Monday, November 12, 2018

Veterans Day: Honoring Those Who Served in Their Final Hours

By Rosemary Baughn, Senior Vice President, VNSNY Hospice and Palliative Care

HEALTH– When Joseph Vitti first meets a veteran to whom he will provide the comfort care of hospice, he usually begins by saying, “Thank you for your service.” But for those who served in Vietnam, he begins with words that have long eluded them: “Thank you and welcome home.” A fitting thought to keep in mind as Veteran’s Day approaches.

Vietnam is very much in the national conversation now, with the debut last year of Ken Burns and Lynn Novick’s documentary series marking the 50th anniversary of the war’s escalation. Among the powerful legacies that the series brings to life is the toll that the war’s brutality and divisiveness still exacts on those Americans who fought and returned.

My colleagues in the Visiting Nurse Service of New York’s Hospice and Palliative Care program who are caring for veterans at the end of their lives find that the silence common to many veterans on the subject of war is compounded in Vietnam veterans by the lack of support—and even enmity—they experienced when they came back home. 

End of life is the last chance to change the equation—to build bridges of communication to family members and loved ones, to other generations—and even to oneself. 

VNSNY’s special hospice program tailored to military veterans helps do just that. Our veterans hospice team of physicians, nurses, social workers, spiritual care counselors and home health aides is specially trained to provide care for not only the physical illness at hand, but also conditions such as PTSD, survivor’s guilt, depression, and substance abuse. We help connect veterans and their families with community resources and veteran-specific benefits, and hold bedside recognition ceremonies that honor their military service. VNSNY’s hospice initiative also benefits greatly from our participation in “We Honor Veterans,” a program created by the National Hospice and Palliative Care Organization in collaboration with the Department of Veteran Affairs, to address the unique physical, emotional and logistical needs of veterans and their families at end of life.

Sharing Stories

This specialized hospice care includes prompting and listening to stories. “End of life is a time—for anyone—to look back on one’s life and reflect on what mark they have left,” says Joseph, who is the U.S. Army Veteran Supervisor for VNSNY’s Veteran’s Program, and is also a veteran himself. “For veterans, we work to create an environment that lets them understand it’s okay to talk, to share stories. It’s not that they don’t want to—it’s that they don’t know who to tell the stories to, or how to tell them.”

So conversations typically begin slowly, with Joseph or a colleague asking straightforward questions: What was your branch of service? Where did you serve? For how long? “Then,” says Joseph, “we take one small step forward: ‘Tell me about your friends.’ That’s where the stories are.” 

Joseph further supports the veterans in sharing their experiences by explaining to them that their stories could help him help other veterans and families. “Veterans are very selfless. Helping others is something they certainly want to do.”

Joseph describes what happens once the stories begin to come. With a Vietnam veteran living on Staten Island, a former machine gunner referred to our service by the Veteran’s Administration, Joseph began with his standard greeting: “From one soldier to another, Welcome home.”

“He broke down in tears,” Joseph recalls. “An instant bond formed between us, and a visit that was supposed to be about connecting his family with benefits became about connecting in a whole different way. It opened the floodgates. He talked about things he’d never talked about before, and said that there wasn’t a day that went by that he didn’t think about them.”

Another veteran, a deeply religious Catholic who was in the final stages of cancer thought to be caused by his exposure to Agent Orange during the war, felt that his life, and now his war-related terminal illness, were a form of purgatory for what he did during the war—namely, survive when friends around him were killed. Joseph helped him reframe the narrative and achieve a measure of closure. “Did you ever think that this wasn’t your purgatory,” he said, “but that you survived because you had another mission—to be a husband to your wife and a father to your children?”

The veteran embraced the conversation, talking as he never had before. “These veterans don’t want to be forgotten, and don’t want their stories or their friends to be forgotten,” says Joseph. “They just don’t know how to begin. So we say, ‘Tell us. We want to know about your experience. We need to know.’”

For those who are unable to share their stories, families can learn their loved one’s history from military discharge papers, which the hospice team will help track down, along with any medals the veteran might have received. One soldier’s discharge paper detailed the circumstances behind his Silver Star, the military’s third-highest honor—a story the family had never heard. The only one in his eight-man team to survive an attack during the Tet Offensive, he kept firing even after he was shot and wounded—saving the lives of countless Americans ahead of him on the battlefield. When Joe shared the papers and the story with the family, including a young grandson, everyone was in tears, hugging the patriarch and hailing him as a hero. “They were a close family, but this brought them even closer,” Joseph notes. “That, the family’s support, is the ultimate medication and therapy.”

Joseph sees this time and again with veterans of all wars, but it is most pronounced with Vietnam veterans—who, after keeping their stories bottled up for decades, take the leap of faith in opening up to their families and find grace where they expected judgment, and honor where they expected contempt. 

“Imagine, your father afraid to tell his stories, maybe because he accidentally killed innocent civilians and he thinks he’s going to hell,” Joseph explains, citing a composite father built out of many fathers he’s worked with. “And then imagine that, instead, he hears from his children: ‘We love you, we’re proud of you. You’re not going to hell. You are a hero.’”

“What we need is a real national conversation that encourages people—especially a younger generation—to engage these veterans and hear their stories,” says Vitte. “Ask a friend, a neighbor, a loved one. Comfort care doesn’t begin with hospice. Many of these veterans have emotional and physical scars that go deep, and we owe it to them to listen.”

Thursday, November 8, 2018

Know the Warning Signs for Brain Aneurysms

By Janet M. McHenry DNP, FNP-BC, CCRN, CNRN
Doctor of Nursing Practice
Family Nurse Practitioner, Department of Neurosurgery

HEALTH– The journey begins: “I looked up from my desk and I felt like a bomb went off in my head. It was the worst headache of my life, it just exploded.”

“I wasn’t feeling well for about two weeks before this happened. The last thing I remember, I went into the grocery store and I woke up three weeks later in the rehabilitation hospital.”

“I was attending a family party and thought I had food poisoning. I felt like something popped behind my right eye and there was flashing in my eye like a light bulb went off, then I vomited.”

“My sister came home from work and said she had a bad day and a headache. She went upstairs to lie down before dinner. That was the last time we spoke, she died the next day.”

These stories are typical of survivors and their loved ones who have experienced a ruptured brain aneurysm resulting in a subarachnoid hemorrhage a type of hemorrhagic stroke.
Fortunately, aneurysmal subarachnoid hemorrhages account for only about 3% of all strokes. However, it is important for everyone to know the symptoms and risks, particularly in our community. First and foremost if you or a loved one get the “WORST HEADACHE OF YOUR LIFE,” please seek immediate and emergent medical attention.  

The sudden onset of the worst headache of your life is a “red flag” and may be a sign of a ruptured brain aneurysm. Other symptoms of brain aneurysm which may accompany the headache include: stiff neck, sharp pain behind or in the eye, blurry vision, light sensitivity, drooping eyelid, nausea & vomiting weakness of the arms or legs numbness and tingling of one side of the face or body, dizziness, confusion & seizures and/or loss of consciousness. There is normally a sudden onset of symptoms as described in the stories. There are a small percentage of brain aneurysms that leak a week or two before the rupture. People report that they have headaches and generally feel lousy, similar to the flu symptoms. When a brain aneurysm ruptures causing a subarachnoid hemorrhage it can cause brain damage, coma and even death.

What is a brain aneurysm?

A brain aneurysm is a balloon that arises from a cerebral artery. A brain aneurysm results from a weakness in the wall of the artery that supplies blood to the brain. Because blood continues to flow and finds the path of least resistance the vessel balloons out. 

Blood fills that sac and as pressure rises, that balloon can rupture and pours blood into the brain. 

Important Statistics

A Brain aneurysm ruptures in this country every 18 minutes impacting approximately 30,000 people a year. Women are affected more than men approximately 3:2 ratio, generally between 40 and 60 years of age. In contrast, approximately 6 million people in the US have unruptured brain aneurysms or 1 in 50. Cerebral aneurysms are twice as likely to rupture in African Americans and 1.6% times more likely to rupture in Latinas and Latinos.  Of those who develop a subarachnoid hemorrhage resulting from a ruptured brain aneurysm 25% will die within 24 hours many more than 50% will have permanent neurologic deficits; approximately 50% will be unable to return to work and others will recover fully. 
 Risk Factors

Certain genetic diseases carry higher risk for the development of brain aneurysm such as polycystic kidney disease, genetic connective tissue disorders that weaken blood vessel walls, history of rupture in a first degree relative: parent, child or siblings. Those with sickle cell disease and Arteriovenous malformations carry a higher risk for development of brain aneurysms. Other associated risk factors include: smoking, drug use particularly cocaine and amphetamines and uncontrolled hypertension. Patients who have a known brain aneurysm are 20% likely to have a second brain aneurysm, usually on the other side.

Unruptured Aneurysms

Since there are rarely signs of unruptured aneurysms they are often discovered “incidentally”.  Patients may complain of headaches or dizziness and they are seen on magnetic imaging. We strongly recommend that anyone who has an incidental finding of a brain aneurysm be seen by an aneurysm specialist such as a neurosurgeon or neuroradiologist. They can offer treatment if it is required, further imaging to better characterize the aneurysm or to follow you on a regular basis. In particular, it is very important for family members of first degree relatives who have ruptured to be screened with an MRI and MRA or CTA if over age 21. We know about the connection to ruptured brain aneurysms it’s always better to find it before the rupture occurs and treat it then.

Brain Aneurysm Treatment

The only treatment for brain aneurysms in the past was open brain surgery. The aneurysm was located and a clip or clips were placed to secure the neck and stop blood from flowing into the sac. While this surgery is performed least often but is sometimes required due to the location or configuration of the aneurysm. Endovascular treatment has developed over the past 25 years and is utilized more commonly to treat aneurysm. The patient is taken to interventional suite and a cerebral angiogram is performed similar to a cardiac catheterization.  

The angiogram or catheterization of the brain is performed. The aneurysm can be treated through a microcatheter by inserting platinum coils to fill the aneurysm. In addition a stent device re-directs blood flow away from the aneurysm may also be used so the aneurysm will shrink. 

Message to the Community 

There are disparities in health care in this country based upon race and economic status. I know from my own experience speaking to patients that this often prevents community members from seeking the help that they need. 

Please don’t ignore the symptoms if they occur, Montefiore is here to help. We are not interested in your insurance or immigration status. We are a nationally designated comprehensive stroke center. We are in the forefront of aneurysm treatment and research. At Montefiore we have a multidisciplinary team that collaborates for the patients highest quality and most efficient care. In order to attain Joint Commission of Hospital Accreditation national designation as a Comprehensive Stroke Center there must be a high number of aneurysms treated and both operative and endovascular treatment must be offered. The entire staff including MDs, nurses and all health care workers who touch the patient must be educated. We must continuously maintain excellent standards of care that are benchmarked against the national standards. The standards are high, but so are the stakes for our community members who deserve only world class healthcare.

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