, find out when the medical team visits so that someone can be there to assist in receiving updates and asking questions that clarify the course of care.  Have a list of questions ready so you are prepared for the team. Another way to handle questions or problems that needs to be addressed is to ask the nurse to set up a family conference so issues can be resolved. This is a common practice in most hospitals today, so don’t be afraid to ask.

I also recommend that you share with the health care providers on your team some information about who you are. Tell them the type of work you do or did; tell them about your family, and some details about your personal life. All of these details remind them that you are not just a patient – but a person as well. While patients are very important and should be viewed as the center of the care team,  many health care professionals may become desensitized as they see so many cases and sometimes forget to consider the uniqueness of each patient. Telling the nurses, doctors and, other members of your team about yourself can change their perspective. Revealing this information reminds them that you are an individual;  you have people in your life who love you depend on you, and want you to get better. So many times, patients lose their identity in the nonstop pace of our complex health care system. Bring in photos of your family and friends so that the healthcare team is reminded of the person behind the patient.

After the third course of chemotherapy, I had an MRI which showed that the tumor was gone: I had not expected to hear this when I went to my appointment with the Hematologist/Oncologists. I had thought the doctor would tell us the tumor shrunk, grew or was the same and he would give us details on the course of care. We were shocked and grateful for this news as it meant the chemotherapy was working. The plan was to continue to course.

As part of a teaching hospital, rounds are made by a large team of professionals. The team on the unit where I was a patient was made up of the attending physician, residents, interns, medical students, a nurse practitioner and the pharmacists. The people on the team changed at different times during the month, so as a patient you are constantly meeting new people.  Again, the burden of keeping the team up to date falls to the patient and their support system so having that binder handy can help. For us, referring to the binder about various treatments, medications and plan of care helped us avoid medical errors and showed the team that we were engaged in my care and could clarify issues they could not find something in the current record.

On week five, the team visited me on daily rounds and checked my reflexes as part of their examination. On exam, it was found I could not flex my feet which meant I had foot drop in both legs. This was a sudden change that had occurred overnight. This made walking difficult to the point that I needed assistance to get up out of bed. As a result of this change, the attending ordered one of the drugs that was part of the protocol (Vincristine) be stopped as it is know to cause nerve damage.  In addition, I was seen by a physical therapist who ordered a rollator walker for me. I received this in the hospital and was able to use it to walk for short distances with someone with me as I was very weak. 

I finished my six chemo treatments at the end of February as an inpatient. My Hematologist wanted me to have two additional treatments for ‘insurance’. These treatments were able to be done as an outpatient as it was a single drug. This was a great relief as I was really tired of being in the hospital, but it was a lot of work for my husband. Once I was discharged, I had trouble using the walker due to weakness and had a few falls. As a result, my husband had to be with me whenever I used the walker so he could catch me if I started to go down. It was a very scary time as I was afraid that I would fall and break my hip or another body part.

On my follow-up visit, I asked the doctor if I could go to Physical Therapy and he agreed. I went to a facility near my home as an outpatient and learned the reason for the inability to walk was due to muscle weakness. They gave me exercises that would help me start to build up my muscles but I was advised not to use the walker as I was a high risk for a fall.  As I still had chemotherapy as an outpatient to be done, the progress was slow, but it was good to be doing something to improve my condition.

As I was unable to walk I had to have help transferring from the bed to a chair, assistance with going to the bathroom and getting a shower. My husband did all of this as well as cook our meals, do the laundry and transport me to doctor’s appointments.  He really did everything for me to ensure I was safe.  As a result of the chemotherapy, I had a poor appetite and did a great deal of sleeping. Many people shared ideas to help with my nutrition.  They suggested protein shakes and other types of food that would build my immune system as well as provide the nutrition I needed to heal.  This was helpful and I tried my best to eat and drink fluids. It was hard as I had no appetite so at times I felt I had to force myself.

Early after my discharge, my husband asked me; should you have really gone home with all of these problems? When I thought about it, I should not have come home as I was not safe, but no one in the hospital did an assessment or asked me if I felt safe.  I wanted to come home, so I did not push the fact that I would be difficult to care for. We were very lucky that nothing happened to me during this time as any injury would have set me back. My husband was an excellent caregiver and never left me alone but having a case manager or social worker evaluate me prior to discharge would have been a safer course of action.  If you are ever in this situation, ask your nurse or doctor for an evaluation by a case manager or discharge planner. This is important as they can help with resources such as home care or equipment that could be set up before you leave so your transition home is safe.

In early April I had finished the additional chemotherapy and went to see the Hematologist/Oncologists. Prior to the visit, I had an MRI done that showed I remained tumor free. As the doctor examined me, he said that he wanted me to go into inpatient rehabilitation as it would be more aggressive and I was very debilitated and weak. He wanted me to go to rehabilitation at the University of Miami, but we could not get an appointment with the Rehabilitation doctor  till mid-May and I wanted to start the process as soon as possible.  I also wanted to go to the facility nearer to my home. The facility I was going to as an outpatient did have an inpatient hospital where I knew I would get excellent care. I went to see the Rehabilitation physician  there and was able to be admitted right away.  The doctor explained I would be in for a two week stay as that is what the insurance usually approved. He said they would monitor my progress and if I needed more inpatient treatment, they would see if it was approved by the insurance company.

Looking back, going into inpatient rehabilitation was the best thing I could have done. I had physical and occupational therapy twice a day, cognitive therapy once a day and pool therapy three times a week.  The therapists were excellent and came up with creative ideas that allowed me to build my confidence and walk safely. They also explained things to me that I did not understand about why I was having trouble walking and gave me exercises to build up my muscles and balance.

Through the therapy team’s guidance, I improved physically and mentally.  I found strength from my faith, support from friends and family, and from the other patients who were at the rehabilitation hospital and worked alongside me. Many were older and many had serious problems. Their hard work and progress made me see that through therapy I could also improve. I learned that the cause of my inability to walk was the result of peripheral neuropathy and nerve damage from the chemotherapy. I am told that this should resolve, but it is a very slow process. After the two weeks, I was discharged from the inpatient hospital and readmitted to outpatient therapy as there was still a lot of work to do. This time when I came home, I was more independent and could do more of the activities of daily living with minimal help. I still needed assistance but I was feeling more confident as I continued to improve.

Another important member of my team was the psychologists/psychiatrist. When life changes and the future is not clear having someone to talk to is important for both the patient and the caregiver. I had two consultations (one in the cancer hospital and one in rehabilitation hospital) with the psychiatric team. To be honest, I was having some doubts about how my life would be if my legs did not improve or the tumors returned and having someone to talk to was important. They could not give me any answers, but knowing that what I was going through was normal was important.

Currently I am able to walk with a walker and transfer independently. This has been a big confidence booster for both me and my husband as it means he can leave me alone for short periods of time. This progress has allowed him to go back to work and do others things that he could not do as I was not able to be alone. I still cannot work or drive so I find things to do at home that occupy my time. This Blog was born out of the need to share my experience while providing ideas and recommendations that could help others to navigate the healthcare system safely.

Next week, I will detail the various healthcare professionals who cared for me and were there to assist me in every way. It is helpful to understand each professional’s role and how and when to access them.

If you have a comments or questions, feel free to leave them in the comment box. If you want to talk to me please email me and we can set up a time to talk or you can reach me via email at allewellyn5@bellsouth.net.

Thanks for visiting Nurse Advocate and have a good week!


To summarize, here is information and a link to some of the tools and resources mentioned in this week’s blog:

Binders: You can go to any office supply store to purchase a binder. If there are multiple hospitalizations, have a binder for each hospitalization or separate by date. The binder can fill up quickly so buy a large one as they are easier to go through to find information. You may also want to buy dividers if the person is being seen by multiple providers. You can get inserts to hold x-ray discs so they remain with the appropriate doctor’s visit.. Keep in mind that you are entitled to these records. You may need to pay something for copies and sign a consent form to release information, but having them will be important as you move through the continuum of care.

Asking Questions: Clarifying the plan of care: As the patient and caregiver, don’t be afraid to ask any question. Many times it may be overwhelming to ask questions to doctors or other staff members who are busy or you may intimidated by. DON’T….they are in place to care for you and your questions, concerns are important for them to address. I do recommend that you take time to formulate your questions in advance of seeing them so that you are organized. Try and find out when the doctor will visit you. If you are in a teaching hospital, the team usually makes rounds at a set time. Ask the nurse or the resident what time the team will be making rounds. If you are in a community hospital call the doctor’s office and find out what time he is expected at the hospital. In my experience, the floor nurses usually don’t know this as their times change according to the office hours and workflow.

If you want to look things up on the internet, ask for websites that would be good to visit. There is a lot of information on the internet and a good deal of it might not pertain to you or may be accurate. 

Ask the nurse, doctors, or case managers for some sites that they recommend you to visit. They are probably utilize the same websites, as they are reliable, help them understand your diagnosis, and explain treatment options and tools. If you don’t understand the information, print it off so you can bring it to your visit. Also, ask the doctors or nurses for information on your condition. They may have printed information ready that will save you the time.

Caring Bridge: A Communication Tool: this site allows you to set up your own website to make posts on your plan of care, progress or lack of progress. This helps communicate information to a number of people at one time and allows well-wishers to communicate with the patient/family. Here is the link   www.caringbridge.org