One day at his job at the VA Pittsburgh Healthcare System (VA), nurse anesthetist William Pileggi (NURS ’97G) was with a patient who was coming out of anesthesia after surgery. The patient woke abruptly, reached through the side rails of his stretcher and shoved Pileggi to the ground as he shouted, “Get down! You’re gonna get shot!”
The patient had woken up in a disoriented state, unaware of where he was, in an episode of emergence delirium (ED). ED occurs when patients emerge from general anesthesia agitated, confused or — in some cases — aggressive. This patient also was a combat veteran with a history of post-traumatic stress disorder (PTSD), which research shows put him at a high risk for emergence delirium. The incidence of ED in adult combat veterans has been reported to be as high as 27%, compared to only 5% within the general population.
Pileggi, a veteran himself, has seen patients thrash on the bed, remove their IV line, self-extubate and even injure hospital staff without realizing what’s happening.
“They go to sleep in Pittsburgh but wake up in Iraq,” he says.
The problem has slowly been gaining attention. In the 2010s, two nurses at the VA started a program called Project Golden Eagle that helped to identify patients with PTSD. Those patients were placed in quiet rooms and given a gold surgical cap, instead of the usual blue, so that staff would be aware of the heightened risk of ED.
Still, when Pileggi joined the VA in 2016, he and his colleagues would encounter ED an average of twice a week. It was distressing to the staff, who feared for their own safety, as well as to the patients, who were thrust back into a state of fear and trauma from past experiences. He knew something more needed to be done.
So, in 2017, he teamed up with behavioral health and education specialists David Julian and Michael Boland, as well as fellow nurse anesthetist Amanda Beckstead (NURS ’15, ’20G) to research more, strategize improved practices and create a training program for better assessment and screening for patients with PTSD. Their group — the PTSD/Emergence Delirium Training and Response Team — discovered that certain anesthesia drugs affect the neurocircuitry of the brain in PTSD patients more than others.
In people who have experienced trauma, the amygdala (which is responsible for the “fight or flight” response) often is perpetually hyperactive, and the hippocampus — which controls emotional memory — does not function optimally. Commonly used anesthetics like benzodiazepines and volatile inhalants are particularly dangerous for trauma patients, due to the way they blunt reactions in the amygdala and hippocampus and wear off quickly. Thus, the team’s plan emphasized using alternative anesthetics and tailoring the dosage and timing of particular drugs to each individual’s risk factors.
They also created preassessment questions to identify patients with a history of PTSD (even if undocumented), what triggers might activate a bad response and how to help those patients wake up with ease.
Finally, they compiled the research into a training program that was required for all perioperative hospital staff, complete with recorded demonstrations and hands-on practice.
The effects were almost immediate: The incidence rate of ED plummeted to 2.7% in high-risk PTSD patients, and in 2019 and 2020, there were no cases of staff injuries, lost airways or lost IVs. Pileggi saw patients cry with gratitude that their worst fears about waking up didn’t happen.
In recognition of their impact, the team won a 2020 Gears of Government Award from the U.S. Department of Veterans Affairs and a 2021 I Am Patient Safety Achievement Award from Pennsylvania’s Patient Safety Authority. Veterans Affairs hospitals around the country are now requesting the training program. Pileggi also was recognized as a 2020 Excellence in Education awardee by the National APRN Council.
In the end, it’s about patient care. “Our home run is making that wake up better,” says Pileggi.
This story appears in the latest Pitt Nurse magazine, which will be hitting mailboxes soon. Photos courtesy of William Pileggi and the VA Pittsburgh Healthcare System
AVANA is excited to announce 'National VA CRNA Week' will be held November 15 - 19th, 2021. PANA joins our friends at AVANA to honor, recognize, and show appreciation for all the VA CRNAs that provide exceptional care to veterans each and every day.
by ABBY MACKEY for the Pittsburgh Post-GazetteOCT 24, 2021Sarah Robison spent months daydreaming about her last night on the Appalachian Trail.
She imagined lying alone in her tent, reflecting on what she’d seen and pondered while walking all 2,190-ish miles of it. But when she got to the campsite at Maine’s Baxter State Park — the home of Mount Katahdin and the northern end of the AT — those plans were in jeopardy because she had only a handful of Swedish fish candies to sustain her.
But as she came upon a group of ex-thru-hikers who drove to the site for a cookout, she remembered the hiker mantra, “The trail provides.”
They invited Ms. Robison, 40, most recently of Point Breeze, and five others who planned to summit Mount Katahdin the next day to join them for all the turkey burgers and fresh vegetables they could eat, plus more to pack for the next day.After dinner, they sandwiched together in a wooden lean-to shelter for warmth. It wasn’t in her daydream, but it was “perfect.”
Ms. Robison’s journey to and through the AT was paved with serendipity found in moments such as this, which makes her trail name, “Serendipity,” or “Dips” for short, fitting. On Oct. 11, she found herself in rarified air at the peak Mount Katahdin: Of those who begin the AT, only 1.6% of them do so in “purist” fashion: from one end to the other, not missing even a foot of the trail.
She writes about the journey on her website, AndThenIWalked.com. But with the Maine dirt still damp on her boots, she shared some of the most impactful lessons from the trail with the Post-Gazette by phone as she “lives into” the next chapter of her life.
(More) Serendipity
Ms. Robison backpacked for the first time in September 2019. The trip with friends came after a sequence of events that seem preordained, in retrospect.
She broke her foot while training for a marathon. She bought a bike as a way to remain fit and bike from her Bloomfield home to her job as a nurse anesthetist at UPMC Presbyterian Hospital in Oakland. She pedaled through some recreational biking trips, too, including an arduous ride — with several flat tires — on the Great Allegheny Passage and C&O Canal trails.
Though they finished the trip, a friend suggested they exact their revenge on that ill-fated journey by hiking Maryland’s portion of the AT, with its beginner’s terrain and relatively modest 40-mile distance. “I’m going to despise this, but I’ve never backpacked before and I’ll add this to my life’s resume,” Ms. Robison thought.
Sarah Robison standing atop Mount Washington in New Hampshire's White Mountain National Park in September. (📸 Courtesy of Sarah Robison)
After just 100 yards of hiking, she changed forever. She saw a sign that read “Appalachian Trail: foot traffic only.”
She didn’t know where it started or stopped, but it sparked the urge to live differently. “I just became enthralled with the idea that one would put their life on hold, live outside, simplify and get themselves over 2,100 miles.”
Intuition
She backpacked twice more over the next two years, but the trips didn’t satisfy the inner voice gnawing at her since she saw the AT sign in Maryland.
“That gut feeling is our internal alarm system,” she said over the phone from Bangor, Maine. “Leaving a relationship that’s unhealthy, to take a hike, to find shelter because you sense bad weather, it’s always the right answer.”
At the end of 2020, she put all of her belongings in storage, moved out of her Bloomfield rental and lived in a Point Breeze Airbnb as she house hunted.
But the “chirping” voice didn’t quit. She was “petrified” of leaving her job of 15 years and hiking 14 states alone.
But paradoxically, while trying to “set down roots,” with no lease and her belongings in storage, she was also set up perfectly to leave everything behind.
In January 2021, she formally decided to follow her intuition.
Thru-hikers sometimes spend years preparing, studying the perfect packs, sleeping pads and lanterns as they balance weight with cost and durability. But Ms. Robison had only two months for those decisions, plus other final boxes to check such as doctors appointments, a haircut and obtaining health insurance.
It taught her that just beginning was a definition of success.
Sarah Robison's "tramily" -- trail family -- walked along the Appalachian Trail together from Georgia to Shenandoah National Park. (📸 Courtesy of Sarah Robison)
“Starting it means you faced whatever you were afraid of to make the changes in your life to get there,” she said. “It’s getting to the starting line but also being honest with yourself and not worrying about what other people think. I didn’t finish it for anyone, and I didn’t not finish it for anyone.”
Find your ‘tramily’
Ms. Robison’s aunt and uncle drove her to Springer Mountain, Ga. and on March 18 she took her first steps on the AT. A friend hiked the first three days with her. She was fully prepared to hike the rest alone, but, about halfway through Georgia, she met her “tramily” — a hiker’s trail family.
The eight of them started and finished their days together, although they naturally separated during hiking hours. Every four or five days, they’d get off the trail together at a hostel or small town to resupply and maybe spend the night in a real bed.
Although Ms. Robison tends to live by this credo anyway, the tramily hammered home a lesson: “The trail knows no age, socioeconomic status, gender, color, anything because you’re with a group of people who all have the same goal.”
For a variety of reasons, the group amiably separated at Shenandoah National Park in Virginia after 800 miles together, but “Dips” stuck with “Wallflower,” a 20-year-old guy from Florida who quickly became her best friend.
Although they stayed near each other, there were many days spent apart, which led to what she calls the “most vulnerable” post on her website. “I always needed people,” she said. “I used them to prevent myself from feeling lonely. That’s why I chose to do the Shenandoahs alone. I’d never walked 100 miles by myself, but it was time to go there. It served me extremely well.”
Ripples
Friends and family couldn’t help but to spread around Ms. Robison’s story of bucking societal norms, and her website did the same, which created a ripple effect of courage.
At each hostel along the trail, she read a few dozen emails from friends and people she’d never met who were inspired by her trek. “I started a weight-loss program,” one said. “I got my paint-by-number set out of the basement,” read another.
Kelly Minney, a longtime acquaintance of Ms. Robison’s from Oakdale, was one of them. “When she started off, I wanted to make better, healthy choices for myself,” she said. “If she’s going to walk 20 or 30 miles per day, gosh, there’s no reason I can’t get on the treadmill and walk at least 2 miles!”
“I decided to make my journey public, not as a self-fulfilling prophecy, not for attention, not for a look-at-me,” Ms. Robison said. “Truly, if I can do it, anyone can do it.”
But it certainly wasn’t easy. She spent time alone on foggy nights, searching for her next sure step in the pitch black. She wrote about preparing herself to crouch when her knees felt like they held shards of glass. But because of the emails and care packages sent by strangers, kindergarten acquaintances and friends of friends — some of whom purchased AT maps and moved pins along it as she progressed — she wouldn’t allow herself to quit.
“Despite being off the grid and completely far away with no comforts of home, I am closer to everyone at home through this,” she said. “I’ve never felt more loved.”
Reaching the top
Although Ms. Robison views starting as her “first success,” summiting Mount Katahdin is certainly the second, but it felt nothing like she imagined.
In her 207 days on the trail, she took 29 days off. While many hikers played cards and relaxed, she tucked herself into corners of small towns and wrote about her experience for followers of her blog to read. But over the last seven states of the trail, she took only three days off, which “created a very stressful finish.”
Logistics and survival pushed her race to the finish. Access to Mount Katahdin closes sometime in mid-October based on snowfall. The closure isn’t meant to protect hikers, but rather to prevent the trampling of endangered mountain flora. Frigid nighttime temperatures were the other pressure, as 30-some-degree nights were already common in early October.
To finish in time, she hiked from 4:30 a.m. to 8 p.m. for the last several states. She was physically and emotionally exhausted. She imagined her finish at the Mt. Katahdin sign in Maine and assumed she’d feel accomplished but minimally emotional.
She was incredibly mistaken.
The day she and “Wallflower” summited, they caught a glimpse of the sign from about 200 yards away. A lump grew in her throat until she could hardly catch her breath.
Traditionally, thru-hikers will stand behind the sign with their arms up in victory and pose for a picture. She did that eventually. But first, in a tidal wave of unencumbered emotion, she knelt atop her pack and laid her body against the sign, wailing.
“In that, I saw my evolution of self over the past 10 years,” she said. “It was proof that I have faced fears and pushed myself and was the person I didn’t think possible.
“I actually do not like to hike. It wasn’t the activity. It was the willingness to fearfully and courageously write our own story and not subscribe to this manual people read that says, at 40, you can’t quit your job.”
Ms. Robison was married and divorced about 10 years ago. She doesn’t have kids or a white picket fence to protect them. But she has her car — because a friend drove it from Pittsburgh to Maine — and she plans to drive around New England for a few weeks before returning to Pittsburgh.
She’ll spend time with friends and family, because she lives nowhere in particular with no job demanding her time. But she “has a lot to say,” which she’ll put to words on her website and, hopefully, publish on a more formal platform.
The next chapter of her life is intentionally blank because “Serendipity” knows her trail will provide.
“I’m going to live with the ambiguity I lived with on the trail,” she said. “I’m going to do the next right thing.”Read more about Ms. Robison on her website: https://www.andtheniwalked.com.
Sarah Robison leaned against the Mount Katahdin sign in Maine's Baxter State Park as she finished all over 2,100 miles of the trail. (📸 Courtesy of Sarah Robison)
