1. Millefoglie, Mia MA

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Having recently emerged from a deep dive into our Agency's historical archives-spanning over 115 years to include nine visiting nurse agencies-I was left pondering what has changed in the day of a visiting nurse? To answer this question, I approached Greg Burns, one of our more experienced pediatric nurses and convinced him to let me be his shadow for just one day! He graciously agreed.

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The day starts earlier than imagined as I meet Greg at 7:00 a.m. in his home office in Portland, Maine. The day begins with Greg checking his computer to finalize details from yesterday's assessments and care plans. There is documentation to complete and submit so the Agency can finalize its billing requirements. Greg knows this needs to be completed before he can head off on visits. He reviews the proposed schedule, talks with schedulers, adjusts and readjusts patient visit needs, and now gets ready to confirm appointments with his patients and families.


It's already 8:30 and Greg is looking a bit anxious as he has four visits to complete and one of them involves a boat ride! Glancing quickly at the ferry schedule, he nods let's go! There is a 9:00 ferry that leaves for Peak's Island. And with some luck, we might even be able to catch the 10:30 ferry back to Portland. Grabbing his computer bag and supplies, and with me trying to keep up with his long strides, we are in the car heading to the waterfront. The fog has lifted but a cold front has brought some winds and a few white caps on the water. To my relief, Greg settles for the lower protected deck with roaring heaters! After a short and sometimes choppy ride, we arrive on the Peak's Island Terminal at 9:15 and begin our walk uphill and about a half mile to our first patient-a healthy newborn. As part of a state-funded grant, HomeHealth Visiting Nurses can offer every new mom in Maine, nursing visits at no charge. A young mom greets us at the door looking a bit worried and tired and in no time Greg puts her to ease. He picks up the newborn infant, checks vital signs, does weights and measurements, and signals with an "A Ok." The visit then refocuses on mom with Greg patiently reviewing feeding schedules, tips for soothing baby, and resources for parenting. All of this compassionate listening can sometimes conflict with the goal of completing as much documentation as possible in the home. Greg leaves instructions, his contact information, and a whole lot of reassurance before we say good-bye.


We are now racing fast as the large yellow Casco Bay Ferry is approaching the dock and we barely make it before the boat pulls away. Relieved, we settle back in, with Greg resuming his documentation, making follow-up calls to physicians and his supervisor. We arrive at 10:30 with hopes to be on time for an 11:00 home visit that is more than 15 miles away. Greg knows this road pretty well as he has cared for this patient for almost 2 years. At the age of 3, Annie was diagnosed with aplastic anemia-a rare blood disorder in which the body's bone marrow doesn't make enough new red blood cells, white blood cells, and platelets. Annie's mom-who also is a registered nurse on our pediatric team-recognized these symptoms and promptly sought medical attention. A home health treatment plan was recommended and Greg was assigned the lead. Annie went through a course of immunosuppression, a drug treatment plan that quiets the immune system in hopes that the body resets itself. Medications were initially administered intravenously, and slowly over time, Annie's condition improved. Today, Greg is scheduled for blood draws and a reassessment. At the door, we are greeted with smiles and before long Greg and Annie are engaged in laughter. Greg completes his blood draw, checks Annie's vital signs, and reviews recent histories. Greg and mom review upcoming physician visits, concerns, or changes in his condition. All is positive as Greg says good-bye and schedules his next visit with them.


We are now grabbing quick lunches and heading back to the city to meet with Amy. As we drive, Greg shares a very moving story of this 18-year-young woman and her journey with a very fragile infant. Joanne's delivery by c-section was complicated by an umbilical knot. At birth, her newborn son presented seizures with a magnetic resonance imaging confirming severe cerebral ischemia and brain injury. Although plans were in place for do not resuscitate, Joanne rescinded this order and brought her son home to live with her for as long as possible. Treatment included Phenobarbital for seizures and a feeding tube for nutrition and hydration. With a grim prognosis of 2 weeks, Matthew progressed surprisingly well at home and began to gain weight and started to feed with a bottle. Matthew lived in the comfort of a loving family until a series of difficult seizures and blocked airways required emergent care and hospitalization. Matthew was placed on a ventilator and died shortly thereafter at the age of 8 months. At this visit, Greg is concerned about Joanne and how she is managing emotionally in this grieving process. I give both of them privacy as they need time to share and process all the emotions of losing a child.


Our final home visit takes us to an isolated rural area where we travel country roads looking for natural landmarks, as road signs are nonexistent. We turn left on a very narrow dirt road that winds its way to a glistening lake. In a very small cottage, we meet Heather, her mom, and dad. As usual, Greg gets hugs as we enter the very modest home. Everyone remembers the day that life changed, Friday, April 13, 2012, the day Heather was diagnosed with acute lymphoblastic leukemia. The 2 years that followed were marked with repeated hospitalizations, aggressive chemotherapy, weight loss, injections, and crushing fatigue. Today, Heather has rebounded and is full of energy and life. She is back in school, playing soccer and more importantly in remission. After 2 years of intensely caring for Heather, monitoring her care plan and advocating for her goals, Greg is here to say good-bye. Heather and the family hug tightly to Greg as they laugh through some tears to say "farewell!" We ride back to the office, silent and grateful.


I am left to answer the question: what has changed in the day of a nurse? We have adopted new technologies, adjusted to regulatory changes, and adapted our care plans for reimbursement; however, the compassionate care provided in the private realm of home and family, the development of trusting relationships between patient and nurse, and the mission of patient-focused care remain essentially unchanged. Thankfully.