The People, Process, & Progress Podcast - Gain Insight into Public Health Nursing with Jill Grumbine, RN | PPP #21

Episode Date: May 15, 2020

In 'Gain Insight into Public Health Nursing with Jill Grumbine, RN, ' Jill and I discuss Public Health Nursing, disease investigation, and the use of ICS in Public Health.

Hey, everybody. Thank you for coming back to the People Process Progress Podcast. I'm your host, Kevin Pinnell. If you haven't, just before we get started with our guest, Joel Grumbine, please subscribe, rate the show, and the more stars we get, the more recognizable we'll be, the more information we can put out there to tell people's stories, share good processes, and help us all make progress. So today is episode 21. I am with my friend and former colleague in public health. She is still in public health, Jill Grumbine. Jill, thank you so much for coming on the show.

Yeah, thanks for having me, Kevin. So we worked together for, I guess, the whole time I was in the local health department in Horeca for five years or so, I would say. And then I went downtown and did hospital stuff. But so how, where did you grow up? Start with, you know, let's learn about you. Where did you grow up? And what led you, you know, through school or an interest when you were younger to get into nursing and then and then in particular to get into public health nursing? Yeah, sure.

So I grew up in Richmond, Virginia. I'm a native Richmonder. And I remember thinking back when I was in sixth grade, we had to write an autobiography as a school assignment. And as part of that assignment, we had to talk about what we wanted to be when we grew up. And at the time, I either wanted to be a nurse or a teacher. So wanting to be a nurse has been part of who I am for a really long time, so since I was a young teenager.

And I think maybe the thing that kind of solidified that is caring for a dying grandparent during my kind of middle teenage years. And just seeing the great nurses who cared for her in our home just steered me on that path. And my mom also has a background in health care, so it's kind of in the blood. So that's what led me to become a nurse. In terms of public health, I can't say it was ever a grand plan that I just knew I wanted to be a public health nurse. I actually started out as a hospital nurse, spent a few years in the hospital doing women's health, women's surgery and caring for high-risk pregnant women. But then, you know, as with many hospital nurses,

the long hours, the 12-hour shifts that were turning into 13- and 14-hour shifts and the higher acuity of patients and the higher number of patients just was very stressful. And I decided that it was time for a change, but didn't know what that change was going to be. Um, and someone who goes to my church said, you know, we're always looking for good public health nurses. And I thought, yeah, right, whatever. And a few months later she said, you know, we have a position open. I really think you should apply for it. I thought, well, what have I got to lose? And it sounded kind of interesting.

And the schedule was definitely more appealing. So I applied for the job knowing that I would probably get an interview, but not really thinking it would go beyond that. And ultimately, they did offer me the position. So I started out working at a local health department and really loved it. Didn't really know what I was going to be doing in public health in the beginning, but quickly fell into a role where I was coordinating the refugee health program as my primary duties, but also my other major duties were in the communicable disease program. So doing communicable disease follow-up for various communicable diseases

and also doing tuberculosis case management for patients who had active tuberculosis. So you went to school, you got your bachelor's in nursing. How much public health was covered? One, where did you went to school, you got your bachelor's in nursing. How much public health was covered? One, where did you go to school? Nursing school, Virginia Commonwealth University, go Rams. Right, right on. And how much public health nursing or public health information is there in a typical or in your, I guess, uh, bachelor's of nursing curriculum? So we had a whole semester of community nursing. Um, and for every, um, you know, clinical based nursing class, you have a clinical. Um,

but my clinical for my community nursing class was parish nursing. So I was paired with a nurse who was doing parish nursing at her church, and we really were looking at kind of doing a health assessment for just that one little church. I know that I had colleagues who spent, or classmates rather, who spent time at the health department, but I didn't have that exposure. So I really did not have a whole lot of exposure to public health prior to actually starting to work for the health department. I remember one of the, during, which was really when I first started, you already been there during H1N1. So I started in January, 2010, H1N1 was, you know, in full swing. And one of the areas that we took vaccinations to was a really big church in the eastern part of the county.

And they had like a whole kind of nursing, really office, station clinic kind of thing set up in there. Is that similar to kind of the experience that you had? So it's you provide, you know, screenings, you know, for the parishioners? Yeah, so I think parish nursing definitely evolved. So my clinical experience would have been a number of years before that H1N1 experience. And parish nursing was, I would say, from my remembrance, was relatively new at the time. But yes, doing health screenings and like I know we have a parish nurse who coordinates health screenings and flu shot clinics, coordinates doing like a CPR class once a year or so, so things like that.

So they do exist and I think it just depends on the size of the parish or the church of how much involvement there is and how much they do. And is that usually their full-time focus? Like they're the full-time parish nurse? Yeah, I think it depends, again, on the church. So in my church, it's completely volunteer. The nurse who is in charge of that has another full-time job. So does the parish nursing gig just on the side.

Gotcha. And you also mentioned in One Eat Your Take 2, so you were working in the hospital, you know, those shifts are, you know, can be brutal between the physical and emotional toll, you know, of just being in that medical environment. Do you find that a lot of public health nurses had a similar experience where they did clinical time, either inpatient or outpatient, and then transitioned to public health? Or what do you think kind of the percentage of, you know, the of the public health nurses, folks that did, I guess, kind of more traditional inpatient or outpatient clinical nursing than those that started purely in public health nursing? That's a really interesting question. So I do think that most of my colleagues started in the

hospital, in some way, shape or or form before transitioning to public health. I think many of them probably did it when they started families because, again, the schedule is better. And thinking back to the nurses, I know like one, well, actually several worked in like the newborn nursery. Some might have started in doctor's offices and then transitioned to public health. I do think that having some hospital experience is definitely valuable because it

really helps you build those critical thinking skills to prepare you for working in public health, which in my experience is a lot more autonomous than working in a hospital. And I recently had the privilege, gosh, it's probably been a year ago now, of I, so once a semester, I go and guest lecture at VCU School of Nursing for a community health class. And one of the students, yeah, it's really cool. It's probably my favorite thing to do. And one of the students approached me afterwards and she said, can I talk to you? And of course, she said, I really, really, really want to work in public health. And I was like, that's great.

Go work in the hospital. Let me know, you know, when you get a couple of years under your belt and I'll help you, you know, navigate the application. And she said, yeah, I'm just really don't want to work in the hospital. I really want to work in public health. I love it. She had done a clinical with a local health department and she said, that's just what I know that that's what I want to do. And I said, okay, I'll tell you what, like, let's set up a time. I will help you, you know, with your resume. I'll help you what like let's set up a time I will help you you know with your resume I'll help you do the application because the state application um you just have to know to find the

right words and build the right words and you know look for the keywords that they're looking for and make sure you mention those in your application right make sure you mention that relevant experience. And so I helped her and she went on an interview and didn't get the job, but then went on another interview and she's working in public health now. So I think you can definitely make a career in public health without having hospital experience. But for me, I think it provided a great foundation for helping me become the public health nurse that I am. Yeah, that makes sense. I mean, to your point, if you've, you know, worked a code or crashing patient or even, you know, done sterile technique or even something non-emergent,

and then you're working the clinic or then you're working, you know, it's a bit of a slower pace, I think is accurate, right? Then it scales it to your point. It's like, oh, okay, this isn't, you know, no one's crashing here and there. We're still, you know, trained to deal with that and all those kind of things, which is pretty awesome. And another, I think, good process and good way people can make progress when they're applying for one nursing. But I think any jobs, as you made a great point of, when you're applying for a job, think of all your experience, whether it's volunteer or paid, and pull out the words that you used and match them to the application.

Truthfully, obviously, but you can cross map tons of experience. And I've seen a lot. So Reddit has been a great, I never really got into it, which is funny in 46. And I'm now using Reddit more often, particularly for the show. And just, you know, there's a lot of good groups in there. So following coronavirus, public health, and, and there's a lot of folks, either new emergency managers looking for experience, or similarly, public health, maybe nurses or just folks that want to get into it. And like we've talked about, as far as opportunities, I've said, you know, you should apply wherever you are to do contact tracing or do investigation and get involved in

there because you'll get that kind of boots on the ground experience. Then if you are, whether you're general emergency manager or you do get into public health, you'll have the sense of what it's like when you're making decisions in an office or the emergency operations center that affect those people that are out doing the shoe leather epidemiology, you know, to make a, make a big difference. So that's awesome that you were able to help her get a job in public health. And you mentioned when you started, so what is life like for someone that transitions from hospital-based nursing to public health nursing? You mentioned you started and then transitioned to communicable diseases

and working with refugees and things like that. So what's it first like, the transition? What are some of the first things that you do when you get into public health nursing? So there's a lot of orientation. Um, and I think, uh, having a really good orientation is so important. Um, there's so many different programs. So, you know, in the hospital where I was focused on women, you know, who were post-surgical or maybe postpartum or caring for high-risk antepartum women. But I had kind of that, I don't want to say narrow focus, but it was just women and sort of specific, you know, diagnosis codes and, you know, things like that to transitioning to public health,

there's just a lot more breadth. Um, so, you know, you learn the basics of communicable disease process and following up on things. Um, but then you also have to learn, um, things like we did maternity care. So pregnant women who were on or underinsured and what does that clinic flow look like. Family planning clinic where you need to know about the different methods of birth control and be able to provide education to women on their method of birth control. Immunization is a huge part of what we do in public health.

So just learning the immunization schedule for infants, toddlers, whomever, and comparing what their immunization schedule looks like now as to compare to what it really should be and being able to calculate doses of immunizations and what they need in order to catch up to make them up to date on their vaccine schedule. To tuberculosis case management, which is a specialty in and of itself, to caring for refugees who come with a very diverse set of needs, very diverse backgrounds, and being able to provide culturally relevant care to them. So just a lot more breadth, but also not always having a physician order to do everything that you do for a patient. So in the hospital, everything that I did for a patient required a physician's order, right? Well, in public health, you do have a lot more autonomy

because you have a patient in front of you that needs, you know, to know, the emergency room, or when, you know, let's just try holding the medicine for a day and see how you do, or let's try taking the medication at a different time or with food or without, just navigating all of those different things. Is that the difference between being under like a health director or clinical director or medical director kind of in public health as opposed to the different, you know, physician teams, you know, that would manage each patient and then hand off. So you're always in public health operating under the umbrella of the health director or their designee if you have like an additional MD there. Yeah. And we have a lot of standing orders in public health. At least when I worked in the hospital, it was individual patient orders for every medication, IV fluid, everything.

Where in public health, again, there's a lot more standing orders. Or, again, like I said, as a public health nurse, assessing what someone's immunization schedule looks like and determining what additional vaccines that child needs in order to get them up to date. Gotcha. And when you, which is not to go down the vaccine debate road, but that's another thing too, right?

Is you see folks that come in that are all in. Do you see folks that come in that question a lot? Or if they've come to public health department, they're pretty much know like, hey, we need to do this and then kind of follow those schedules. Yeah, my experience in public health was yes, that if they were coming to the health department, they were coming for a reason

and knew that they needed to be there. Um, and we're coming to get the vaccines that they need, you know, that they needed. And, and some patients, it's kind of funny. Um, if you told them they didn't need any vaccines, that they were good, some of them, you know, depending on cultural background, um, might've been disappointed because they thought they were coming to the clinic because they needed something. And you tell them, oh, no, you're good. Everything is fine. And they leave a little disappointed because they thought they needed something. Oh, wow.

But they were already where they needed to be with their vaccines and everything. Yes. Huh. Interesting. I mean, that's, and honestly, from a practical standpoint, keeping up with that, even being from here, being in public health, like with your, you know, kids vaccine schedules. And that was a great service and a service that I would venture to say many, if not all the public health departments, many of them in the country, let alone in Virginia, provide is annual like school vaccination. So if, if you haven't gone to your primary care physician or CVS or anywhere else,

you can go to the health department that typically hold those every year. Right. Yes. Yeah. I think it varies, you know, sometimes you need an appointment, sometimes you don't,

but yeah, definitely. That's a fundamental task of health departments is to provide childhood vaccines. And so you mentioned tuberculosis, which you definitely know a lot about. So with that, as far as vaccines, there's a difference in what we do here largely, right? And internationally, whereas internationally, a lot of folks are vaccinated because it's more prevalent. Whereas we're not, or what's the difference there?

Because that seems to be a big thing, certainly as far as screening and just the prevalence of that in the U.S. or not. Or is that a picture of the state of the U.S.'s public health compared to maybe other areas? Yeah, so definitely our incidence of TB in the United States is much, much, much, much lower than it is in most parts of the world. And there is a vaccine called BCG that is given in many parts of the world. And it's really to help prevent the more serious forms of tuberculosis, so like disseminated tuberculosis or TB meningitis. But because our incident rates are pretty low here in the U.S., we do not give BCG routinely. It's, in fact, very hard to come by. And interesting that you asked because

occasionally we'll get a request. In fact, just last week someone called me to say I'm going back to I forget which country soon. And I have a baby and I want to get them BCG because we give that in my country. But I want to get it here in the U.S. before we go back to our country. And I had to say I'm really sorry, but we just we don't have it. It's not a vaccine that we routinely give in the U.S. So I didn't have a way to provide or offer that vaccine to that person and had to just say, I really recommend that when you get back to your country, that you go to a clinic there and get it there. Wow. Which is good for the state of the U. I guess, right, in our public health. But an interesting contrast, too, of many other places in the world that aren't as fortunate, even now, when this comes out with COVID-19 and everything, but all the other stuff that's still happening, the other diseases that are still here, the other, you know, levels of public health. And,

and I wonder if we could use cause you and I worked a tuberculosis investigation, a pretty big one, but maybe as an example to, and it was you know, someone that was active, right? Yeah. Someone who had active infectious tuberculosis. And around a lot of other folks, closed spaces, breathe in same air. So to me, a lot of similarities of what happens now if I happen to have COVID. Near a lot of other people sharing air, like very similar, right? And so I wonder if we could, and I think we ended up testing a few hundred maybe in the back of a big box store, right?

We did. Which, again, a plug for the incident command system. We use the incident commander to an outstanding job. Well, thank you. And, but I wonder if we could use that as an example to give folks an idea of what happens when someone has, in this case, tuberculosis, but you know, something which I think there's a lot of parallels and certainly correct me if I'm wrong to a COVID positive person. But what happens when we find out this person has something that's really infectious, but use, you know, TB, maybe that case, obviously not details, etc. But what happens when someone says, hey, we think or we know this person has tuberculosis? One, how do

we find that out as a health department? And then can you walk us through the steps of what we do from there? Yeah, sure. So tuberculosis is a reportable disease in Virginia. So if a physician or a laboratory discovers that someone has tuberculosis or even suspects, and that would be a physician, suspects that a person has tuberculosis, they report that to the health department. And when we have cases of confirmed tuberculosis, and it would be laboratory confirmation of a culture of some sort, frequently it's a pulmonary specimen, so a sputum specimen that tests culture positive for tuberculosis, we look at the people who've had the most contact with that person, which usually is household

contact. And we look at those people and test them to see if they have been exposed to tuberculosis. And if that rate of positivity exceeds what we would expect to be, quote, normal, then we look to kind of the next group of people. And it really depends on the individual what that next group is. So it might be workplace contacts, or if someone is very active at church, we would want to look at the contacts that they're closest to at church. And we look at those people and we also test them for exposure. We go through a questionnaire screening for symptoms of active tuberculosis. And then we would offer a tuberculosis test, either a TB skin test or we now have blood tests to test for exposure to tuberculosis. And we work our way kind of out from that source case, from that original case,

until we get to a background level of positivity that is, quote, normal. And what is that? So positivity meaning that someone has antibodies, but they didn't have it? What does that mean, kind of a normal positivity? Yeah. So for tuberculosis, a normal test would be a negative TB test. So either a negative TB skin test or a negative blood test. Those are interferon gamma release assay tests, IGRAs. And so we would expect it to be negative. If it is positive, then that indicates that you have been exposed or close to someone with tuberculosis. And then we would look at those individuals who test positive. We would want to first rule out that those people haven't developed active infectious tuberculosis. And we do that by providing an x-ray. If the x-ray is normal and the person is asymptomatic, then we would recommend treating them for a latent TB infection.

And those treatment times vary, but treating them helps reduce their risk of developing active tuberculosis in the future. And then so after that, would they then be a candidate for the that vaccine that we talked about earlier or no? No, that vaccine really is only usually only used in childhood, usually given to infants overseas, sometimes multiple times. So yeah, normally only in childhood do we use that vaccine. Gotcha. And so that's a similar process to COVID or influenza H1N1 that you would do if, you know, I was sick, now we're going to talk to my family, who were they around? Who were they around and kind of keep going out from the center kind of patient zero, if you will. Yeah. And yeah. And depending on the disease

might determine how widely we cast that net. So or something like tuberculosis, which takes prolonged contact with someone before really we wouldn't consider it being an exposure. When you compare that to something like measles, which is highly infectious, we would cast a broader net with measles initially because its level of infectiousness is much higher than that of tuberculosis. Gotcha. So hence, per se, if there were measles outbreaks in college campuses, folks are close together, spread out um other uh and just another example of you know incidents um that public health works of these um are that now are those um because there's another term um that that i've heard for sure i think that's been in the news but cluster so if you have one spot like one place or where tuberculosis was in the store or

say in the dorms on a campus, is that considered a cluster or do you, do you use that term when there's more than one, you know, place of, of an outbreak or something like that? Um, that's a good question, Kevin. We, in, in the TB realm, we tend to use outbreaks of tuberculosis more than clusters. Okay. And to be considered an outbreak, I'd have to look at the official rule to be considered an outbreak. But I think it's either two or three cases that are epidemiologically linked within a certain frame in one area in order to be considered an outbreak. So we don't usually see clusters of tuberculosis and it takes usually a longer time to identify what we would call a TB outbreak. And an outbreak, I mean, so an outbreak really isn't like hundreds of people.

It's a pretty small number of people. Yeah, for tuberculosis, it is small. But, you know, when you think about other communicable diseases, like I said, measles or hepatitis A, things like that, we do see outbreaks. Influenza, we see outbreaks every year. So, yeah, we see more of that in those types of diseases than we do with tuberculosis so with kind of talking about you know how we work together and everybody else again because it's all the partnerships relationships to find the person help them test everybody else for that

big tuberculosis case in particular and given obviously the kind of incident management, project management skew on the show, to me, those small things, and I've said this probably, I don't know how many times on this and the previous Freedom Slides podcast, but the little things, and this, even a few hundred is not enormous like it is now, but the smaller, but the more frequent outbreaks you know, outbreaks or, um, if you can practice getting your folks together and, and using these systems like the incident command system, um, you know, I, I think there's so much benefit that maybe not in scale, like we see now, but in muscle memory and coordination that there's huge benefit to,

um, how did you as a public health nurse, um, and someone that was, you know, leading that, um, how did you find the process of using the incident command sensor incident command system to, uh, manage and, and, you know, support operationally or run operationally and investigation? It's a great question. It was really imperative. I remember early on when we were first talking about that case and the potential need that maybe we're going to need to expand this contact investigation beyond the household. And I remember our health director at the time saying, you know,

just let me know if we need to scale this up, if we need to go into incident command. And I thought, no, I can handle it. And then it very quickly became apparent that no, I needed help. So I think just having those resources and knowing who was going to handle each task and knowing, for example, that I didn't have to worry about getting the pipe and drape partition. I didn't have to deal with that. I could just say, this is what we need. You take care of it, was, I think, fundamental to the success of that operation. And I look back on that investigation as one of the absolute highlights of my public health career, because everyone came together to work toward a common goal. And the partnerships that we established and the things that I learned, um, were just amazing. Um, and just gave me exposure that I didn't think I would

have at the time and has really provided a great foundation for my continued growth in public health. Nice. Yeah. I, I agree as far as, you know, one of those that, you know, is on the trophy shelf of things that you're always proud of, you know, and to your point, you know, you didn't have to worry about the pipe and drape and, and not what you would think, but our environmental health people became the experts for us in logistics in all forms, you know, vaccine coolers and freezers, we'll get pipe and drink, but we'll do it. And, you know, one, it was the people, right? It was, they had, they had great initiative. They were really hard workers and there's, you know, plenty of other folks like that around the country, but I really think we had, and we joke, but like a dream team of people. And, and to your point, that is, that's one thing that that many folks and I kind of laughed when you said I thought I could handle it but but not really at you because I think initially for public health in in other incidents or even big events you kind of you know you probably could have and then you

have to get to the point which is really credit to you to go oh wait a minute I I cannot do this on my own but a lot of people push through and try and do it on their own for too long. And then you're behind the curve and you run into the other thing I've talked about, kind of the time wedge, right, where your time's running out and so are your options. And in particular, public health. And again, you know, I got way into incident management to a point where I actually got a little grief about it for not doing the checklist stuff. I mean, and I still did them, but I'll just stop there with my complaints. But I'll say this, but I do not regret it for one second because of the work that I know that we all did and the abilities it gave me and other folks. But when I was initially going through that

training and even, and not so much through the years, but I was like the public health guy. Right. And so folks don't think about it as much, but public health, if you had a window into what it actually is, like the stuff we're talking about to me is way more overwhelming than going to an EMS call on the street because it's like everything, you know, diseases, vaccines, sanitation, well water, like it's a whole gambit. All the, like none of these restaurants would be open without it and the inspections and just tons of stuff. And the relationships you mentioned, you know, we were huge players and we were, had local partners fortunate enough and to realize, hey, like this is, let's let the experts handle this what can we do to help so law enforcement was like hey

well yep sheriff will provide security there for you no problem firing a mess on standby you know all our partners there and us working together with them coordinating lunches and you know I agree I'm probably a little biased but but that it was a great example of, hey, we hear some rumblings. Our leader, right, who's awesome, saying, you know what? I'm going to let you handle it, but let me know, right, instead of jumping on it and saying, no, no, I'm going to take this from you, which happens. And then also when we did scale up to step up and say, okay, let me get in a position to kind of lead this and then go, you know what? I don't need to lead this.

You lead this. Yeah. Right. And hand it off because that was our health director and you were a public health nurse, right? So she could have said, no, I got it. Right. Yeah. She could have.

Yeah. I really admire that because you're absolutely right. She could have easily said, oh, no, I'm going to be the incident commander. But she really encouraged me and said, Jill, you can do this. I know you can do this. I'm right there with you. And I had your support too, Kevin. So you're right. We had the dream team and I relied you on that planning, which was just key. Um, but then I could just kind of do lead the show, but I had so many people helping. Um, and it was just amazing. And I just, I think really good leaders recognize when other people can take that on and encourage them.

And I, for one, really appreciate that. Yeah, that's a great statement. So how you, I think that's one interesting thing too, because from my standpoint, knowing you, when that started, like you were already a leader leading program, right? Leading folks through all the different things you've done in public health, but particularly leading that program. And getting to the point, how was your transition from mentally and then actually going, Oh, no, no, I can do that instead of going, Oh,

can't why don't you do this, you know, actually giving direction to other people to do tasks that may be in a smaller instance, or you would have done yourself. How did you, how was it handling transitioning going from that? It's hard, um, because I, under normal circumstances, I have a very hard time asking for help. I'm pretty independent. Um, but when you're testing hundreds of people, obviously it takes more than just me. Um, I think having fewer people, not, I don't want to say to talk to, but, um, you know, as the incident commander knowing, um, so-and-so is going to handle operations and so-and-so is going to handle logistics, and Kevin, you're going to handle planning, having that core team of people, and really that was the team that I dealt with. So then they could ask other people to do stuff. I think we definitely helped me. And I remember, I don't know why I still remember this,

but I remember during one of the events when we were on site, somebody coming up to me and asking me a question. And I wanted to answer that question so badly, but I said, you need to go through your chain of command. You need to go back to your section leader and ask them. Because what I didn't want to happen is everybody coming to me, because everybody knew me as a subject matter expert and coming to me but i knew i couldn't get overwhelmed with getting into the weeds because there might be something else that i really needed to address and that's a that's an outstanding growth progress thing is getting to the point where you're a leader and you're not shutting people off, you know, really, but you are directing them to the right system, not just to go, well, there's a process,

but truly it actually helps so that now it takes less time. They don't get up and leave their station or leave their area. They're just right there with their leaders and, and it makes them gel as a team. Um, and we saw that, I think, probably during trainings before these kind of things. And then for sure, when I would teach incident management, same thing, right? Someone would sit there and keep being the go-to person, partly because in public health and public safety, like helpers, right? Folks want to give answers. They want to help.

They want to give answers. They want to help. They want to do it. But that's such a growth area in being able to redirect someone to have them, you know, use that chain of command. And so you mentioned, you know, like the operations section. So largely for investigations and outbreaks, they're also public health nurses, right? Yeah, I think in my experience, they do tend to be public health nurses, sometimes at the supervisory level or the manager level. And I suppose it could be somebody, it could be not a public health nurse, but definitely needs to be someone, when we're talking about communicable disease, who understands the fundamental aspects of communicable disease and communicable disease investigation, because it just helps to make for a successful investigation.

Like an epidemiologist. Yeah, an epidemiologist. Yeah. And I think we mix that, too, between having largely nurses be public health nurses or nursing assistants or lpns be the operations right doing you know giving the shots drawing the blood giving the pbd those kind of things but then also like for safety because epis are disease experts like that's their whole thing and then working closer with y also, you know, between an advisory and an operational position, but to your point someone and for public health,

but also in general and incident community, like someone that knows needs to be like leading operations, you know, that's, that's the go-to at least at the, you know, different levels. And I've said before, if someone can kind of coordinate people and do operations, they could kind of do it. But when you get into diseases and in a certain area, it just seems to make sense that way.

Yeah, and I think it depends on what you're doing. You know, when we were doing the TB contact investigation, we were administering TB skin tests, which has to be done by a nurse. So you have to, or a licensed person. So you can't, and you really need nurses overseeing nurses, because it's just critical to have that knowledge. If we're talking about another type of investigation where maybe you're not doing invasive procedures definitely might lend itself more to an epi being in charge of that particular operation.

So I think it is somewhat dependent on the disease and what exactly you're doing, but definitely you need that background knowledge. And so how important, because another thing that like I know you do and other nurses and epis do is like the data management of, so we've tested this many, you know, the looking at how many results we've gotten, because you have to track the PPDs and then follow up on them for tuberculosis, right? So then you've got kind of a timer going on. Okay, when is someone due back to us and, and then schedule all that out?

Yeah. You really do have to have good data management to track. Okay. Did I test everybody that I needed to test? Okay. If I did test them, do I have the results of that test? And if I don't, where are they? How can I get them? Um, and if I never got them, maybe I need to look at retesting that person. Or if that person wasn't there on the day of the testing event, then we need to figure out how to get them in. And then you're right, for tuberculosis, we do look at retesting eight to 10 weeks after exposure is broken. So where we might have done an initial test and only four weeks had passed maybe, we do need to then schedule another set testing set out again for eight to ten weeks after contact was broken. So making sure, okay, who tested positive

the first time, we don't need to test them again, but we need to make sure that we get everybody else and then following up on all of that information again that second time around is key because without all the information we wouldn't necessarily consider an investigation completely closed until we had made every attempt possible to get information on all of the patients. Okay. Gotcha. Wow. Yeah, there's a lot of contact management, data management.

There's a lot of things that, going back to our beginning conversation, there's still a lot of data management, vital signs, meds, things like that for kind of hospital-based, but thinking about, again, the breadth, like you mentioned, of public health and looking at two three hundred people you're tracking you know it's it's pretty huge um and and keeping up with that and that again is a one that the good public health it seems and good folks like you and the other nurses and then a good system a good process of working together helps shore all that up because it it helps you communicate so if you've stood stood up, you know, you have an incident commander,

safety planning, operations, logistics, like if you're planning well, the communication and you're conscious of the communication flow, then the data management becomes an operational thing. You know, it's not kind of just a fall by the wayside, but it's a critical component of doing that. Yeah. Yeah. And data management and documentation is so key. I know, you know, people who I could follow behind them and, you know, they were out for a day or whatever, they were sick or whatever. And I could look at their charts and know exactly what I needed to do for that patient on that day.

And I've had the opposite where things were very disarrayed and I didn't know where anything was. And so I think it's so important for any kind of nursing, but in particular for public health, for good documentation, good data management. And when you talked about, you know, following up on 200 patients or whatever it was, that was only for that one TB patient. You know, you might have another TB patient completely not even related to this one. And you're also following up on that patient and their contacts, you know, and then if you get someone who ends up being identified as having active infectious tuberculosis, who's part

of this, this case investigation that you're doing, then that spins off its own contact investigation. Wow. So it's like, it's just this huge, you know, I picture kind of, um, you know, the, the image of a molecule with the first patient, all these different, you know, lines and circles and, and going out there where it's just so connected, which, which can be overwhelming it seems right. But just thinking of, you know, how to do that and the manpower to do it and how how does a um you know a tb program do that really keep up with that and because there's also some especially now um but but even you know during normal times i guess if you will when folks are being treated then there's also a matter of helping make sure that they're

taking their meds, right. That they're, that they're doing that. So do you just still kind of try and coordinate, um, you know, operations with the folks that you do have? And then what is the followup like for somebody that has tuberculosis as far as the treatment, how long does their treatment go? It really is very dependent on the person. Um, the minimum timeframe of being treated for tuberculosis is six months. Um, but when we talk about drug resistant tuberculosis,

it could be up to two years, um, or more. So we follow depend again, depending on the patient for a long time. Holy smokes. So in your time, it sounds like, again, depending on the patient for a long time. Holy smokes. So in your time, it sounds like process for folks for connecting that, the documentation just in general, if you're going to, as a standard, it's just a good colleague, co-worker is to leave. If it's not documented, it didn't happen kind of thing, right? There's no gaps in information. The process of bringing folks together when recognizing, hey, I can't handle it. Let's get some help and then having good leadership. And so if you're a

leader out there listening, you know, I would suggest, you know, kind of do what our leader did and look at the situation, let your folks, you know, kind of decide to the point where, you know, if it gets to the point where they can't then kind of jump in, but if not, you know, let them keep rolling and then support them, you know, once they've, they've stood that up. How have you seen, you know, with what we've talked about kind of from when you started public health to now kind of the process of public health nursing itself change, meaning, you know, we mentioned the difference in what was happening by the time I got into public health in 2010, from when you started, and then to now in 2020, what are some, some, you know, kind of big process

changes that you've seen happen that are based on, you know, I guess, whatever it is, you know, kind of big process changes that you've seen happen that are based on, you know, I guess whatever it is, you know, what's come up, what diseases come up, or improved processes, or what are kind of some big process improvements that you've seen in public health nursing overall since you've been in it? Gosh, that's a big, broad question. Yeah, it is. And some of it might be a little difficult for me to answer because I've been away from frontline, what I call frontline public health nursing for a little over seven years now. So I left the local level where I was, you know, based in clinics and actually doing patient care to now a more administrative role at the state level. Or how about for program management, for maybe managing a TV program or something like that,

either what you've seen or what you would suggest to keep folks making progress? I think just continually looking at things. And sometimes change is forced or process change is forced on us. So thinking in terms of my program, our federal reporting requirements changed. So the database that we were using and the data that we were collecting is not the data that the feds want anymore. So that required looking at our current data system, realizing it really was not, we weren't going to change it. We weren't going to be able to update it to what we needed. So then looking to, and it was an access-based system.

Oh, gotcha. So we could only access it from the central office. We had to do all of that data entry centrally. Now we're in a system that is web-based so that eventually we can push that data entry out to the local level instead of doing 100% of the data entry centrally. So it reduces our central office need to do all of that data entry and perhaps frees up some staff time to be able to do other things. I've seen a lot of process changes in recent months where almost 100% of the staff that I work with on a daily basis, I actually think all of us now are working from home. So what did it take to do that? sure that we have encrypted email so that if we need to send patient-sensitive information, that we have a secure way to do it.

Looking at, we do a lot of faxing, looking at trying to get that fax-to-email capability. Instead of having face-to-face meetings, or now having virtual meetings. So lots of processes have changed, some of them really recently, and definitely unexpectedly. But I do think it's important to look at things, and that old adage of if it ain't broke, don't fix it has some validity. But I also think if there are opportunities to change things and improve processes to make things more efficient, I think that's much better. For data and using more technology, are you seeing many folks with nursing informatics degrees get into public health in recent years? I have not seen that, but it would not surprise me

if we do start seeing an increase in that. Right. Yeah, so for me just being down the street, or I guess when I was there, I'm in Blacksburg now, not in that area, but certainly nurse informaticists or clinical informaticists, if they're not nurses, big in health care. And that ability to, you know, look at data, use technology more. And to your point, you know, so as we're using more systems, but still have that clinical spin has been really invaluable for for the IT folks, for the health folks, for the patients. You know, so it's a great mix. And I would imagine similar for, you know, TV program,

public health, nursing, um, and then the folks that you're treating and another big area similarly, um, that we've talked about or touched on earlier was, you know, telemedicine, telehealth, um, virtual visits or virtual care, whether it's inpatient outpatient. Um, but I could see or that it would make sense doing that, you know, via zoom or FaceTime, particularly for like the TV followups in home, you know, and so there with the contact list and then having to look that way.

So, and from there you could do that really from anywhere, I guess. Yeah. And that is actually one of the things we have been over the last, I would say, three to get from the local health department to a patient who needs their TB medicine. app to watch, you know, as long as the patient has the ability to do that, where we can watch that patient take their medicine, you know, while the public health nurse stays at the health department and the patient is at home. And that's definitely, in recent months, the use of telemedicine in public health has increased a lot. We've encouraged to the greatest extent possible that any TB related visits that need to be done, that they be done using telemedicine. And is that, so you mentioned watching people take the medicine, is that because it's a

reportable disease and obviously not, you know, exposure is pretty bad, although fortunately, I guess, you know, you have to have kind of a longer exposure, but do you have to see them take it so you can validate that they've taken it and as they get better, that they're not a public health threat? Is that, is that kind of why you have to watch them or? Yeah, it's for a couple reasons. One, tuberculosis medicine, it's not just one pill. Um, it's four different medications, usually sometimes more, um, and multiple pills of each. Um, and so before we did what we call directly observed therapy, you know, what we think was happening was that patients just decided, oh, I don't feel like taking that pill today.

Or because you don't always feel good after taking that much medicine, people just wouldn't take it at all. And so what we were finding is that people weren't taking their medicine and then we thought, you know, that they had. We, not really me, because we've done directly observed therapy for as long as I've been in public health. But when they, and then we thought that they were done. But then people developed TB again, and you run the risk of if you develop TB again,

then you run an increased risk of having a drug-resistant form. So, and two, when you. So, um, and, and two, when you think about like, I know for me, if I have a sinus infection or something, I'm terrible about taking my antibiotics every single time I'm supposed to. I always take the entire course, but very rarely do I take them every day the way I'm supposed to.

Not a perfect schedule. I'm not on a perfect schedule. So how would you expect a TB patient for six months or more to do that every day? And so that's part of why we do directly observed therapy. Wow. Yeah. I mean, and to think about it now from the practical standpoint, say you're using FaceTime or Zoom, so you're scheduling those like every day for six months now.

So you have in standing meetings constantly, which, I mean, which isn't really hypothetical, like that's happening or going to happen as the norm. Right. Right. Right. Yeah. And I guess a good thing though, is that's also an opportunity for folks to work from home. Cause you know, one thing now with, you know, we did tons of, everyone did surge planning, right? Hospital wise, folks may or may not have gone to the hospital. So capacity,

there's actually capacity. So whether it's doctors, nurses, depending on where they are, or laid off or something. But as far as, do you have to be a public health nurse credentialed to be like an observer for someone to do that? Or is there opportunity there for health care providers, particularly nurses, to help with that as it grows? I mean, as the kind of, you know, telehealth monitoring of medication consumption grows? I would think that there would need to be some sort of formal relationship. So either brought on as a staff person or like I was saying, as a medical reserve core volunteer, just to have that legal coverage or relationship for someone who would be

helping with like a telemedicine visit or something, you would need something in place in order to make that happen, I think. That's a great, I'm glad you brought that up. So thank you to the Medical Reserve Corps in particular. So for health emergency coordinators like myself, regional folks, another duty of ours was to supervise and help maintain the Medical Reserve Corps training cycle, staff directory, all that kind of stuff. But they're such a force multiplier.

And I know we called on them many times and they're great folks. A lot of them retired nurses, either public health or medical or some physicians and a mix. I think that is a great resource that I hope folks are using now and keep using and keep maintaining. And I know it's a federally funded program, but they have made the difference from, you know, a nursing home hepatitis outbreak through a few hundred to now. And so, you know, for anyone that's listening that I think even to getting into, you know, we're talking before folks that want to get into public health, that's a great way, even if you're not done with your degree, that you can get into public health is be a volunteer because they

take both medical and non-medical folks. Right. Right. I'm glad you pointed that out, Kevin, because I think you hear medical reserve core and think, oh, you have to be a nurse or a doctor. We had pharmacists, dentists, but we need more than just the medical help. There's a lot of administrative functions that they can help with, logistics. You know, I remember we had medical reserve corps people helping pack up kits that we would take with us when we were doing H1N1 vaccination. You know, there was a whole box of just supplies that we needed at each event. So having staff or volunteers who were able to just step in and do that was really critical to the success of those missions.

Yeah, it was huge. And the administrative side isn't nearly as, you know, sexy, I guess, as the needle and bandage side of the house. But, but, but the, but one, they can't happen alone. You know, if you don't have the coolers, it doesn't work. If you don't have folks with the clipboards and pencils. Um, and I did a few episodes back, like anatomy of a point of dispensing, you know, just going through kind of knowing, and there's been probably don't know how many drive through COVID screenings,

you know, it's very similar setup, you know, swabbing instead of giving a shot or something like that. But all the, the administrative work that goes into it, that's done by the logistics folks is invaluable. And I think it is a great point of, you know, for folks that are brand new, if you're an emergency management, Homeland Security, medicine, public health, EMS, whatever, public safety, if you're heading down that route and you're not there yet, getting some boots on the ground experience like carrying boxes as part of a clinic or a shot or an investigation will serve you extremely well down the road to, again, keep that perspective on what it's like on the ground when you're one day making policy decisions or your operations or you're leading the project. You know, it's invaluable that will help you for your whole career.

Yeah. Yeah. And sometimes, Kevin, it's not necessarily the day of the event. Like sometimes we need help even beyond that. So we talked about data earlier and sometimes there's a lot of data entry or data management that needs to be done after an event. So just because an event is quote over doesn't mean that the need for assistance is over.

That's true. That's true. I guess you got out between, you know, falling back up and all that. That's, that's true. And again, it's, you know, it's one of the least exciting ways, but best ways to gain experience and learn something in depth is by hours at a time sitting there, you know, doing what seems mundane, but is critical, you know, a critical task. But so definitely, again, encourage folks. And I've found, you know, working from the bottom up, so to speak, just from really hands on doing that kind of

stuff to being the leader, you're much more well rounded leader, and you're just you're just better because you do know things, you know, in detail when when if someone gets stumped or something like that. Yeah, I think I definitely found that my experience at the local level, doing the various things that I did, have definitely helped me in my current situation and in my current job rather, and with the current COVID situation, just taking on different tasks and doing different things instead of my normal duties. So Jill, we, just taking on different tasks and doing different things instead of my normal duties. So Jill, we're just over an hour, which is amazing.

I think we talked about like, it's amazing how fast when you're just catching up one with an old friend of like how much you eat up time, which is cool and give great helpful information. So we always like to, you know, I think we've given folks a lot of process, learned about you, how for folks, and we touched on some of it, but how for folks that are nursing and in particular interested in public health nursing, either interested in getting into it, which now seems like, you know, quite a time to get into it or are in it now. So first, I guess, for folks that want to get into it, what can they do to make progress toward getting there?

And then for folks that are in public health now, what would you suggest for them to continue making progress in their careers given that you already have almost a couple of decades in public health? So one, I think your suggestion of getting involved with the MRC is a great one. Sometimes that's just a good foot in the door. Um, and if not with the MRC, um, is there some other way that you can just volunteer at a health department, whether it's filing or you mentioned back toschool clinics, is there something that you can do with that? Sometimes just making your face and person known to the people there just

helps to give you some background. Two, just keeping your eyes open on state job postings and keeping your eyes open for public health positions. I'm certainly happy to help mentor and share my experience with people. And I was really fortunate to work with many, many great public health nurses who mentored me. And so if I can provide that to the next generation of public health nurses, then that's really my duty and my pleasure. So just getting involved and figuring out ways to help is probably the best way to get your foot in the door with public health. And what would you say for folks that are in public health now, maybe a couple years in, for them to keep making progress in the field?

Learn as much as you can. Don't keep too narrow of a focus. So learn as much as you can about your different programs. Take the opportunities. You know, I think I was one of the public health nurses who was always ready and willing to go do the quote unquote emergency preparedness events. So anytime that I could get involved with a mass flu clinic or a point of dispensing clinic, taking those opportunities to participate in those because you never know who you're going to meet and where it could lead to a new connection

and something that you might not have ever thought about. That's a good point, yeah. You're definitely in a cross-section of, I mean, again, public safety, public health schools. Right. Right. You know, cause for us and I think many other places, I mean, schools are big places, they have drive-thrus. So often they are targeted for points of dispensing or something like that. So that's a whole nother group of folks general government. And then,

and then again, you know, when you develop that trust and that confidence to do like what you did with that investigation in a big name, big box store, you also then get the relationship and respect of your local government partners who are like, oh, they're pretty squared away. To your point, down the road, it could come in handy either way. If they need help, if we need help again, something like that. That's a great point. Right. need help if we need help again something like that that's a that's a great point right and then right like so establishing those relationships and you know maintaining those relationships and

knowing um that not that i'm a big name dropper but when you meet a common colleague and you'd say oh yeah i worked with kevin pannell when he was the emergency preparedness guy at Henrico Health Department. And it just helps establish more of a rapport maybe with those new colleagues. Yeah, that connection. Yeah. For sure. That's awesome. I always enjoy catching up with you.

Always admired the work you did. Appreciate, again, the great works that we did together on the flu clinics. Certainly the big investigation we talked about. For folks that want to reach out to you, is LinkedIn the best way to do that if they have questions about public health or just want to ask you more questions about this? Yeah, LinkedIn is great. I am on LinkedIn. And, Kevin, I know you'll share the podcast. So my information will be there. Okay, cool. Yep. Yep. We'll have it there for everybody listening.

We're on all the, all the platforms subscribe. We'll post this on LinkedIn, Facebook, Instagram, everywhere it goes. Jill, thank you so much. Stay safe out there. Thanks for all you're doing, all you've done and for being such a great mentor to me in public health and a friend. Yeah, thank you, Kevin. It's great to connect with you, and really thanks for having me on your show. Absolutely. Everybody, thanks so much for listening.

Stay safe out there, wash your hands, and Godspeed.