SBAR is for those who live, work, study, love, or simply wonder about the world of healthcare. Invitation to all nurses, physicians, APNs, PAs, students, researchers, techs, caregivers, patients, family members, and anyone curious about what happens behind the scenes.
Here, you’ll find stories from the bedside and beyond. I will share reflections on nursing, clinical research, memory and aging, yoga, writing, grief, gratitude, burnout, healing, and the strange, beautiful business of being human. You are invited to share your stories as well.
Pull up a chair. Read, reflect, ask questions, share your own experiences, or simply listen for a while.
It’s been six years since obtaining my board certification as a family nurse practitioner. A Master of Science in Nursing, a milestone I was so proud to achieve. COVID-19 entered the US during one of my clinical rotations while I was working full time in the ER. Having to navigate the fear of being a first responder while completing coursework and attending clinicals on my days off was one of the most trying times of my life. The pressure within constricted my throat and nearly blinded me. The fear of this spiky green virus silently entering my respiratory tract with just one inhale, then possibly exhaling it to infect my daughter and husband after my shift, was debilitating. Entering through the garage, stuffing scrubs into garbage bags, running naked to the shower, and sleeping in the guest bedroom only lasted a week or so. It was simply not healthy to isolate myself from the two people I needed more than ever, and they agreed.
Once certified, I took the first job offer as a nurse practitioner in an outpatient oncology office. With limited oncology experience or interest in this specialty, my acceptance was simple: to get out of the ER. COVID had officially burnt the toast I had already become. Most of the staff were good people, caring, hardworking, integrity-driven nurses and techs. However, the toxic ones were like black mold, too difficult to remove, so they just lingered within view of everyone, spreading their darkness. Why, why would management know this mold exists and seem to make no effort to cleanse the environment? It’s been over six years since being physically there, but my mind and body feel it still today.
But, ya see, I missed it. After three years or so as an NP, unable to find my niche, I pivoted back to the ER, a different one, and I really enjoyed it. But, similar to an old relationship or a past home, we often remember the good memories and conveniently forget the mold…or outdated wiring. I had to face the mirror, remove the boa constrictor, and speak my truth. The home within me had been rewired, and my internal breaker couldn’t handle the amps of the ER anymore. But where would I go?
A phone call from a doc I once worked with in the ER brought me to an opportunity in research, and within eight months the site was closed, my position severed, and what finally felt like my niche, my place, evaporated into thin air. But a wise teacher once said, “A cloud never dies.” This experience will manifest into another pathway for me to take. Still, after six years as an NP, I wished to have been established somewhere by now. Here I am, feeling like I’m back to square one.
This is what it must feel like to be single, swiping left and right in search of my right now or forever. The vertigo, the disgust, the confusion, the questioning myself: what IS my type? Thank GOD I’m married. But, like the game f, marry, kill, I had killed all my per diem positions to marry a job in research, just to get blindsided and divorced with minimal alimony aka severance pay. Maybe I am simply not ready to “date” again, in this case, apply for jobs. Maybe I need time to breathe and find my footing.
As Zen master Thich Nhat Hanh says, “The only way out is in,” and maybe that is what I need right now. The space and time to observe who I am today. I will still be an experienced nurse and nurse practitioner one month from now, even if the month of October is blank on my résumé. I must trust the advice of my loved ones, strangers, friends that I deserve this breath without guilt. Yet I am still here applying for unfit positions. I am trying so hard to give myself permission and cannot understand why it’s so difficult.
I keep putting this fucking boa constrictor on my own neck after everyone helps me take it off. This writing is just another way for me to release this energy into the universe, to allow it to become something else, yet it ricochets back to me each time. Where is the reset button? “The only way out is in,” I keep saying to myself.
I wrote this last week… knowing it was my last week….
It has only been seven months at this research institute, but I have gained invaluable knowledge about Alzheimer’s disease (AD).
This site was founded in 2013 by board-certified internist and geriatric specialist Dr. Sanjiv K. Sharma and was formerly known as the Advanced Memory Research Institute. In 2021 it had been acquired by a nationwide clinical research network known as CenExel.
The facility specialized in phase II-IV clinical trials specializing in Alzheimer’s disease, memory loss, and dementia, but also offered others such as vaccine and diabetic neuropathy investigational medications.
This site was nestled in the perfect location near Holiday City in Toms River, a community with a large senior population. Yet, for reasons that still do not fully compute for me… a new CEO, lack of profitability, corporate decisions…it is being shut down.
Whatever. I digress.
Back to AD.
Situation
Alzheimer’s disease, or AD, is the most common cause of dementia in adults over age 65. Approximately 6.9 million Americans are living with Alzheimer’s, and that number is expected to nearly double by 2050!
Dementia is an umbrella term for a decline in memory, thinking, or functioning. Alzheimer’s is its leading cause, but other causes include vascular disease, Lewy body dementia, frontotemporal dementia, Parkinson’s disease, traumatic brain injury, and certain metabolic imbalances.
Alzheimer’s is progressive. It often begins with subtle cognitive changes, sometimes diagnosed as mild cognitive impairment, or MCI. Of importance, not everyone with MCI develops Alzheimer’s, but when Alzheimer’s is present, symptoms gradually worsen and may eventually interfere with a person’s ability to live independently.
We should all have a stake in this disease. Aging is the greatest risk factor, and growing older is what happens when we are fortunate enough to remain alive.
Background
In 1906, German psychiatrist and neuropathologist Alois Alzheimer performed an autopsy on a woman who had experienced progressive memory loss and confusion… what may once have simply been called “senility.”
In her brain, he discovered two abnormalities that remain hallmarks of Alzheimer’s disease today: amyloid plaques and neurofibrillary tangles.
Who Is at Risk?
Age is the greatest known risk factor, but genetics also play a role.
We all carry two copies of the APOE gene, inheriting one from each parent:
APOE2 is the least common and may offer some protection.
APOE3 is the most common and is considered neutral for Alzheimer’s risk.
APOE4 increases the risk of developing late-onset Alzheimer’s. Two copies generally carry more risk than one.
As you might imagine, APOE4/4 carries the greatest genetic risk of these combinations, but it does not guarantee that someone will develop Alzheimer’s.
Another important piece is a protein called tau. Everyone has tau, and some phosphorylation of tau is normal. Tau ordinarily helps support the internal structure of brain cells.
In Alzheimer’s, tau becomes overly phosphorylated. It detaches, misfolds, and clumps together, eventually forming the neurofibrillary tangles first described by Alois Alzheimer. Elevated phosphorylated tau, or p-tau, can therefore serve as an important biomarker of the disease.
We cannot control our age or genetics, but we can work on modifiable risk factors. In general, what is good for the heart is also good for the brain:
Following an anti-inflammatory eating pattern, such as the Mediterranean diet.
Exercise regularly.
Limit alcohol.
Stay socially connected.
Keep the brain engaged through reading, writing, puzzles, learning, and other constructive activities.
Manage blood pressure, cholesterol, diabetes, hearing loss, and other health conditions.
Memory concerns should always be discussed with a healthcare provider. Brief cognitive assessments can establish a baseline and identify areas requiring further evaluation. I really enjoyed meeting so many lovely neighbors here while offering them memory evaluations.
Genetic tests and biomarker testing can provide useful information, but they must be interpreted carefully. Carrying APOE4 or having an elevated p-tau level does not, by itself, confirm that someone has Alzheimer’s or guarantee that they will develop it.
An amyloid PET scan can show amyloid buildup in the brain, but it is costly and is not routinely ordered for everyone. Blood tests, spinal-fluid testing, imaging, cognitive testing, symptoms, and the exclusion of other possible causes may all contribute to the diagnostic process. No single result should be interpreted in isolation.
Assessment: What Can We Do About It?
Treatment remains limited.
Traditional oral medications may temporarily help manage memory or thinking symptoms, but they do not cure Alzheimer’s. We often would say, docs would prescribe these and say good luck. I have heard countless people say they were simply ineffective.
Newer disease-modifying treatments, including the anti-amyloid antibodies lecanemab and donanemab, may be offered to carefully selected people in the earliest stages of the disease. These treatments became available because people volunteered for clinical research! And right here at this site actually! I was very proud to work alongside those who helped make that possible, bravo…
However, they are not appropriate for everyone. They are expensive, require ongoing monitoring, and carry real risks.
One potential side effect is ARIA, or amyloid-related imaging abnormalities. ARIA may involve temporary brain swelling or small areas of bleeding. It is often symptom-free but can cause headaches, confusion, vision changes, or other neurological symptoms. Rarely, it can be fatal. The risk is higher in people who carry two copies of APOE4.
Recommendation: We Need to Do Better
Alzheimer’s is a genuine fear for many people, especially those who have watched someone they love succumb to this awful thief.
I watched it happen to my mom, Virginia.
Her symptoms began subtly, but as they progressed, Alzheimer’s became a disease of our entire family.
That is why I was so proud to learn that Alzheimer’s research and clinical trials were available right here in Toms River, near Holiday City, where so many older adults live. Closing this site is a true disservice to our community!
I wanted to share a little of what I have learned because other research centers and clinical trials are still available. If you or someone you love has memory concerns, please speak with a healthcare provider and ask what evaluations, specialists, or research opportunities may be appropriate.
This is only a drop in the bucket of what there is to know about Alzheimer’s disease, but knowledge is where advocacy begins.
I am watching Rooster on HBO Max, and one scene just stopped me.
The temporary dean loses a position she didn’t even want, yet she still misses it. She is grieving. She says she misses feeling heard.
Rooster tells her to stop looking at it as a loss and see it as a gift, because now she knows what she wants.
I took pause…..
Maybe that is what this moment is asking of me.
Maybe I need to pause all the random job applications and look inward…not just at the job I’m losing, but at what I loved about working in research.
The teamwork. The hope. The location. The intellectual niche of it. The feeling that my voice mattered.
Something was always haunting though, that it might be temporary… and it was. I used to say that when I finally found my professional home, if my office didn’t have a window, I would bring my own…a painting of a window overlooking an island….
Well that painting never made it to my office. It remains in my living room.
I often wonder if the mental health epidemic in our country is actually a pathology of the brain, or if some of it is a response to the socio-economic construct society has built around us.
Were we created to sit in offices all day? Commute in cars? Sit at desks under harsh, fluorescent lighting, working to make this paper that continues to feel like it is never enough because the cost of everything keeps increasing?
Then take healthcare.
Our healthcare system is becoming increasingly less accessible and less affordable. I tried to contact my provider’s office today to request an earlier appointment, and the call doesn’t even go to the office itself anymore. It went to some centralized Hackensack-Meridian vortex to someone clearly in a different time zone…
How is it that with all of our advances in technology, connection somehow feels more disconnected then ever?
And it isn’t just healthcare.
It feels like every foundational aspect of society; healthcare, education, government, the economy, community, the environment, infrastructure, has been stretched beyond its ability to function the way it was intended to.
Like a rubber band pulled too far. Maybe it snaps. Or maybe it doesn’t. Maybe it simply loses its elasticity, quietly shrivels, and becomes something different. Something no longer able to function the way it once did.
And yet, when we begin to feel anxious, overwhelmed, exhausted, distracted, disconnected or depressed, we think something is wrong with us? Are we, in some ways, gaslighting ourselves?
Maybe nothing is “wrong.”
Maybe our brains are responding to the mass confusion and unsustainability of what we have collectively accepted as normal society.
I am not saying mental illness isn’t real. It is. Medication, therapy and psychiatric care can be lifesaving tools…
But I do wonder if we have become too quick to label every uncomfortable human response as internal pathology without also asking what is happening around the person experiencing it.
Maybe the pathology is not always entirely internal….
Go ahead and Google the happiest countries in the world. The United States ranks 23rd in the 2026 World Happiness Report. That alone should make us curious.
Have you ever heard of the village of Bakhta? It is a remote village in the Siberian taiga featured in the documentary Happy People: A Year in the Taiga. Life there does not seem easy. There is constant work, survival, brutal weather, animals, solitude and craftsmanship.
But while I was watching it, something stood out to me.
Everything has a rhythm.
The weather has a rhythm. The work has a rhythm. Survival has a rhythm….
People work with their hands. They prepare and repair. They move with the flow of the conditions around them. They use their human bodies and brains in ways our bodies and brains were built to be used.
And I can’t help but think…
We are out of rhythm.
We wake to alarms. Rush into cars. Sit in traffic. Sit under artificial lighting that makes me want to wear sunglasses indoors. Stare at screens…. Work in a hospital? You work 12 hr shifts with no proper lunch break and minimal support. Can’t even find a pillow or blanket for your ill patient despite working for a multimillion dollar healthcare system. Everyone around you is stretched just as thin, morale drops, patience disappears, and communication that should feel supportive inevitably has become toxic as baseline. Come home exhausted. Scroll some more. Worry about money. Worry about healthcare. Worry about the future…..
Then we lie awake wondering why our nervous systems won’t calm down. Maybe our brains are not failing us. Maybe they are responding.
Is our anxiety a signal? Is the exhaustion a signal?
Maybe we haven’t all suddenly become pathological.
Maybe we have simply become profoundly out of rhythm.
I don’t know…
Maybe we don’t need to fix every uncomfortable feeling within us. Maybe sometimes we just need to listen to what it is telling us about the world around us….
Because somewhere between the alarms, the traffic, the screens, the fluorescent lights, the constant striving and the constant worry, we may have forgotten something very basic:
We are human beings, not machines.
Maybe healing isn’t always about becoming better at tolerating the way we live. Maybe sometimes healing begins by finding our way back to a way of living that actually feels human.
If you have followed the Lindsay Clancy case as obsessively as I have, I wonder what your thoughts are regarding telehealth…..
Access to healthcare has become progressively more challenging, and telehealth has undoubtedly helped bridge that gap. It provides access to people who otherwise may receive no care at all.
But when does virtual care become inappropriate?
As defense attorney Kevin Reddington has brought up multiple times, you cannot truly assess the physical body of someone through a “television.” (He’s like the Robert De Niro of attorneys, by the way.) And beneath the theatrics, he raises a legitimate question.
Through a screen, how much of a patient can we actually observe?
Typically, we see the face, head, neck and maybe the upper chest. We can a basic mental-status examination. But what about the rest of the objective assessment?
Are the patient’s pupils dilated or pinpoint? Are they sweating? Tremulous? Picking at their cuticles? Is a leg bouncing uncontrollably beneath the desk? What is their heart rate? Blood pressure? Respiratory rate? Are there physical findings suggesting medication effects, withdrawal, intoxication, severe anxiety or another condition requiring further evaluation?
What are their damn vital signs?
These observations cannot diagnose a psychiatric condition, but they can provide pieces of the clinical picture that simply aren’t available through a screen.
So perhaps the question isn’t whether telehealth is good or bad. Perhaps it’s when should telehealth become triage?
I believe there are circumstances in which concerning symptoms should trigger an in-person evaluation or higher level of care…..particularly when treating vulnerable or higher-risk populations. Suicide risk is not distributed equally across the population, and risk factors, symptoms, history and clinical presentation should matter when determining the appropriate level of assessment.
And if “television” is the only available access point, shouldn’t we be especially intentional about using evidence-based guidelines and validated screening tools to help identify risk?
Take the PHQ-9, for example. Many of us have completed it at a doctor’s appointment. It is a standardized and validated depression screening tool.
A depression screening tool.
It is not an anxiety screening tool.
That distinction caught my attention while watching the Clancy trial because postpartum anxiety was part of her clinical presentation.
Reddington also questioned the psychiatrist about the Edinburgh Postnatal Depression Scale (EPDS), a standardized and validated 10-question screening instrument developed specifically for use during pregnancy and the postpartum period.
HER PSYCHIATRIST NEVER heard of it and testified that she did not use the EPDS.
That doesn’t automatically mean the care was wrong. The PHQ-9 itself is a legitimate screening instrument, and no questionnaire replaces a comprehensive psychiatric evaluation….
But it raises a larger question for me:
When providers are offering psychiatric care virtually, especially to someone presenting with significant postpartum anxiety, depression or suicidal thoughts, shouldn’t the limitations of the screen make comprehensive risk assessment even more important?
I have tried virtual talk therapy myself. After a couple of sessions, I noticed my therapist becoming distracted, possibly texting, with her grandson playing guitar in the background. I did enjoy the cat walking across the screen, though.
I digress.
Another theme from this trial that I cannot stop thinking about is the discussion surrounding suicidal thoughts and whether someone was considered an emergency because they did or did not have a specific plan.
A suicide assessment is more nuanced than a single question:
“Do you have a plan?”
Having a plan certainly matters. But so does intent, access to means, previous attempts, escalating symptoms, psychiatric history, protective factors, medication changes, agitation, hopelessness, RISK FACTORS?
Telehealth can be an extraordinary access point. It can connect people with clinicians when geography, transportation, childcare, staffing shortages or countless other barriers might otherwise leave them with nothing.
But sometimes an access point needs to become a triage point.
Please don’t interpret any of this as me assigning blame to one individual. These are questions and thoughts I have had while watching this case unfold.
As both a mother and a healthcare provider, I have tremendous empathy for everyone affected by this tragedy, most especially three beautiful children who were its ultimate victims.
I will continue following along with the rest of the online “TikTok jurors.”
But beyond whatever verdict ultimately comes from this courtroom, I hope this case forces a much larger conversation:
How do we make mental healthcare more accessible without allowing convenience to replace comprehensive care?
Because access matters.
And so does knowing when a screen is no longer enough….
The first time I resigned from ER nursing was during the COVID pandemic.
However, it wasn’t because of the bipolar hellfire that was emergency nursing during COVID. It was because I had finally met all the requirements to become an FNP.
I punched out on 12/11/2020 and started my first FNP position on 1/4/2021.
To describe what the years, months, and days between then and today have been like would be difficult to put into words.
Instead, imagine an abstract painting.
Harsh colors. A few smooth lines, but mostly jagged ones. Splashes of literal blood, sweat, and lots of tears.
Not tears of joy.
And right when I felt like I was about to drown in the dark oceans of this career path, another chance would find me.
Still, when the colors of being an FNP turned gray, I pivoted back to ER nursing.
Why not pivot back to something that was what and who I had identified as for so long?
Why not get back on the ol’ bike?
Well, I did.
And I have no regrets.
Nursing invited me back as if I were returning home….. to the controlled chaos I knew so well.
After some time, though, I recognized that I just wasn’t wired for the chaos the way I once was.
I still enjoyed the hustle. The fast pace. The camaraderie – which I LOVE.
(I’m such a nurse.)
But I also knew I had to find an FNP job that fit.
So I tried many on for size: outpatient, hospitalist, veteran disability exams…
But I still couldn’t give up ER nursing.
People often describe emergency nursing, somewhat unoriginally, as being “in your blood.”
Maybe it is.
So I went per diem.
And for a while, it was perfect.
I could still show up for my team – and for myself – but on my own terms. If I had a bad shift, I had plenty of time to recover.
And honestly, I didn’t often have bad shifts.
RMC ER is a special place.
Some of the kindest people I have ever known work there. Every hospital has a culture, and I can personally say the ER culture there is gold. It is increasingly rare to find that small community ER feeling in the era of giant corporate mergers and the relentless pace of New Jersey healthcare.
So why did I resign today?
Space.
With a new hard requirement that per-diem staff work one weekend every month, I started to feel that pressure again.
Paint splashing onto that canvas again.
I need space.
Weekends become precious when you work full time. Sheesh, I can barely maintain my house and yard while finding room for hobbies, self-care, travel, the people I love… and sometimes doing absolutely nothing.
And doing absolutely nothing deserves space, too.
The requirement to give up one weekend every month was simply the wind that finally blew me off the cliff.
The brushstroke that signed the canvas.
The recognition that NOT ONLY am I no longer wired for chaos…..
I have been rewired to require more space.
Maybe resigning from nursing again doesn’t mean I’ve rejected nursing.
Maybe it means I finally understand what all those years of nursing gave me.
I don’t have to keep clocking into an ER to prove that I am a nurse.
Those years are already in me.
The instincts. The stories. The people. The blood. The sweat. The tears. The dark humor. The camaraderie. The ability to walk into controlled chaos and somehow know where I belong.
I still pick up the occasional ER nursing shift to maintain my per-diem status for funzies. Well, fun is probably an overstatement these days, but I genuinely enjoy the people I work with. The emergency department sits in one of the most charming waterfront towns in New Jersey, and after working in several hospitals over the past two decades, I’ve learned that every ER develops its own culture. That culture often reflects the community it serves.
One thing, however, is universal: patients struggling with opioid dependence or seeking opioids can be found in every emergency department.
Early in my career, these encounters frustrated me. Now they mostly make me sad. What kind of life is it when your days revolve around returning to the same emergency department, hoping that this time someone will order morphine, or, as many patients have phrased it over the years, “the one that starts with a D”….
Over the years, I’ve also watched emergency medicine evolve. Providers have become much more thoughtful about opioid prescribing and far more comfortable setting boundaries. Yet consistency matters. If even ONE provider repeatedly reinforces the behavior by prescribing opioids when they are not clinically indicated, patients quickly learn who is most likely to say yes and often return asking for that person by name….
One evening, EMS transported in a young man via stretcher and immediately recognized that I was an unfamiliar face. The EMT as well as several experienced nurses quietly prepared me of what I might be walking into. He was well known to the department. He lived nearby, frequently requested specific providers, was known to name drop a specific hospital leader, and on previous visits had become loud and aggressive enough to require security.
When I introduced myself, he barely opened his eyes. Curled onto his left side, clutching an emesis bag, he described a long and complicated medical history involving persistent abdominal pain and multiple gastrointestinal and vascular evaluations. He explained that specialists had sent him from one office to another without answers. His frustration seemed genuine.
His chart revealed repeated emergency department visits over the preceding weeks. Each visit had included complete work-up with repeat labs and CT scans of the abdomen and pelvis. Again and again, the results were reassuring. No acute surgical process. No obstruction. No perforation. No explanation for the severity of his symptoms.
As I reviewed his imaging history, I couldn’t help but wonder whether anyone had ever talked with him about cumulative radiation exposure. Repeating CT scans can absolutely be necessary, but they are not without consequence. The difficult question for many ER providers isn’t simply whether to order another scan. It is whether we could safely avoid one without overlooking the rare visit when a familiar patient truly has developed a new and significant pathology… you remember the story of the boy who called wolf.
Cases like this remind me just how difficult emergency medicine can be. Deciding not to order another CT scan is often much harder than ordering one. We constantly balance the possibility of missing an evolving, life-threatening condition against the very real harms of repeated imaging, unnecessary radiation exposure, incidental findings, and low-value care.
I was proud of the physician assistant caring for this patient. From the outset, expectations were set respectfully but clearly. Opioids would not be prescribed. His vital signs were stable, labs were reassuring, and he had undergone another CT scan just three days earlier without acute findings. Based on the available clinical evidence, there was no indication to repeat the imaging and again expose this young man of more radiation that will put him at higher and higher risk of developing cancer!
The response was predictable. His volume increased with profanities, threats, and name dropping. Security was called once again not because we had failed to provide care, but because the discharge had become verbally abusive. He was again encouraged to continue following with his specialists and to establish care with pain management, where chronic pain can be evaluated and treated in a setting designed for ongoing management rather than emergency stabilization.
As I reflected on the encounter, one thought lingered: perhaps he returned because of inconsistency. On a previous visit, another provider had prescribed morphine. This visit was different. In healthcare, mixed messages can unintentionally reinforce repeated emergency department utilization, making future encounters even more difficult for everyone involved.
It’s tough. Clinician impressions of “drug-seeking behavior” may lead to bias and may actually represent undertreated pain, opioid withdrawal, or another unmet medical need. Patients DO deserve compassionate, evidence-based assessments…not assumptions..
At the same time, compassion does not mean abandoning clinical judgment. Emergency clinicians should avoid allowing assumptions about drug-seeking behavior to replace thoughtful decision-making. Every patient deserves to have their pain acknowledged and an appropriate evaluation performed.
The challenge is balancing the risk of missing significant pathology when repeated presentations are dismissed with the harms of unnecessary CT imaging and cumulative radiation exposure. Sometimes the hardest decision in emergency medicine isn’t deciding what to do. It’s deciding what notto do…
That decision isn’t always easy. The fear of missing a diagnosis – and the potential liability that follows – can keep providers awake at night. Defensive medicine, or as we call it “CYA” (cover your ass) medicine is real, and ordering “just one more CT” is often the path of least resistance…
But this night, the right decision wasn’t the easy decision.
As he walked out of the emergency department yelling, cursing, and threatening us with yet another name drop, I couldn’t help but think…
