Relief option for chronic pain; rewards of nursing: Upstate Medical University's HealthLink on Air for Sunday, Feb. 5, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a pain management specialist discusses how neuromodulators are being used to relieve pain.

Vandana Sharma, MD: ... It's more important for us to know if it made a change in your quality of life. And if that happens, and you think it was useful to you, then we go ahead and do the permanent placement. We first remove the temporary leads, give the body rest for a few weeks, and then go ahead with the permanent placement. ...

Host Amber Smith: And a veteran nurse shares why he loves his nursing career.

Nurse Scott Jessie: ... I do think you have to definitely be a committed and caring person. I think everybody who gets into nursing at the base level likes to work with people, likes to help people. That's why they do it. ...

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, chief nursing officer Scott Jessie tells why he chose to be a nurse and what makes the profession so rewarding. But first, we'll learn how neuromodulators are being used to relieve patients of severe pain.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Chronic pain can be frustrating to live with and a challenge to treat effectively. Today, I'm talking about one potential solution called neuromodulation with Dr. Vandana Sharma. She's an anesthesiologist and the director of Pain Management Services at Upstate.

Welcome back to "HealthLink on Air," Dr. Sharma.

Vandana Sharma, MD: Thank you, Amber. Thank you for having me on air.

Host Amber Smith: I understand a neurosurgeon implanted the first device designed to relieve intractable pain more than 50 years ago. It's more recently that these devices have proven themselves. What can you tell us about neuromodulators?

Vandana Sharma, MD: I will go back to the very basics and talk about neuromodulation. In very simple terms, neuromodulation is a way to regulate the nervous system. This is what it technically means when we use that in the sense of chronic pain, as we all know that chronic pain is carried by nerve fibers that go to and from the spinal cord.

So neuromodulation is basically using electrical signals to modulate or regulate the response of the body so that the chronic pain can be modified with more pleasant stimulation.

Or the pain can be masked in a way that it doesn't bother the patients as much as it would without neuromodulation.

Now, we know that opioids or pain medications could do that, but this is a better form of pain control because it is done in a non-pharmacologic way.

So we are just using electrical signals to their best value and help modulate the pain signals.

Host Amber Smith: Is the neuromodulation used on a temporary basis, or is it a permanent thing? In other words, if you start taking over for the nerves in a particular area, is that forever?

Vandana Sharma, MD: It can be done both ways, actually.

Neuromodulation can be done at three levels.

It could be done at spinal cord level, what we call spinal cord stimulators.

It can be done at the level of peripheral nerves, and it's termed as peripheral nerve stimulation.

And occasionally, neurosurgeons or pain physicians might also modulate at the level of dorsal root ganglion, which is, again, a part of the central nervous system as it comes out from the spinal cord, and these are called DRG stimulators, or dorsal root ganglion stimulators.

So, to answer your question whether it's temporary or permanent, it starts out as a temporary trial. That's where we actually place the percutaneous (passing through the skin) leads. These are cylindrical plastic leads that are placed around the spinal cord. I would talk more about spinal cord stimulation here, but the similar things can be done for peripheral nerve or for DRG stimulation as well.

And these leads are placed first temporarily. These are percutaneous leads, and they're externally connected to a generator, and then the rep could actually stimulate the generator and see whether it covers the area of pain.

It's temporary left in the patient's body for about five to seven days. And during this time, the patients are made to do the routine activities, except for bending or twisting, so that the leads do not migrate. And we want to evaluate them very closely during this time: how much pain reduction they get or what are the things they couldn't do before that they could do while the neuromodulation is in effect.

If the patients report a good, sustainable pain relief, which is at least 50%, and again, 50% may make a meaningful change in somebody's life and sometimes may not make a meaningful change in somebody's life.

So, it's more important for us to know if it made a change in your quality of life. And if that happens, and you think it was useful to you, then we go ahead and do the permanent placement. We first remove the temporary leads, give the body rest for a few weeks, and then go ahead with the permanent placement.

And in that case, in addition to those leads, we also placed this pulse generator under the skin permanently.

Host Amber Smith: I see. Now you used the term DRG stimulation. What is that?

Vandana Sharma, MD: DRG stimulation, the full form is dorsal root ganglion stimulation. It is a fairly new form of neuromodulation, and in this, FDA (Food and Drug Administration) has only cleared very certain levels which can be modulated that way, just because of the complexity of the procedure and sometimes not very well tolerated.

So, spinal cord stimulation still remains one of the most widely used ways of neuromodulation.

Host Amber Smith: So which patients are candidates for spinal cord stimulators?

Vandana Sharma, MD: Basically any patients who have intractable neuropathic pain, and neuropathic pain means when it's originating from dysregulation of the nervous system in some part of the body.

The most common indication for placement of spinal cord stimulators is for failback surgery, which is, again, a loosely coined term for patients who undergo surgery for back pain or for neck pain, but in the end, the surgery does not relieve the pain, and they continue to have back pain and/or leg pain after the surgery.

So those are the patients that show most benefit from spinal cord stimulation.

Other than that, it can also be used for complex regional pain syndrome, which is also not very common, but a cause for severe neuropathic pain in arms or in legs. It's also used, very rarely, for peripheral neuropathic pain.

And actually, recently FDA cleared spinal cord stimulators for diabetic peripheral neuropathy, and we are using it, if in patients who have well-controlled diabetes, but the neuropathic pain bothers them the most, we could use neurostimulation for treatment of those patients as well.

Host Amber Smith: What does the stimulator, the piece that goes under the skin, what does that look like? And can you feel it or see it once it's implanted?

Vandana Sharma, MD: So there are two parts of what goes inside the body. One, as I mentioned, are the percutaneous leads. These leads are plastic cylindrical devices, and at the end of the tips of those leads are the contacts. These contacts are made of metal, and it's an inert metal, mostly platinum-based alloys. So these are the contacts that actually generate the electricity or stimulate the electric signals. the other end of this lead, two leads, is connected to a pulse generator, and that's the implantable pulse generator.

It's a thin disc, almost like a vanilla wafer thickness. And that can be implanted under the skin very next to the paraspinal (adjacent to the spine) area, so like almost four or five inches away from the midline. And in between, these leads are tunneled under the skin, so the patients do not feel the lead part of it, but they do feel the IPG (implantable pulse generator) part of that, which as I said is a thin metal device, and it's put in like almost a centimeter to 1.5 centimeters under the skin. So if they would want to touch it, yes, they could touch it, and feel it, but it's not something that would interfere with any kind of their functioning or even laying down on that side.

One more thing I would want to mention there is that when we are planning for a spinal cord stimulator placement, we always ask the patient about their sleeping patterns, like if they sleep on one side of the body versus the other, and having this thin plastic or metal thing under their skin, would that interfere there with their sleeping position in any way?

In that case, we would just put it in an area where patient would prefer it. So that discussion, all that about where to implant it, and what kind of stimulator they would need and all those, and we'll talk about that further as well. All this discussion happens beforehand.

Host Amber Smith: How long is it good for, or will it have to eventually be replaced or batteries changed or something?

Vandana Sharma, MD: That's a great question. And that's one discussion that I always make sure that I do before we select the patients for this kind of a procedure. There are two kinds of IPGs, rechargeable and non-rechargeable. The rechargeable ones are the newer ones, and they are made of lithium-ion batteries.

The patients have to, for a few hours in a week, they have to charge those batteries, and it definitely extends the battery life. it also depends how often you are using the spinal cord stimulation. Suppose you're using it for several hours during the day, so you know that the battery's going to be expended very soon, and that's where the rechargeable ones are better.

But even though they're rechargeable, they still have a certain battery life, and most companies say that it's anywhere between seven to 10 years. On the other hand, the more traditional ones were non-rechargeable ones. And once you placed them, they were good for about four to five years, and at the end of that period, you had to remove them and put the fresh IPG in with a new battery.

And again, it was dependent upon how much you were using and what settings you were using. So obviously if you're using it for longer time and stronger settings, the battery would run out sooner and the patient at some point, again, would need a surgery to replace it.

Host Amber Smith: You're listening to Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Vandana Sharma, the director of Pain Management Services at Upstate.

For patients who want to try a neuromodulator, is this something they can seek as a first therapy, or do doctors generally want them to try medications or surgery or physical therapy before they embark on a neuromodulator?

Vandana Sharma, MD: So, again, it depends upon what kind of pain syndromes you have, and sometimes we feel that acting faster is in the best interest of the patient. But again, I would not offer an invasive procedure as my first-line management right away. And I would want to try the non-invasive or more conservative management first as the patients arrive to our clinics.

We start out with pharmacologic physical therapy, and along with that, epidural injections or some kind of injections to help them with their pain, in the beginning. But after we have seen, and we quickly arrive to a decision, in their treatment plan, how they responded to both medications, therapy, as well as the injections.

If we see a great response from the injections and medications, then we move ahead and stay on that path. However, if we do not see a great response and we are seeing a rapidly progressing neuropathic pain, for example in complex regional pain syndrome, then it's best to start with neuromodulators early on rather than waiting and letting it become more complicated.

Host Amber Smith: I was interested by how you were explaining really they get kind of a trial period with this, to see whether it's going to help them, before it actually gets implanted. Do we know about the effectiveness of modern neuromodulators? Do most patients get some relief?

Vandana Sharma, MD: For the most part, patient selection is what matters the most.

If you have selected your patient very well, and if you have prepared them psychologically as well, like what to expect and how much pain relief you get out of that. Just as with any other therapy, like not just for chronic pain management, but for any other treatment plans. If the patients know exactly what to expect from the treatment and you chose it for the right indication, for the right kind of pain management, they work tremendously well, like really seriously well. But then, if you are falling out on any of these parameters, the chances of success go down. With all that said, sometimes there are complications related to the device itself.

For example, lead migration happens or lead fracture happens, and the device, which may be functioning in the beginning, may not function after that. In certain cases where we are not a hundred percent sure whether this is going to work or not, but we still feel that we have tried everything else, and this is one last resort that is left to help a patient, that's where our trial period helps us a lot, which is more like just placing two epidural leads, like you would get epidural catheter, but these are two of them and using a bigger bore needle. So it's more invasive than just placing an epidural catheter, but it is done in an outpatient setting, requiring some minimal to moderate sedation and some local anesthetic.

The patients could just arrive in an ambulatory surgery center and could get these leads placed, which stay in for five to seven days. And this gives them a good time to check whether this is a great treatment option for them or a useful treatment option for them, and, if not, then they can always decide not to go ahead with the permanent implantation.

Host Amber Smith: What are the devices made of, and do you ever see patients who have, their bodies have, like a reaction to the material?

Vandana Sharma, MD: Just like any other implantable material, there are chances of body reacting, like tissue reaction might happen. It's not very common though. Like in my own personal practice I have not seen that happening a whole lot.

But yes, there are case reports of that happening. The leads are mostly made up of plastic, but at the end, the contacts could be made of metal alloys. As I was saying, it's mostly platinum-based inert material that does not stimulate the tissue reaction.

IPG, on the other hand, again, is made of inert alloys, but they're metal.

More commonly than tissue reaction, what is seen is occasionally skin sensitivity at the site of the IPG implantation. I wouldn't say it's very common, but it can happen. And if it happens, it can be a very annoying complication from this, occasionally leading to explant (removal) of a nicely functioning device.

Host Amber Smith: What do patients need to know about how the surgery is done?

How do you tell them to prepare?

Vandana Sharma, MD: So, as I was referring to earlier, the initial part, which is the percutaneous lead trial, is not really a surgical part, where we are just using two needles to place the percutaneous wires at that point. However, the second part, where we are doing the permanent implantation, this is done under general anesthesia because it's at that point that we do not need the patient's input.

We have already trialed and tested the placement of these leads at a certain level, and patients have certified pain benefit out of that. So, our job is to just mimic what we did during the trial at this time, so patients can be put to sleep. And this is a little bit more uncomfortable part of it. That's why general anesthesia works the best.

We make two incisions, close to four to five centimeters. One is made right in the center, in the midline. And from there, the epidural needles are again placed, the same two needles as they were placed for the trial, but this time through the incision. And then the wires, the other ends of the wires that are coming out of the spinal canal, are tunneled under the skin, using a metal tunneler, and then connected to another incision, where the pulse generator is placed. And as I was saying earlier, this is about one to one and a half centimeters under the skin. It is nicely, joined and locked in place, the leads are anchored to the skin and underlying fascia, and that's when the device is ready to go.

Host Amber Smith: How long does that take?

Vandana Sharma, MD: It's about couple hours, I would say close to like two, two and a half hours.

Host Amber Smith: And is it done in a pain management office, or is this done in a hospital?

Vandana Sharma, MD: This procedure, for its infectious risk and the involvement of the placing a surgical incision and closure, we want to be as safe as possible, and that's why it's better to do this in an operating room. I have never done this procedure outside the operating room. Whether it's an ambulatory surgery center operating room, or the main hospital operating room, that is strategically the best place to do this.

Host Amber Smith: And how soon until the patient feels a difference?

Vandana Sharma, MD: There is some incisional pain that we anticipate, right after the procedure is done, which could stay for a few days, like two to three days to up to a week after the permanent implantation. But after that, the patients come in for a follow-up visit at our clinic. That's when the sutures are removed, and we check for any signs of infection or any complications at that point.

If everything is cleared at that point, then that's when the medical reps also come and meet the patients on the same visit, and they, start increasing the settings because in the very beginning, the settings are kept at a minimal to keep patients comfortable. And it's only at the post-operative visit when we start increasing the settings to make patients more comfortable. Sometimes it might take a few weeks for us to reach the final settings, and that's when the patients get the best benefit.

Host Amber Smith: Please stay tuned to Upstate's "HealthLink on Air." We'll be back after this short break.

Welcome back to Upstate's "HealthLink on Air." This is your host, Amber Smith, and my guest is Dr. Vandana Sharma. She's the director of Pain Management Services at Upstate, and we've been discussing neuromodulation.

I'd like to talk about what life is like with a neuromodulator after you've recovered from the surgery. How might life change for someone after they've recovered from the surgery?

Vandana Sharma, MD: So right in the very beginning, once either the trial leads or even the permanent leads are placed, we tell the patients not to bend or twist or do anything that would make the lead migrate, as I was telling you before that one of the commonest complications from this procedure is lead migration.

And that could also cause the device to fail. I mean, after all that the patients go through to get this placed, you do not want the leads to migrate from the initial spot. And that's why no strenuous activity is advised for first three to four weeks after the permanent implantation, and slowly the body starts creating fibrous tissue around those leads, so it's hard for them to move afterwards. But the first few weeks are when they could move the most, so no such activities like bending, twisting, lifting, heavy weights or any strenuous kind of activity like running or all that should be done in the beginning.

Apart from that, patients are also advised not to turn this on when they're driving because sometimes the leads are transmitting these electrical signals, and they could go on a setting that may take your attention off from the road onto this buzzing sensation that could happen in your back. So we do not advise patients to drive with the stimulator on.

If they are going to have any surgeries later on for any other reason, it's best to turn the device off because use of electrocautery during the surgery, especially if it's closer to the device, could cause permanent damage to either to the device or the leads that are going into the spinal cord. Almost like a cardiac pacemaker or a defibrillator, where you want to be very careful about the electrocautery that is used for the surgery. So those things might change some of the ways you would want to proceed.

Host Amber Smith: Does having a neuromodulator affect whether you can go swimming?

Vandana Sharma, MD: In the beginning, we would be advised not to do swimming for like few weeks. However, after that, there is no contraindication not to do any of those desired activities.

For example, some of these patients may still want to continue doing physical therapy, as it is a very important cornerstone of recovery from pain states, and we actively tell them to go ahead and do physical therapy afterwards.

Similarly, swimming is totally fine and should not be a restrictive thing.

Host Amber Smith: Will the device show up on a metal detector or an airport screening?

Vandana Sharma, MD: These patients should tell the authorities beforehand that they have a metal device in.

So there are two concerns.

One is whether it would show up or not, and second is going through those metal detectors. If they have a strong field, they might interfere with how the stimulator is working. So it's best to disclose that in the very beginning, before you actually go through that.

And secondly, you should turn it off. It's best to just turn them off so that there's no electrical signal being transmitted between the spinal cord and this IPG, and go through the metal detector as quickly as you can, as is feasible.

Host Amber Smith: Does someone with a neuromodulator, does that affect any other health conditions they may have, either positively or negatively?

Vandana Sharma, MD: As I very briefly referenced to cardiac pacemakers or AICDs (automated implantable cardioverter defibrillators), it's not a contraindication to have a neuromodulating device when a patient already has a pacemaker or a defibrillator in place, but it could interfere significantly with electrical signals that are going that way.

So anytime we are implanting the spinal cord stimulators, in these patients, we make sure that first they talk to their cardiologist. So the team that is managing the pacemaker or a defibrillator should be consulted first. They should make concrete plans on what would happen and how close would these leads be from the pacemaker leads, because the spinal cord stimulators could be placed anywhere in the thoracic spine or up in the cervical spine, and there could be a possible interference with the electrical signals going to the heart.

So that all has to be, like a multimodal or a multi-team, kind of a multi-specialty approach to ensure that it's safe to proceed with this procedure.

Host Amber Smith: Can someone with a neuromodulator safely take aspirin or ibuprofen for a headache or something?

Vandana Sharma, MD: Yes, yes they can. But at the same time, with the patients on anticoagulants, or blood thinners, they are at higher risk for developing spinal hematomas (swellings filled with blood) in the epidural space or in the spinal space.

So, we take extra precautions in those patients for stopping these medications before we even place the spinal cord stimulator device. Anyone afterwards, we tell them to be careful, and if there are any signs or symptoms that could suggest hematoma formation, they are told to go to ED (hospital emergency department) because this can be a catastrophic complication.

Host Amber Smith: Is there maintenance involved in keeping the neuromodulator in good working order?

Vandana Sharma, MD: That information, for the most part, is given to the patients by the reps as well. And most often what I mean by that is how often to charge it, how to charge it, how to keep your charger in the best possible shape, or even a remote-control device that helps you program or go up or down on the settings.

So all those things the patients are given very thorough instructions on those as soon as the device is implanted, and even further on, if they have any questions, concerns, these reps are available at a phone call away.

Host Amber Smith: Well, before we wrap up, Dr. Sharma, can you tell us about intrathecal pumps? .

Vandana Sharma, MD: Yes, absolutely. Intrathecal pumps are, instead of neuromodulation, they are actually directly depositing the opioid or any other form of pharmacological pain medications into the spinal canal directly. So when we take an opioid medication, or any pain medication for that matter, through the mouth or through the intravenous form, the medication has to be absorbed by the body, and then it goes to its receptors, and most of these receptors are present in the spinal cord.

From there they work, and also in the peripheral nervous system as well, but spinal cord is the major place where these medications act.

So the goal of doing an intrathecal pump is to place the medication very close to the targeted area. So a plastic catheter is placed in the spinal space, and just like a neuromodulating spinal cord stimulator, the other end of this plastic catheter is connected to a reservoir that's implanted under the skin. And this reservoir has to be filled with the pain medication every month, or depending upon how quickly the medication is being dispensed, it has to be periodically filled with the medication.

They have to come to a physician's office for that, and it continuously delivers the medication right into the spinal canal.

Host Amber Smith: So patients who qualify for a neuromodulation device, would they also be candidates for intrathecal pumps, and would they have to choose between one or the other?

Vandana Sharma, MD: Basically, the answer to this depends upon their etiology (cause) of pain.

Suppose the pain etiology is more neuropathic pain, where it's stemming from nervous system disorder, like, as I said, CRPS (complex regional pain syndrome) or failback surgical syndrome or any other neuropathies. Then neuromodulation would be the best treatment option for them. However, if we are seeing patients who are requiring opioids or other pain medications, for example, someone has spastic cerebral palsy and are requiring baclofen and require the medication to be put in close to the spinal cord at that level. Then, the intrathecal pumps would be used there.

Sometimes we see patients with both etiologies, where they have neuropathic pain and they have required opioids for a very long period of time, and you want to cut down on the amount that they would use. Then they may be candidate for both, but it's a very rare indication.

Host Amber Smith: So it sounds like this pain management is really individualized, and it's encouraging that there's a lot of options these days.

Vandana Sharma, MD: There are several options at this point, and as the technology is emerging, even talking about the spinal cord stimulators, in the last 10 years, there has been such a tremendous change in how the different programming options are available, different kinds of IPG, the battery options available, rechargeable versus chargeable. Their sensitivity to MRIs has changed so much. In the past, we couldn't do MRIs on the patients who had neuromodulators in place, but nowadays most of these companies are making spinal cord stimulators that are MRI compatible.

So patients have several different things to choose from, and talking about the pain treatments per se, there are several advances in the technology as well as in the pain treatment options to help and offer to the patients as they need it, based on what kind of pain syndrome they have.

Host Amber Smith: Well, Dr. Sharma, thank you so much for taking time to share this information with us. I appreciate it.

Vandana Sharma, MD: Thank you for having me. It's my pleasure.

Host Amber Smith: My guest has been anesthesiologist Vandana Sharma, the director of Pain Management Services at Upstate.

I'm Amber Smith, for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," what a nursing career might look like. From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Careers in nursing provide work that is meaningful and rewarding, and today, especially nurses are in high demand. Joining me for a look at the rewards of his career is Scott Jessie. He holds a master's degree in nursing from Upstate's College of Nursing, and he has more than 20 years experience in the health care field. Today, he's a member of hospital leadership, serving as Upstate's chief nursing officer. Welcome to "HealthLink on Air," Mr. Jessie.

Nurse Scott Jessie: Thank you, Amber, for having me; excited to have a conversation with you.

Host Amber Smith: Nurses really are at the heart of patient care. And I don't think the health care system could operate without them, but the importance of the role comes, at least potentially, with a lot of pressure. Does the profession naturally attract people who are good at working under pressure?

Nurse Scott Jessie: I think the profession attracts a really wide variety of people, and I think that's the beauty of the profession, honestly. There is a lot of pressure in some kinds of nursing, for sure. It can be very, very intense, and in other different types of nursing practice, maybe a little bit less so, and I think that gives a lot of different people options when they get into the career. I do think you have to definitely be a committed and caring person. I think everybody who gets into nursing at the base level likes to work with people, likes to help people.

That's why they do it. It is a such a difficult career, if you didn't like to do that, I don't think most people would last very long, to be honest. The pressure comes and the pressure goes; it depends where you work. The pandemic made the pressure relentless, honestly, for a lot of nurses for a long time. We're still in it, right? The last two years have been, professionally, the most challenging thing I have ever done. I daily make comments like "I never thought I would ask somebody to do that," "Oh, I'd never thought I'd make a plan to have to react to that." The pandemic brought forward what we all learn about in school, all health care providers learn a little bit about it in school, but none of us in our lives, no one alive ever lived through a pandemic, so it was all theory, and we had to put that to practice essentially overnight. So the pressure for that was tremendous.

Day to day, however, it depends. I mean, everybody knows health care is stressful, whether you work in a physician's office where you see an awful lot of patients a day, or you work in the emergency department or an acute care med-surge unit taking care of patients, patients' lives are in your hands. It's a high-responsibility position. It's stressful. It is beyond rewarding, and I think that's why people do it and go through that stress, because if there was no reward at the end of that, I don't know if you would willingly stay in such a stressful spot. But yeah, it is stressful, it's challenging, and I do think people who get into it, I don't know if they're all great at dealing with pressure initially; they learn that over time. I think what they do realize, or come to the profession with often, is the ability and acknowledgment that they need to be flexible. Our day's never the same, no matter what we do, and you have to be able to pivot, and that's really important.

Host Amber Smith: So, someone who enjoys helping others, maybe high school student or college student who likes science classes. Is that important, to like science or biology or chemistry? Do you need to have that ability and interest?

Nurse Scott Jessie: I would say yes and no. We end up getting nurses with all different kinds of backgrounds and degrees. We have a lot of nurses, ultimately, who end up going back to school after they've earned a bachelor's in something else, for example, and end up in the health care profession. Science: I think naturally you have to be an inquisitive person to be a nurse. You have to like and understand how the body works. That's really important from that perspective. I, 100% agree in the science piece. Do you have to love chemistry? Maybe not so much. I can certainly tell you a lot of nurses would say they didn't love their chemistry classes, but you have to have some basic understandings. The amount of knowledge that you need to be a nurse is tremendous in reality. We take care of all ages of patients under all circumstances and all disease types. And the number of medications, for example, that are available has grown exponentially over the years.

And you have to know how they work and how they interact. And we, thank goodness, have tremendous partners in pharmacists who help us with those things, but at the bedside, you're the person giving the medication, nobody else is, and you have to know the risks and the safety concerns and how they interact, and if it's the right medication, and so, yeah, science is very important. Excellent communication skills are very important. Being a people person is very important. So, science is key, good, broad background is really important, I think, for people who are interested in getting into the field, though.

Host Amber Smith: Well, let's talk about what attracted you to nursing. When did you decide you wanted to be a nurse?

Nurse Scott Jessie: I wasn't going to be a nurse. That was not my career plan. In high school I got a scholarship to go to Syracuse University for electrical engineering and go into the Air Force. I was very excited about that. I did go to Syracuse for my freshman year. I did not enjoy electrical engineering very much; it turned out not to be my favorite thing. And I was struggling with boy, could I do this as a career? So I went and talked to the Air Force, and they had given out scholarships by degree types because they need certain people in certain roles, and I said, can I change to a different specialty of engineering?

And they said all the slots were full. And I had a friend who had just become a nurse. And I said, what about -- SU still had nursing at the time -- and I said, what about nursing? I would be interested in that. And they said those slots were full. So I made what was a very difficult decision as an 18-year-old to walk away from the scholarship and potentially that whole career path and finished my freshman year and moved home and went to community college at Cayuga Community College in Auburn.

Nurse Scott Jessie: And, I was a little, like, I don't know what I want to do. I got a degree in criminal justice. And, while I was interviewing for a position as a police officer, I decided to apply to nursing because I had several friends at this point who had gone into the nursing program at CCC, and I joined the program.

I was also involved in my volunteer fire department, was an EMT and had some exposure that way. Getting involved in that solidified for me that health care was the career path that really was right for me. I got into the nursing program, stayed in the nursing program. It was the best decision I ultimately ever made, although it was difficult at the time, and CCC was a fantastic place to get my entry into the program. I had wonderful experience, and obviously it has worked out well for me over my career.

Host Amber Smith: Now in general, what's involved in the educational training of a nurse? I'm assuming there are classes in anatomy and physiology. What else?

Nurse Scott Jessie: There's definitely anatomy and physiology, pharmacology, there's hard, basic science classes: chemistry, biology, math, common requirements that are typical in a lot of undergraduate degree programs at base level. And then there's other things that are very nursing focused and obviously the clinical program, and experiences for school, but population health, public health nursing, pharmacology, things like that that are very specific, patient assessment, things like that.

Depending on what kind of degree program you're in, if it's an associate's degree or a bachelor's degree program, the length of time varies, but a lot of the core courses are very much the same in either program. And at a minimum, you have to have an associate's degree to be a registered nurse in New York state, but you can enter nursing with a bachelor's degree as well.

Host Amber Smith: So talk to me about the difference between an LPN and an RN. Do you start out as an LPN and then become an RN?

Nurse Scott Jessie: So LPN programs, traditionally in some schools, I think some even high schools still have LPN programs through like a BOCES-type program. The LPN program is, a lot of the materials are the same, but it's not as completely thorough as the registered nurse program.

It's shorter, normally. Some nursing programs -- I don't know if they still do this in associate's programs -- when I got my associate's degree, they did let you test out to take your LPN license, if you chose to, while you were still in the program. I did not do that. A couple of my classmates did.

Nurse Scott Jessie: But, a lot of common material, but there's more material and more intensity to the associate's degree program. And obviously the bachelor's program, different licensure exam, more responsibilities in the registered nurse role. but both roles are tremendously helpful in the health care system. They're partners, they collaborate, and we need more of both.

Host Amber Smith: So how many years does it take to become a registered nurse? What's the shortest period that you might be able to do it in?

Nurse Scott Jessie: The quickest that I'm aware of that you could do it if you were full-time in an associate's degree program would be two years. That often includes some summer classes. It's an intense course load.

I was lucky because I had already had an associate's degree, so I was able to focus mostly just on my nursing courses and a couple of science classes. So I was able to go somewhat part-time, which made it easier because clinical and school was hard and I needed to work. I had a life, too. So it was hard. The quickest really, though, would be the two years. There are some three-year accelerated bachelor's programs, and most are four years, depending on which path you choose.

Host Amber Smith: And is it half classroom work and half clinical, or at what point do you start seeing patients as part of your training?

Nurse Scott Jessie: Sure. In associate's programs, you start pretty early in your first semester with patient contact because you have to. I don't know the exact requirements on hours, currently, but there are a specified number of clinical hours you must reach in the programs. And in the associate's degree programs, it's pretty early on. Some bachelor's degree programs wait a little bit of time before people start engaging clinically, and they focus on some of the other coursework and some incorporate that right from their first year all the way on through, and they have clinicals all the way through the program. It kind of depends on where you end up at school.

Host Amber Smith: Can you give me a ballpark about how much nurses working in hospitals in New York state can expect to earn starting out?

Nurse Scott Jessie: Sure. I do think it's a little bit geographic dependent, obviously. People down in New York City area, large metropolitan areas, have higher pay scales. It costs a lot more to live there.

We are lucky it's a fairly low cost of living up here in Central New York. Typically, in our area, I think most hospital-based nurses start out in the low- to mid-$60,000, bordering on $70,000, range, and salary varies based on years of experience, degree type, things like that.

And often there's a stepwise increase over a number of years, probably topping out, for base pay. and I'll explain that in a second, for base pay, probably in the mid-$90,000 range for full-time work. On top of that, a lot of hospitals offer shift differential for working off shift, which obviously increases that base pay.

Some hospitals offer additional pay for location pay or geographic pay, which could also increase that. The health care market, uh, has had itself turned upside down with the pandemic, though, and pay scales for lots of jobs in health care and outside of health care have changed significantly, which is part of the workforce challenge right now.

One of our biggest challenges is travel nursing. The popularity and need for travel nursing has exploded during the pandemic. So that's when a nurse usually leaves their home area and goes and takes a committed assignment, usually a 13-week assignment in some hospital, somewhere. They work with a company who places them, and they get paid very, very well to do that.

The pandemic has increased the rates the travelers make significantly, and the demand for travelers has exploded by hundreds of percentages over the last two years because of hospital staffing challenges. So I think many hospitals and health care systems nationwide, and you see this in the literature, are all looking at their salary structures, they're reassessing what they need to do to make sure they can be competitive in their markets, get people in the door and keep people. That's important. Remember we talked a little bit earlier about the fact that nurses can do lots of things, and that's true. And there's lots of nursing jobs that are outside of hospitals, too, along with other health care jobs that are outside of hospitals. So, we compete for the same people. It's hard to compete and we have to stay competitive.

Host Amber Smith: Do nurses have to get licensed in each state where they work? If they go with a traveling company, do they have to go through certification and licensing in every state that they travel to?

Nurse Scott Jessie: Yes, essentially you have to either go through the process or go through what's called reciprocity to get a license in any state that you work in. The only circumstance I know of that that's not true, I believe, is the VA system, because they're federal. And if you have a license in some state, you can work in the VA.

I believe that is still the truth, but yes, normally there's a licensure process. A lot of nurses actually travel within their own state. Up or down the Thruway, for example, to Rochester or Albany.

Host Amber Smith: Well, let's talk a little bit about the jobs beyond hospital-based jobs that would attract nurses. I wonder if a nursing background is helpful to have for other related careers?

Nurse Scott Jessie: Sure. My answer to that would be a resounding yes. There's lots of actual nursing jobs outside of hospitals, for sure. Physicians' offices, clinics, insurance companies, things like that, but the nursing background really is very adaptable.

We talked about people need to be flexible in this profession, and I really do believe that. You can do a lot with this kind of education and training. You can teach, for sure. There are nurses who go on to have legal careers. There are nurses who go on to write for a living, to be consultants, to be speakers, educational offerings like creating or owning your own educational company and traveling around the country, offering continuing education seminars, things like that. So, there's a lot that doesn't have to be directly tied to the health care profession, but once you're a nurse, you're a nurse. That's in you; it's who you are.

It's going to be there no matter what you do, but it makes you better at all the other things you do, in my opinion. I'm biased, obviously, but I I really do think that's true. There's really no limit. Really kind of exotic examples: There are nurses who work in the entertainment industry and provide reviews of scripts and things like that. Medical consultants for shows for accuracy. Really, it's limitless what you could do with your degree. It's just really a valuable profession across the country, and we are still the most trusted profession in the nation and have been for a very long time.

Host Amber Smith: You mentioned continuing education. What are those requirements like for nurses? And that just means once you're a nurse, you still have requirements to stay up to date, right?

Nurse Scott Jessie: Every state's different, and there's two, different kinds of versions of this. For your license in New York, you have to do a small amount of continuing education that's focused mostly on infection control practices, I believe that's every four years. In some states you have to have a certain number of continuing education credits every time you renew your license. That is not required in New York. However, what is required for continuing education, if you're certified and we push very heavily for our nurses to be certified, we have, I believe we are up over 750 certified registered nurses at Upstate, which is a tremendous amount.

When you're certified, you do need continuing education credits to maintain your certification. That number and what those are varies by certification, but every type of certification requires them to some degree.

Host Amber Smith: Let's talk a little about advanced training options. What's available for nurses, and where can that take a person? Because you have advanced training.

Nurse Scott Jessie: Again, a lot of options Your bachelor's degree really starts to open your doors in the nursing profession. If you want to do things other than bedside care, that's usually always a requirement, uh, for jobs like case management, some leadership and management jobs require that. We're a magnet organization, so it is required our nurse managers all have to have a bachelor's or higher in nursing. That's part of magnet standards. But when you want to start to do some other options, there are plenty of them in nursing. you can get your advanced education and degrees and become a clinical nurse specialist. You can become a nurse practitioner in a variety of different types of nurse practitioner roles. There's a lot of them now. You can go on to other types of specialties, a certified registered nurse anesthetist is an advanced practice nurse. They function similarly to anesthesiologists. That is a specialty nursing can go into it. You can become a certified legal nurse consultant. You can become a forensic nurse. There's a lot. There really is a lot of options. some require formal advanced education and degrees, some require certificate programs, but there are plenty of choices, and there's good options to find them.

At our own College of Nursing, we have nurse practitioner programs, we have a doctor of nursing practice program. There are tremendous opportunities for people. We have a great tuition support policy for our staff as well. So we put a lot of people through school.

Host Amber Smith: It's nice the way you describe such flexibility, because it seems like this is a profession that might work for a person at different life stages. They could work full-time hours when they're young and energetic. And is it something that you can do as a part-time sort of thing as you're nearing retirement?

Nurse Scott Jessie: Yeah. We have a lot of staff who are full-time, and we have a lot of staff who are some degree of part time.

It is a very flexible profession from that perspective. It's flexible for a wide variety of lifestyles for people who have kids, for people who don't have kids, people who are going to school, people who are not, there's a lot of ability to be flexible there. And even at those flexible positions that the pay is fairly competitive, and often, much more than you would make in other types of part-time employment.

We also give benefits for our part-time staff. We give tuition benefits for our part-time staff as well. So I do think that is one of the draws to the profession, aside from the flexibility of choice of work, the amount of work that you choose to do, you can be half time, three-quarter time, per diem (by the day) -- there's a lot of options. I've even had some nurses over the years who worked for me, who only worked in the summer because they were teachers, and they would come over their summer break, and they worked as a nurse and filled in for people who were taking summer vacation. It was a win-win for everybody. It was wonderful.

Host Amber Smith: We've heard doctors complain that they don't get enough time with patients. Do nurses have those same complaints, or do nurses generally get more face time with patients?

Nurse Scott Jessie: Yes, they have the same complaints. It is hard with the pace of work to ever really have, quote, enough time in any of the roles in health care, I believe that to be true. The biggest barrier, honestly, with time with patients, is both how sick people are and how much of a workforce we have available. That's one.

The other is interfacing with technology and patients at the same time. We use a lot of technology in health care, right? If you've had the need to be a patient in the hospital, for example, I'm sure you've seen nurses and doctors rolling around carts with computer screens on them. So we do all of our documenting. We don't use paper anymore. We used to use paper all the time. So we use computer screens; well, the computer screen can be right between you and the patient, for example, right?

We don't want to talk to a computer screen; we want to talk to patients. So you have to make conscious efforts to find ways to stay connected to the human touch. That's what nursing is about. That's what it's always been about. And taking a minute or two out of a crazy, hectic day and literally going into a room and sitting and talking to that patient is sometimes the most meaningful thing that happens for that patient throughout their whole stay.

And I'm going to be honest, it's one of the most meaningful things that happens to the nurse, too, because we really do value that human connection. We don't have connections to computer screens. We do connect with people. And we talk about that a lot because it's very busy in health care. Everyone knows that; the pace is intense. But we are taking care of people. We're not building widgets. We're taking care of people. And that's what it's always going to be about. So we go out of our way and find the ways to make those connections. And we have to; it is ingrained in who we are. Physicians are the same way. I know they want to spend more time with their patients. It's difficult. It's very difficult.

Host Amber Smith: Well, thank you so much for making time for this interview.

Nurse Scott Jessie: Absolutely. Thank you.

Host Amber Smith: My guest has been Scott Jessie. He's Upstate's chief nursing officer. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Aging can assume many guises. Poet Lisa Wiley teaches English at Erie Community College in Buffalo, New York. Her poem "Sundowning" describes a common occurrence in elder care, the eternal hope that this time the parent might remain calm and be able to sleep.

"Sundowning"

I used to race the feathered sunset

on summer nights when I embarked too late,

realized I had too many miles to make it home

before stars pierced an indigo sky.

I'd sport a white t-shirt so traffic might see me

a scout leader neighbor would pull over

to my side of the road, instructing me

to wear a headlight or start earlier.

I'd just pump my arms harder.

Now we race to my father-in-law's side

on late winter afternoons

when a cotton candy sun drops too soon

on his sharp, mathematical mind.

Gentle, humble, Teddy bear, his students said.

If we arrive in time, we guide him through

simple tasks like shaving, as he offers

lucid moments of secret childhood handshakes

before bedtime combat settles in.

Joanne Clarkson has published five poetry collections. Her poem "The Last Piece" describes a part of her job that was probably never in the job description, but which defines caring for the vulnerable.

"The Last Piece"

When, as a nurse, I visited homes

of the dying, jigsaw puzzles

were often spread across tables: kitchen,

coffee, card, bedside.

A thousand pieces a common theme.

I watched a wolf come together

in the woodlands. An orca leap

from the Salish Sea.

"It passes the time," Karl, always cheerful,

explained as his ragged heart stuttered

then thrummed. "It all makes sense this way,"

John's wife Nancy told me

since John could no longer speak.

It gave visitors something to explore

besides grief. They felt useful

finding a splinter of the weathered barn.

I drove boxes of fragments from house to house,

trading, and never lost a piece

as I listened to the whining breath

and measured pain on an impossible scale.

Karl gave away every puzzle except

the wolf. His daughter glued it

to a board, framed it after, tribute

to small connections

when the greatest was taken away.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," meet the Upstate scientist who ranks among the top 80 scientists in the world.

If you missed any of today's show or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Bill Broeckel. This is your host Amber Smith, thanking you for listening.