MedStar Health Blog

As a nurse at MedStar Washington Hospital Center for more than two decades, I have always known that our nursing team is among the finest, anywhere. Witnessing their work during the COVID-19 pandemic only served to reinforce my heartfelt appreciation for every one of them.

Our nurses are the bravest, most thoughtful, most compassionate, brightest and most talented I’ve seen in my career. They continually go the extra mile in their work with our patients—as well as with each other. Words cannot adequately describe their sense of professionalism, camaraderie, empathy and kindness.

I’ve known this for a long time—it’s part of the reason I was inspired to become Chief Nursing Officer. I saw it nearly 20 years ago, when our nursing team rallied after the Pentagon was attacked on September 11^th. At the time, I was 39 weeks pregnant with my daughter. That morning specifically, I did not feel well and had decided to take a sick day.

But then I saw the news. I felt like it was my obligation and duty to get to the Hospital Center immediately, so I jumped into my scrubs and raced there.

I didn’t regret the decision: it was inspiring to witness the commitment and solidarity of my colleagues on that monumentally tragic day. Every one of us felt compelled to take action—assuring that patients and colleagues were cared for throughout that traumatic and emotional week.

The Challenge of a Pandemic

But the challenge of the COVID-19 pandemic has proven even more intense. In the face of this new health emergency and despite widespread initial uncertainty about a completely new and frightening virus, our nursing team rallied again to provide exceptional care to the community. Going the extra mile to assure a patient’s well-being is what nurses do every day.

Throughout the long struggle against the coronavirus, our nurses have been amazing. They arrived right on schedule every day to care for very sick patients struggling with an unfamiliar and frequently deadly disease. And they did so despite their own concerns of potentially bringing the virus home to kids, a spouse, and/or elderly parents.

I was so humbled and inspired to witness that dedication—and appreciated the incredible opportunity to serve as chief nurse at such a remarkable time.

Until COVID-19, I’m not sure the community at large—or even our own families—truly comprehended the expertise of our nurses. But during the pandemic, it was heartwarming to see the community acknowledge their courage and resilience and to give them the recognition they deserve as invaluable frontline healthcare professionals. The supportive lawn signs and banners, the expressions of gratitude, and the gifts of food were welcome encouragement for the nurses who had to care for patients while family members stayed safe at home.

What our team did was beyond extraordinary. And thankfully, with the experience gained by our medical and nursing teams in the early phase of COVID-19, and now with the success of virus treatments and the new vaccines, we’re a lot better at managing this disease.

(Incidentally, if you really want to show your support for nurses and other healthcare workers, be sure to get your COVID-19 vaccine!)

Ready for the Challenge

As clinicians at the biggest hospital in the Nation’s Capital, our teams spend significant time training and preparing for different disasters. We have always maintained an intense focus on emergency preparedness: we drill regularly to ensure we’re ready for potential disasters, mass casualties, evacuations—any scenario that might threaten the health of our community. I saw that level of preparedness prove invaluable when COVID-19 began to spread.

Today’s MedStar Washington Hospital Center nurses are just as eager to support their colleagues in a crisis as my colleagues and I were on 9/11. As the pandemic worsened, members of our team would fill in for each other if there was a need. Nurses who weren’t needed because elective surgeries were cancelled helped in the ICUs as part of the COVID teams. Many of us in management worked 15-16 hour days, especially in the beginning, so we could support our nurses and help where needed.

It was our responsibility to ensure our nurses had all the necessary resources, particularly personal protective equipment, or PPE—the masks, gowns, and other gear that quickly became in short supply across the country. The protocols to provide COVID-19 treatment and protect caregivers changed frequently, sometimes daily. We had to be nimble, adapt quickly, and communicate clearly and completely.

Our nurses really showed initiative in solving problems and introducing efficiencies. One of our nursing units, for example, realized they could streamline patient care and preserve PPE simply by using walkie-talkies and whiteboards right in the patients’ rooms to communicate with other members of the team about patient care, saving the time needed to leave the room and discuss elsewhere and avoiding the need to repeatedly discard critical PPE.

I have dozens of stories of the heroism and compassion I’ve seen from our nurses. For example:

• We helped a young mother infected with COVID to deliver her infant. At the time, the infant’s father was out of the country and the illness had caught the little family unprepared. When dad returned, mom was improving, but the baby was still receiving care in the neonatal intensive care unit (NICU). The NICU team delighted the parents by throwing them a baby shower.

This thoughtfulness and generosity toward patients that our nurses have known just a short time is another reason I’m so proud to be associated with our team.

Professional Recognition

Crises like 9/11 and the COVID-19 pandemic shine a spotlight on the caliber of our nursing team. It validates the excellence that has helped our Hospital Center nurses earn a number of important distinctions and designations:

• Our nursing team is well prepared, both academically and clinically: 86 percent of our nurses hold bachelor’s degrees, exceeding the national standard of 80 percent. Most of our nurse managers have master’s degrees, and some are working toward doctorates as well.
• Our robust commitment to professional and educational development ensures that our nurses have the tools, training, and other resources to do their very best. Our development and practice teams work diligently to carefully and thoroughly prepare each nurse regarding all new or changing clinical practice guidelines, therapies, and equipment.
• Not surprisingly, our nursing program has achieved several distinguished national awards and designations, including:
  • Pathway to Excellence® designation by The American Nurses Credentialing Center, a distinction awarded to only 152 hospitals in the country
  • A Beacon Award for Excellence (Silver) from the American Association of Critical-Care Nurses
  • A PRISM Award® from the Academy of Medical Surgical Nurses
  • Exemplar Status Recognition—Nurses Improving Care for Healthsystem Elders (NICHE)
  • Baby-Friendly® designation from Baby-Friendly USA
  • Accreditation of our Nurse Residency Program by the Commission on Collegiate Nursing Education

Members of our nursing team have also been honored locally in the Washington Post and Washingtonian Magazine, praising their excellent work.

Resilience for Tomorrow

Throughout the pandemic, we’ve definitely realized how resilient we are! We learned just how adaptable we can be. We know we can move quickly to embrace new protocols and shift resources to meet demand.

We continue to embrace the highest standards of professionalism and clinical care for our patients. And we remain vigilant that, like patients, we must help our entire team to stay healthy and grounded themselves during a crisis, via internal support programs.

Whether you call it fate or circumstance, 2020 was designated the Year of the Nurse by the World Health Organization, and I feel that the Washington, D.C., community is privileged to have our amazing group of nurses at MedStar Washington Hospital Center available for their care.

I believe I am doing the work I was intended to do, placed here to lead this phenomenal team, to support them, to advocate for them and do everything in my power to help them be their best, second to none. It’s a huge job, I’m humbled and grateful to do it…and I would not want to do anything else.

Editor’s Note: The photo of Tonya used in this piece was taken prior to the COVID-19 pandemic.

In 2020, cancer diagnoses plummeted by 50%, as many people delayed routine physicals and cancer screenings that have been proven to save lives, according to the National Cancer Institute. For Steffanie Sheppard, a routine mammogram saved her life and she hopes her story will encourage others to stop delaying these life-saving screenings.

“It was truly gratifying to be able to induce her remission without the toxicity of traditional chemotherapy,” said Steffanie’s oncologist Eric Rubenstein, MD, medical director of cancer services at MedStar Southern Maryland. “I also felt grateful to have had the technology to diagnose her cancer remotely and to have the resources of the MedStar Georgetown Cancer Institute to arrange care with the clinicians from all the disciplines needed to direct her treatment in the best possible way. Most importantly, I felt fortunate to be graced by Steffanie’s lively, transparent, and joyful spirit. Her attitude and outlook definitely helped us to succeed.”

Now, Steffanie’s encouraging all women to not delay their regular breast cancer screenings and check-ups. “It’s really important that women take care of their bodies and know the signs and symptoms of their bodies. When they don’t have the answers, go get the answers.”

Regular cancer screenings increase your chance of early detection and a cure.

Cancer screenings are critical to finding and diagnosing cancer early when it is more easily treated. Amidst the COVID-19 pandemic, many people canceled or delayed scheduling important screenings for breast cancer, colon cancer, lung cancer, and others. As a result, oncologists predict an increase in mortality rates from cancer in the next decade, as many people who have cancer may not be diagnosed until a later stage when it’s harder to treat and less likely to be cured.

During a cancer screening, a doctor uses advanced imaging to evaluate certain parts of the body. A mammogram, for example, takes a detailed X-ray image of the breasts, allowing cancer experts to detect breast cancer long before it can be felt. This early detection is your best chance of survival if you are diagnosed with breast cancer.

Similarly, lung cancer screening tests can find lung nodules before lung cancer symptoms appear. While lung nodules are often harmless, they can grow into lung cancer. If they’re found during a screening, your doctor will recommend follow-up testing and surveillance to ensure they don’t develop into cancer. If they do, you can rest assured that you’ll have more treatment options than if you waited to seek a lung cancer diagnosis until after it spread to other parts of the body. In fact, people who are diagnosed with early-stage lung cancer experience a 27 to 61 percent five-year survival rate, depending on the type of lung cancer. In contrast, once lung cancer has spread to both lungs or surrounding organs in later stages, the five-year survival rate is only 3 to 6 percent, according to the American Cancer Society.

During a colonoscopy, doctors use a flexible tube attached to a small camera to search for and remove abnormal growths in the colon called polyps. Polyps aren’t cancerous but when left in the colon, some types of polyps can develop into cancerous tumors. Removing any polyps during a screening before they have a chance to turn into cancer eliminates your risk of colon cancer. Because doctors can remove any signs of polyps during the screening test, you can leave the appointment reassured that you won’t have to come back for an additional procedure until your next screening.

When to start cancer screenings.

It’s important to start cancer screenings early before you notice any signs or symptoms of cancer. Your primary care provider can recommend when to start certain types of screenings, depending on your risk factors or family history. If you don’t meet screening criteria, it’s important to continue getting regular physical exams from your primary care provider, even during the pandemic.

Many screenings are free or low-cost and only take minutes of your time. That’s time well spent if it means adding decades back to your life. Just ask Steffanie.

Melanin is the pigment that shades our skin and protects it from harmful radiation in sunlight. Because it is naturally dark, melanin absorbs light, including much of the ultraviolet energy in sunlight. But it can only absorb so much—when it reaches capacity, the skin begins to burn.

What Causes Melanoma?

Melanoma occurs when melanocytes, the skin cells that produce melanin, grow in an unchecked manner. These can appear as new and unusual dark growths or as a change in an existing mole.

Most cases of melanoma can be attributed to sun exposure or ultraviolet light from artificial sources—tanning beds or light therapy for certain skin conditions. Repeated exposure to ultraviolet light can scramble the DNA in our skin’s pigment cells, leading to cancerous growths.

It’s important to remember that this skin cancer can occur in patients of all racial and ethnic backgrounds. Melanomas can even occur in areas with limited exposure to the sun, like the palms of hands, soles of the feet, beneath fingernails, in the mouth, and even within the intestines or vagina. It can even occur at the back of the eye! Because it’s not purely due to sun exposure, you want to pay attention to any new, changing, itching, or bleeding dark marks.

Know Your Risk

Patients with fair skin, red hair, and blue or green eyes who have a history of repeated sunburns or tanning bed use, particularly in their youth, are at significantly increased risk of developing melanomas. It’s especially vital for parents to protect their children—UV damage is especially harmful in the childhood years and impacts skin cancer development later in life.

A deeper skin complexion doesn’t render you immune to melanoma, however. Continuous exposure to ultraviolet light, as well as random genetic mutations, may still spur cells to become cancerous. So regardless of skin type or skin tone, it’s important for everyone to protect themselves.

There may also be a predisposition within some families for the development of melanomas. The risk of contracting melanoma skin cancer may be higher in people whose parent or sibling had melanoma, and may also be associated with other genetic syndromes that predispose individuals to developing cancers. In addition, we know that people with many moles have an increased risk of developing melanoma.

Finally, melanocytes can also be affected by hormonal changes. If you notice a changing or bleeding mole during pregnancy, consider having the lesion checked for malignancy.

The Importance of Sunscreen

Many cases of melanoma skin cancer are preventable, simply by using common sense—and that means avoiding the sun and applying sunscreen.

Two kinds of ultraviolet light are present in sunlight: UVA and UVB. In sunscreen products, sun protection factor (SPF) ratings target UVB rays, the cause of sunburn. UVA rays are less likely to burn us, and more likely to cause a suntan—but, like UVB, UVA can also cause DNA changes within our skin cells.

When you purchase sunscreen, it’s important to look for the words “broad spectrum” on the label, to assure that the product blocks both UVA and UVB rays.

What do those SPF numbers mean on a sunscreen product? Sunscreens are rated according to how much sun they block. To determine the SPF number, product developers consider how many seconds a patch of skin with the sunscreen applied can remain in the sun before it begins to turn slightly red (say, 300 seconds). That number is divided by the number of seconds it takes for the skin to burn slightly with no sunscreen applied (say 10 seconds). So, in this scenario, 300 is divided by 10, for an SPF of 30.

Of course, any use of sunscreen is better than none—but users must be sure to apply the product correctly! We have very reliable data that shows most people apply only 1/4 of the sunscreen needed to protect their skin…and using too little can significantly decrease the product’s effectiveness. This particularly applies to spray products, which don’t cover as well as lotions.

In a laboratory setting, SPF 100 isn’t much more effective at blocking UVA/UVB than SPF 50, but in real-life application studies, patients have better outcomes when using the higher SPF. I recommend that my patients use at least SPF 50, because it offers a better margin of protection for people who don’t apply enough.

Also, don’t forget to reapply regularly, according to directions—sunscreen loses its effectiveness as it’s absorbed or broken down by skin oils, or as we sweat and swim.

The Best Type of Sunscreen

My patients often ask me what’s the best product to protect skin from the sun. The best sunscreen is the one you’ll wear!

But, when it comes to greatest effectiveness, dermatologists favor products that contain zinc oxide. Dense, white, and nearly opaque, it stays put and reflects a large portion of the sun’s rays. For optimum protection, choose a sunscreen with zinc oxide as its active ingredient.

Besides applying sunscreen, wearing a hat with a wide brim can protect the head and neck. Long sleeves safeguard the arms. Sunglasses shield eyes and eyelids but be sure the glasses are UV-rated. And staying in the shade offers better full-body protection.

These steps are important regardless of season. Even in winter—playing in the snow or on the ski slopes—you need sunscreen. UV light reflects off snow so you can still get a sunburn in the winter!

Signs of Skin Cancer

Although melanoma is less common than other types of skin cancer, it can be aggressive and ultimately much more dangerous. Of the 200,000 Americans diagnosed with melanoma each year, as many as 7,000 don’t survive.

But caught early, melanoma is actually quite treatable.

I recommend that patients take note of any existing spots on their skin, then check regularly to take note of anything new that develops. If you notice any “ugly ducklings” on your skin—that is, spots or moles that seem out of the ordinary—remember your ABCDEs:

• A is for Asymmetry. Is a portion of the spot different from the rest of it?
• B is for Border. Does it have an irregular, scalloped, or poorly defined border?
• C is for Color. Is it varied in color, possibly including multiple shades (tan, brown or black, or areas of white, red, or blue)?
• D is for Diameter. Keep a sharp eye out, as melanomas can start very small. Seek attention from a dermatologist for any spot larger than a pencil eraser.
• E is for Evolving. Besides looking different from other spots on your body, has the spot changed size, shape, or color over time?

Any one of these indicators could be a good reason to reach out to your family doctor or dermatologist for guidance. Evolving spots are among the most important warning signs—and, for that reason, be sure to observe carefully…but not too frequently. If you study the spot daily, you may actually be less likely to notice a change. Assess spots no more than once per month.

The scalp is particularly prone to suspicious spots, especially in older men with thinning hair. Yet patients often neglect to examine this area. Ask your hair stylist or barber to report any changes to your scalp. And be vigilant about new moles that appear after age 40. New growths are less common at this age and should be investigated.

Diagnosis and Treatment

Most of us can tell if a spot on our skin seems out of the ordinary. When one of my patients reports a suspicious spot, more often than not, the concern is justified.

To understand what we are dealing with, we remove suspicious cells in an outpatient procedure (performed with local anesthesia to numb the area) and submit the cells for lab analysis.  Biopsy is the most reliable way for us to verify if cells are cancerous and enables us to determine the stage—or depth and spread—of the melanoma.

The easiest-to-treat melanomas are shallow, limited to the uppermost layer of skin. More concerning lesions are those that penetrate the skin more deeply. The most serious are those that have spread into the lymph nodes, where they create a potentially life-threatening situation.

To treat melanoma, we typically begin with surgery, removing the lesion and a margin around it to eliminate as much cancerous tissue as possible. In early-stage disease, surgery is often enough.

If we become concerned about systemic involvement, we can add immunotherapy, using a class of drugs known as immune checkpoint inhibitors that direct the body’s natural defenses to target cancerous cells.

Why Choose Our Team

Here at MedStar Washington Hospital Center, the Dermatology team works very closely with medical oncology, radiation oncology, and other experts across MedStar Washington with advanced knowledge and experience at treating cancer. Together, this multidisciplinary team is able to do amazing things for our patients.

We’re also part of the multi-disciplinary tumor board at the Georgetown Lombardi Comprehensive Cancer Center. In order to develop the best possible plan for each of our skin cancer patients, every case receives full consideration by the board members, who represent many specialties. The team has access to the most current knowledge and clinical trials in our fields, and many of our team members are also engaged in research.

So, if you notice a strange spot or growth on your skin, remember—it’s never too soon to reach out to your primary care physician or dermatologist. I can’t emphasize enough: if you see something out of the ordinary, act quickly. Like other cancers, the sooner we diagnose melanoma and other skin cancers, the easier it is to treat them effectively.

Collaborative research from MedStar Diabetes Institute, MedStar Health Research Institute, and the Georgetown University Department of Psychiatry examined the feasibility of co-delivering a mental health intervention with an evidence-based type 2 diabetes (T2DM) boot camp care management program. The research team also examined the preliminary impact of participation on symptom scores for depression and anxiety and A1C.

In the United States, over half of the adults living with type 2 diabetes mellitus have at least 1 other chronic physical or mental health condition. Depression is one of the most prevalent comorbities of type 2 diabetes. To improve type 2 diabetes outcomes, it is important to diagnose and treat both diabetes and depression/anxiety when patients present with both.

The study was a 12-week pilot intervention with African American adults with uncontrolled type 2 diabetes and moderate depression and/or anxiety, who were participating in an existing Diabetes Boot Camp program. The participants were then enrolled in the diabetes and mental health co-management (DM-MH) pilot study. This program was offered via a combination of 2 initial on-site visits and subsequent remote telehealth visits using telephone, text, or email. The mental health intervention component involved 6 structured sessions with a mental health interventionist, who was also trained to recognize worsening mental health symptoms, identify and evaluate safety concerns, seek consultation, and make appropriate referrals. The structured mental health component targeted depression and/or anxiety symptoms based on the PHQ-9 and GAD-7 baseline scores. Participants were assessed at baseline and 90 days.

The study results showed significant improvements in mental health outcomes, as measured by a reduction in Patient Health Questionnaire − 9 scores of 2.4 ± 2.9 (P = .01) and in Generalized Anxiety Disorder − 7 scores of 2.3 ± 1.9 (P = .001). The pre-post intervention mean A1C improved by 3.4 ± 2.1units from 12% ± 1.4% to 8.5% ± 1.7% (P < .001).

The study team concluded that the data supports the feasibility of delivering a diabetes and mental health co-management intervention using a combination of in-person and telemedicine visits to engage adults with T2DM and coexisting moderate depression and/or anxiety. Further research with a control group and a larger sample size could show potential in improving glycemic and mental health outcomes in patients with T2DM via co-management of their T2DM and moderate anxiety and/or depression.

The research team included Michelle F. Magee, MD, MBBCh, BAO, LRCPSI from MedStar Diabetes Institute, MedStar Health Research Institute, and the Georgetown University School of Medicine; Carine M. Nassar, RD, MS from MedStar Diabetes Institute and MedStar Health Research Institute; Mihriye Mete from MedStar Health Research Institute and Georgetown University Department of Psychiatry; and Stacey I. Kaltman, PhD from Georgetown University Department of Psychiatry.

Funding for the study was provided by an intramural grant from the MedStar Health Research Institute.

Congratulations to all MedStar researchers who had articles published in April 2021. The selected articles and link to PubMed provided below represent the body of work completed by MedStar Health investigators, physicians, and associates and published in peer-reviewed journals last month. The list is compiled from PubMed for any author using “MedStar” in the author affiliation. Congratulations to this month’s authors. We look forward to seeing your future research

View the full list of publications on PubMed.gov here.

Selected research:

1. The Impact of Smoking on Early Postoperative Complications in Hand Surgery
   Journal of Hand Surgery, 2021.DOI: 10.1016/j.jhsa.2020.07.014
   Cho BH, Aziz KT, Giladi AM. 

    

2. Comparison of Characteristics and Outcomes of Patients With Acute Myocardial Infarction With Versus Without Coronarvirus-19
   The American Journal of Cardiology, 2021. DOI: 10.1016/j.amjcard.2020.12.059
   Case BC, Yerasi C, Forrestal BJ, Shea C, Rappaport H, Medranda GA, Zhang C, Satler LF, Ben-Dor I, Hashim H, Rogers T, Waksman R.

3. Providing Care for Caregivers During COVID-19
   American Journal of Nursing, 2021. DOI: 10.1097/01.NAJ.0000749752.80198.c0
   Morales C, Brown MM.

4. Does Scalp Cooling Have the Same Efficacy in Black Patients Receiving Chemotherapy for Breast Cancer?
   The Oncologist, 2021. DOI: 10.1002/onco.13690
   Dilawari A, Gallagher C, Alintah P, Chitalia A, Tiwari S, Paxman R, Adams-Campbell L, Dash C.

    

5. Representation Matters: An Assessment of Diversity in Current Major Textbooks on Burn Care.
   Journal of Burn Care and Research, 2021. DOI: 10.1093/jbcr/irab066 
   Shivega WG, McLawhorn MM, Tejiram S, Travis TE, Shupp JW, Johnson LS.