Thursday, November 13, 2014

This was my week:

On Monday, my Sonicare toothbrush bit the dust. I'd been limping it along for months, and it finally coded and couldn't be revived.

Today, I had a decision to make: I had money in the budget either for a new Sonicare or a bottle of Laphroiag.

I chose Scotch. Oral care, I am not up in you right now.

And this is why:

On Tuesday, I was minding my own business when I saw a coworker hurpling cheerfully down the hall with what looked like a liter suction container full of bile. I shook my head and blinked twice, and damned if it wasn't a liter suction container full of bile.

Now, normally when one is faced with a quart or more of straight-up digestive fluid that has to be removed from, say, a patient's room, one gets a bottle of this nifty fluid-solidifying stuff and takes it in to the room where the straight-up digestive fluid is. One then dumps the solidifying stuff into the container of SUDF, waits until it solidifies, and tosses it into a biohazard bag.

One does not bop down the hall, hugging the still-liquid, suctioned-out contents of a stranger's stomach.

So I stopped the coworker, and took her into the storage room, and grabbed a bottle of solidifying stuff. And then told her how to handle the liter of green corrosive goo, and what to wipe down, and where to throw it all away.

And she argued with me. She wanted to take it into the nurses' breakroom and deal with it there, because you can't deal with that stuff at the sink in the clean utility room. She argued, and continued arguing, until my hero the unit secretary came in and laid down the law.

Wednesday was a blur. I think it had something to do with more than one bottle of wine, consumed such that I maintained a happy glow throughout vacuuming and napping and cooking dinner. I know there was some Doctor Who involved. (Does anybody else get a creepy vibe from Danny Pink? I sure do.)

Today that same coworker, who is a nurse (well, a nurse who hasn't been a nurse in, like, twenty years) but who has a non-nursing job, approached me with a sunny smile. Here is what she said, verbatim, with no prelude:

"As soon as the car arrives, they can go to rehab!"

What car? I asked. And who, and where, and how?

Turns out she was talking about a patient she'd been rounding on and case-managing for *for a week.*

Dude has a dense hemiplegia and is globally aphasic. He's also incontinent, has no truncal control, and requires frequent suctioning. He's a max assist with two people to sit edge of bed and can't tolerate an hour in a geri-chair.

And she wanted to send him to a rehab four hours away in the family car, with only his wife and son (no suction, no help) to watch him.

And she argued when I said we needed an ambulance.

Unfortunately, the Hero Unit Secretary wasn't working today. I was forced to say, "You are out of your effing MIND" before she would stop arguing and call the ambulance company.

Why is bile green, anyhow? What, chemically, causes that to happen? I never learned that in school.

Anyway, tonight it's Scotch and muscle relaxants (don't try this at home, kids!) because I also threw my back out this week, and then bed. I'm hoping I don't get awakened by Playful Mongo at some ungodly hour of the morning.

Tuesday, November 11, 2014

We need our own goddamned poster.

Recently, the unit I work in won an award. It was one of those not-Press-Ganey awards; the kind of award that has to do with things that are nursing quality indicators. You know, the "you haven't had a central-line infection in two years; here's a cookie" kind, but bigger.

Much bigger.

And it was nurse-driven, nurse-implemented, and exacting. And national. So, kind of a big deal.

During the hootenanny surrounding the award, we were shown a slide of everybody (so said the CEO of the hospital) who'd had a hand in making Such A Great Thing possible.

There, front and center, was the CEO. Next to him was the director of nursing operations, a man who's been actively obstructionist and slashed staffing and resources, and who has visited our unit maaaaybe three times in as many years. Next to him was a woman I didn't recognize but who, I was told, was instrumental in something statistical.

Arranged behind those people were dozens--maybe as many as a hundred?--people, all in varying degrees of business attire.

No scrubs.

Not one nurse.

Not. One.

Especially not one from the unit, the unit I work on with some of the best nurses I've ever worked with, that won the award.

So, I'm thinking we need our own. Goddamned. Poster.

Yeah.

Saturday, November 01, 2014

So, finally, my patient died.

Once in a very long while you get somebody under your hands who ought to have been let go months before.

We had somebody like that the other month: multiple surgeries for a brain tumor that was not going to go away (grade IV glioblastoma), multiple rounds of chemo and radiation, and in the middle of all of that, a surgery for an abscess that led to wound-vac sponges all down one side of the poor sot's body.

The spouse didn't want to let them go. The mother didn't want to let them go. The brother didn't particularly say one way or the other.

Ever smell a person who is, quite literally, rotting from the inside out? It's not fun.

Because, see, a glioblastoma (that's the most common form of malignant brain tumor and is, thankfully, still very rare) slowly takes away your ability to think, speak, walk, control your bodily functions. Then it starts to take away your ability to breathe. And your brain's ability to control things like its temperature and blood pressure. And, eventually, it will invade the areas of your brain that register pain. At that point, you will be in pain all the time every day forever for as long as you last.

Yeah.

It sucked. For us, as well as for the patient.

The only reason I can think of that this person was kept alive was that they had a significant pension that would've ended upon their death.

So their spouse, the person who was supposed to keep their best interests in mind, kept them alive for two entire months in order to get money.

I very rarely get *existentially* angry at work. I get angry at the administration, or at Manglement's bad decisions. There's one house supervisor in particular that I suspect was put on this earth to make sure my lungs get a workout every three weeks or so. But I generally don't get to the point that I go in search of things to punch. Ask my coworkers: they'll tell you that I'm the sweetest-tempered, most cheerful, helpful person they work with.

Seriously. And I haven't drugged a one of 'em.

Anyway. When this person came to us (and I'm carefully not using gendered terms here, because it would probably surprise you), they were reasonably compos mentis. By "reasonably" I mean that they knew their name, they knew where they were and why, and they'd mostly follow simple commands.

Within two weeks, the leftover tumor in their brain had doubled in size. Glios do that. The things that cancer loves are space and glucose and a good blood supply, and the brain has all three. What makes glioblastoma particularly nasty is that it's a tumor of the structural cells of the brain, so it sends out little undetectable filaments all around the original site. You can never get rid of it entirely.

But you can resect, and irradiate, and chemotherapize, and that's what happened. And when the patient developed an abscess on the right side of the abdomen, it didn't heal. It kept filling up with pus and tissue kept dying, because all the things we were doing to kill their brain tumor kept the rest of their body from fixing itself.

So at the end of the day we had a patient who was not a DNR, who was not on palliative care, who could not have a feeding tube inserted into their stomach courtesy of the twenty-five centimeter wide wound in their belly that would not heal; who had been intubated and extubated and who, finally, had to be four-point restrained because the tumor had hit the pain centers in their brain.

The family didn't want continuous pain control because they felt the patient was still able to communicate. This, when the MRI showed that three-quarters of this person's brain was tumor.

All of this made me vent uncontrollably to my buddy Mark, the neurointensivist. It made me vent to Ginny The Inappropriate Chaplain, and to my coworkers, and once to the patient's spouse (in a controlled and therapeutic manner). Ethics came in, ethics bowed out, case management was crushed under the wheels of the Sustain Life At All Costs juggernaut, and we all started to have a bit of twitchy post-traumatic stress.

Finally we discharged the patient to an acute-care, long-term setting. And there they died, after multiple codes, a day ago.

.*** *** *** *** ***    *** *** *** *** ***   *** *** *** *** ***

What nobody tells you about nursing is how cases like this can haunt you. I've dreamed about that poor person at least once a week for two months, now; the news that they'd died has turned the nightmares into milder anxiety dreams.

There's something about changing and bathing and turning a person who begs to be left alone to die that scars you. I am supposed to be alleviating pain, not causing it. I have a personal rule to touch every patient in my care at least once a shift *without gloves,* no matter what they've got, in a way that doesn't cause pain. Because, frankly, a lot of people in the hospital don't get touched without at least discomfort, and that fucks a body up.

But what do you do when there's nothing you *can* do? We were barred from starting a morphine drip or giving IV pain meds. The poor patient's brain was working against them. Everything hurt. Everything was futile.

And through most of it, the patient asked, then begged, to be allowed to go home with Dad. Dad had been dead for some fifty years, but showed up at the bedside on a daily basis, trying to get our patient to go with him.

I do not often have to get angry about injustice and cruelty. I don't often cry over my patients any more.

This one, I'll do both.

Wednesday, October 15, 2014

An excellent op-ed from a Minion in lovely EnZedd. . .

This is what we all should be worried about.

Conclusions.**

Thanks to the Virally-Knowledgable Minion who pointed out that I made an error by referring to Ebola as EBV. That is Epstein-Barr virus, not Ebola. As you can see from her/his comment below, Ebola is referred to as EVD or EHF. That error's now been fixed. Thanks very much for that correction, VKM! I knew there was something off about my abbreviation, but I couldn't think of what and (of course) didn't bother to check. Der.

The whole EbolaPocalypse is wearing on everybody's nerves.

I have friends who work in Dallas. A couple work at Presbyterian there. And holy shit, are things bad there. Last I heard, surgeries had been cancelled and the ED was turning away ambulances. I don't know what's happened in the last twenty-four hours, but that's what I heard on Monday.

Here's what's happened at the hospital so far, for those of you who have either been under a rock, across the uncharted oceans, or simply hiding under the covers:

A symptomatic patient, Thomas Eric Duncan, showed up at Texas Health Presbyterian Hospital (Presby) in late September. He had a fever and abdominal cramps, and told the intake nurse that he'd come from Liberia, but was sent home with antibiotics. He was later readmitted with bloody diarrhea and projectile vomiting and put in isolation.

At first, Presby officials said that he had lied on his intake form; that he'd said he hadn't been in Liberia. That turned out not to be true.

Then, Presby officials said that the intake nurse had not communicated Mr. Duncan's travel history to anybody else on the health care team. That story stood for a couple of days until some bright person pointed out that travel history is right there in the electronic medical record for anybody to see, and obviously warn't nobody checkin' nohow.

Then they said that he'd been isolated immediately. That story stood until today, when a nurse at the Presby ER said no, he'd actually (during his second admission) been sitting in a common area for as long as seven hours.

Then he died. But not until after getting dialysis and being intubated, both of which the WHO says won't do shit to prolong life and *will* do a lot to spread aerosolized virus or increase the risk of bodily fluid exposure.

And, as it turns out, the nurses at Presby who cared for him spent two days in standard isolation gear (flimsy plastic gown to the knee, goggles and mask if you're lucky, gloves, booties if you can scrounge some up) and also had other patient assignments during the time that they cared for him.

Of course, the CDC said the minute the first nurse came down with the virus, that there must've been a breach in isolation protocol on her part.

But then it turned out that holy crap, the hospital had waited until final results of viral testing from the CDC had come back to get their workers into proper gear and limit their patient-care assignments. The preliminary positives apparently weren't enough, combined with the poor man's travel history, to alarm the administration. So it wasn't so much a breach of protocol on the RNs part as it was sending a nurse into a forest fire with a bladder full of piss and no backup. Nurses were cobbling together whatever they could in an attempt to replicate proper isolation gear. They were borrowing from other departments and MacGyvering stuff for two days.

Now a *second* nurse has come down with Ebola, and she travelled from Dallas to Cleveland and back in a state of as-yet-undetermined contagiousness. I got nothin' to say about that except holy shit what a . . . .wait, no. I can't judge. Because if she'd been told she wasn't contagious without symptoms, and her movements weren't restricted, then. . . .? I don't know what to think about this part of the story, because, if it's like the rest of the story, there's more and different facts to come.

So. What conclusions can we draw from this?

Conclusion the first: The first reaction on the part of everydamnbody has been to blame the nurses. From the first inkling that Mr. Duncan's diagnosis was missed to the news that a second nurse was infected, the director of the CDC and the administration of Presbyterian Dallas have pointed to the RNs as the weak links in a chain.

I'm sorry, guys (because they are all, frankly, guys, and NOT nurses): in order for a fuckup of this magnitude to happen, a number of links in your chain of failsafes have to break. It doesn't matter if you have a "health care team" if members of that team only see each other in the bathroom and when they're punching in. People have to communicate, yes, but they have to be given the opportunity to communicate, which means proper staffing levels and backup when it's needed.

For one, nobody noticed the travel history when it was submitted the first time. That means that the ER staff was either understaffed or slammed, or both, and/or that the intake nurse never got a chance to communicate face-to-face with the rest of "her team." So you had a team in name only, screenings in name only, and procedures in name only.

Conclusion the second: Whoever had the job of preparing the Dallas area (and my area, come to that) as a whole for Ebola did a piss-poor job. The nurses I work with have been talking about the probability of caring for an EVD-infected patient since July, when it became apparent that the outbreak was getting out of hand overseas. ER nurses I work with have been wondering what, exactly, to do for protective gear and isolation facilities, since not a lot of hospitals have more than curtained cubicles in the E R. We do not even have an international airport in this area. What must it have been like in the breakrooms in Dallas?

To give you some idea, one of my besties works at a large academic medical facility in the Dallas area. It's the sort of place you take gunshot victims or people who've been hit with a chemical contaminant or folks who've been bitten in half by a llama. She told me yesterday that her facility's prep for Ebola (and keep in mind that this place has a busy ER in a highly international area) has consisted of one streaming video and a lot of assurances from administration that they're working as fast as they can on a protocol.

Guess what, Administrators of the World? The CDC and WHO and MSF already have protocols in place. All you have to do is devote the time to learning them and the money to proper materials.

Conclusion the third: If you are a nurse anywhere in Texas, you are screwed to the wall. You might wonder why the nurses at Presby who spoke out are being protected by the largest nursing union in the US. It's because you're told, as a nurse, that if you say anything negative about something that happens at your facility, you will be fired. Period, full stop, do not pass go.

A couple of years ago, somebody got mugged in our parking garage. A nurse I worked with put it up on social media that she no longer felt safe in that garage, and wondered why we didn't have better lighting. Two weeks later, she was gone. Fired. For a med error that had happened months before, and for which she had received no prior counseling. All totally fine and legal in Texas, kids.

Imagine what it must be like for the Presby nurses who were sent home, day after day, to their families and dogs and cats and knew what they'd been in contact with. They can't say boo for fear of being fired and placed on the informal blacklist that exists in this state.

Conclusion the fourth: Texas nurses need a union. Yes, unions tend toward the bloated and bureaucratic. Yes, unions sometimes do more harm than good. Yes, yes, yes, I know all the arguments.

But right now? The nurses in this state are being hung out to dry by their bosses, and nobody's getting upset, except in a very low-key, please-don't-fire-me kind of way.

If I had to care for a patient with Ebola tomorrow, I would have no appropriate protective gear. I would also have no way to refuse the assignment (not that I would; I'd pull up my big-girl panties and pray like hell). I would have no way to protest that I was taking care of the patient without proper safeguards in place. The most I could do would be fill out an incident report after the fact and hope that it got to somebody who gave a good goddamn.

They say you can't be fired for calling safe harbor here, but I've seen it happen many times. And there's no way to register that you're nursing under duress. None.

Unions add a little muscle to the arguments that nurses make. It would be nice, for once, not to feel like I'm stepping out on a tightrope over a windy canyon full of hungry alligators, naked, with a bad case of chiggers on my ankles. I would like some fucking backup, please; a little bit of muscle that I could use to enforce the staffing ratios and protocols that my administrators brag about on promotional materials.

I have no problem at all taking care of somebody with Ebola. I don't think it's necessarily the best idea to have such a disseminated system of care; perhaps we should look into certain hospitals specializing the way Emory and Nebraska do.

However, if it comes down to it, I am more than happy to do it. I did not sign up for this job because I thought it would be glamorous or easy.

All I want is a little consideration, a little preparation, and a smidgen of concern for my safety. From what I've seen of how things have been handled up to this point, I doubt I'd get any of that.

**It occurs to me that this is the most bolded, italicized, and screeching post ever posted in the posting history of this here blog. Sorry 'bout that, y'all.

Sunday, October 12, 2014

In Which Jo Has Doubts About Her Floor.

WARNING: THIS IS A RENOVATION, NON-NURSING POST. IF YOU DON'T LIKE HEARING ABOUT CONSTRUCTION OR DEMO, GO ELSEWHERE.

Some of you longer-term minions might remember when I bought Casa DogHair and renovated the bathroom. The shortest version, for those of you who haven't sobered up yet, is this:

The people who owned CDH before me were both of some size. They were also not good with maintenance. This led to the bathroom being entirely rotted out in vital areas, which in turn led to Then Boyfriend and I redoing it.

I should mention here that Then Boyfriend had a weird work schedule and I was working all the time, so I had very little input into the construction. I helped with demo, tiled the floor, and that was it.

So when I stepped through the bathroom floor a few months ago, it came as a bit of a surprise. TB had told me he knew what he was doing; in fact, I knew he had worked construction in the past. So I trusted that he knew how to install a bathroom floor, make the shower water-tight, all that stuff.

Instead, what I found was un-taped cement board in the shower that had been waterproofed on the wrong side, weird joints that weren't water-tight, and a floor that. . . .well.

Normally when one installs a tile floor, one lays a sheet of plywood down and fastens it to the joists. This provides a stable surface for what's to come after. Then, one lays a quarter-inch-thick layer of thinset mortar down and uses that to bed cement board. It's important, when you're laying tile, to have a deflection-free (no bouncing), solid (won't shift laterally), independent (not screwed to the joists) surface for the whole shebang. Plywood screwed to joists is layer one. Mortar-bedded cement board, screwed to the plywood bur not to the joists, is layer two. Properly done, the resulting monolithic surface should last a lifetime.

He had laid half-inch cement board over a vapor barrier and nailed it to the joists. There is so, so much wrong with this that I can't even. I had to liberate a fair two gallons of water from under the floor, atop the vapor barrier, where the weird seams had leaked.

Here's the deal: demo of a properly-installed tile floor of this size ought to take a solid day or day and a half of work. It took me forty-five minutes, and I didn't even break a sweat.

After I demo'ed the floor, I began to get the willies about the shower, so I started peeling tile off of the walls with my bare hands, no joke no kidding, and the whole project got exponentially bigger in about ten minutes. Shower tile should not be removable with one's bare hands. 

But it was and it was and here we are, with a plywood floor barely tacked down and shower walls covered in plastic.

Which brings me to the floor. All of the preparation for laying tile will result in a floor that's at least 3/4 inch higher than the floor outside the bathroom door.

The Boyfiend, who actually *does* know how to do this, has done it before, and is doing it right this time, floated the idea of lowering the joists under the bathroom to give us sufficient clearance to have a seamless transition between the wood floors outside the bathroom and the future tile within. Over dinner last night, he and his brother The Psychopath debated the various ways this could be done, with The Psychopath insisting in a querulous voice that we'd have to pull the tub (find me four strong and patient men and a space warp, dear; that tub is wider than the doorway) and jack up various bits and bobs of the foundation.

Boyfiend insists this is not a big deal. I have my doubts about that. As I told him last night, when I hear a man say "It's no big deal; it'll work out fine" I know that I'm gonna need three hundred bucks and a course of antibiotics, stat.

So I started thinking of alternatives and came up with a roll of rubber flooring in a coin pattern. It's exactly the same thing that Daniel used over at Manhattan Nest a gazillion years ago. It's cheap, totally waterproof, and there will be no seams.

And it's thin enough that we won't have to lower any joists or do any other major structural work.

Boyfiend is still snoring away, but I plan to hit him with this idea once he's up and has had some coffee. And we shall see.

Thursday, August 28, 2014

Meh.

I've decided it's not the heat here in Central Texas that bothers me; it's how long it lasts. I could easily handle a worse summer than we've had here--only a couple of days over 100 degrees!--if it just ended sooner.

Something about the constant bright sunlight and the lows in the 80's really wears me down.

So does work. Work is wearing me the hell down, People.

I almost had to call in the Ethics Peeps this week. Mama is dying of a nasty sort of metastatic cancer that's hit her brain, liver, spine, and various other bits of important equipment. She has a midline incision from her breastbone on down that won't heal, a couple of cracked ribs from a previous code, 3+ edema every-damn-where, she's breathing too fast and her heart's wearing out, and she's seizing constantly and has been for about the last three weeks. Oh, and she has a galloping infection under her scalp, where a bone flap was taken out when some other neuro guys somewhere else resected a tumor in her brain. That's the least of her problems, frankly.

We've spent the last two weeks trying to convince Son that perhaps Mama should, when Jesus calls, actually pick up the phone. She was a full code this entire time. That means, for you non-medical people, that if her heart or breathing had stopped, we would've gone into Super Nurse Grey's Anatomy Mode and tried our best to bring her back. (Well, not really. I would've walked slowly to that particular code.)

The trouble is that, when you're trying to save people who are that sick, you end up torturing them.

Even the best, most well-executed code has only about a three-in-ten chance of bringing the patient back. And by "bringing the patient back," I don't mean they walk out of the hospital. I mean we stabilize them enough to get them into the CCU, where they'll be intubated and sedated and have drugs pumped into them that will keep their blood pressure up while causing their intestines to slough off and their hands and feet to turn black and gangrenous and we'll put 'em on external continuous dialysis and they'll have tubes coming out of every orifice. . . .

It's ugly. In twelve years, I have heard of--not actually seen--one patient leave the hospital under his own power after a code. Part of that has to do with the people we code: not many, because we're big on comfort care and being rational. Part of it has to do with the population we serve: once your brain goes bad, there's not much point in keeping your heart beating, and no real good way to do it.

Anyway. Mama and I had gotten well-acquaint (or as well-acquaint as you can with somebody who twitches and moans) and I was looking forward to the probability that I would be breaking more ribs, causing her belly wound to come apart and her guts spill everywhere, and generally doing something I didn't want to do. We actually had a call in to the ethics committee about Mama, when a doc I had not met before came sailing in like a white knight and saved the fucking day.

The dude is new to the hospitalist program. I met him for the first time after he'd been straightforward and a tiny bit brutal with Son about Mama's chances. I could've hugged him. Instead, I called Ethics back and told 'em to stand down.

Mama is now a DNR. She's not on palliative care yet, but I'm happy just being able to not have to consider coding her.

Sometimes things work out okay, relatively speaking.


Wednesday, August 13, 2014

What I thought/What I said

The interviewer asked, "What's making you want to leave your current job?"

I'm tired of watching my coworkers coming in, looking defeated.

I haven't had a sit-down lunch in six weeks. One of my coworkers weaned her baby early because she couldn't get anybody to relieve her so she could pump breastmilk.

Our acuity increased at the same time our director cut our staff, so there are delays in care that I find unacceptable.

We've been rebranded a "step-down" unit, so none of us will get critical-care raises or credit, but we're still taking CCU patients. We still float to the CCUs.

The attitude of the administration to our unit is "do more with less; you're nothing but big whiners." When the director brushed off legitimate concerns with the response that we were "jibber-jabbering," I died a little.

I showed up at six yesterday and started working immediately, because there were three admissions at once and none of the resources or help we were promised were available.

We're having falls and bad patient outcomes as a result of short-staffing, and we're getting disciplined for them.

I can't get a damn MRI statted because I can't find somebody who can monitor a patient on a drip in the tube.

Our manager refuses to back us up when things get dangerous.

The doctors I work with recognize the problem, as do the nurses in other departments, but still nothing is done.

I'm exhausted from not eating, not peeing, not taking a day off, and the rest of my life is suffering.

Although we stand in solidarity as a unit, the director is telling his bosses that there are a few bad apples spoiling the whole bunch, and that getting rid of them would fix the problems.

Which is why, I guess, that all but one of us are looking for new jobs. And that one person is reconsidering.

Because when you have a wife who's on palliative chemotherapy, even a potential gap in insurance coverage beats working here.

The training and education we were promised hasn't materialized.

We're used as a dumping ground for VIPs, when actual sick patients are pushed to other, even more crowded units.

We've won awards and have certifications out the wazoo, but the things that made those certifications and awards are gone now.
Yet we're still expected to make do, somehow.

And if we stand firm on staffing grids and patient safety, we're written up and our patients are moved elsewhere, to make room for the aforementioned VIPs.

I dread coming to work every day. The only thing that makes it possible for me to sleep the night before a shift is Benadryl. And bourbon.

I'm terrified that something horrible will happen, that a patient will die or be injured, because we don't have enough staff.

That almost happened last week. A patient with a sudden neurological decline had to be transported to the operating theater by two doctors, because we were short nurses to monitor him.

I miss the days when I could leave work and not ruminate on possible mistakes or oversights I might've made.

I miss being a nurse rather than a combination unit secretary, patient care aide, phlebotomist, janitor, social worker, and engineer.

Broken equipment stays broken for months.

Our infection rates are up and our patient satisfaction scores are down. We've been told we can be disciplined for both.

I loved this job for years, and fought really hard to keep just this thing from happening. I'm incredibly proud of the work that we do and the outcomes we've had in the past. We've done it all together, as a group of very stubborn nurses, in spite of--not because of--our managers and administrators. I'm tired now, and I want to back off and not fight every single day for basic safety and resources.

"Well, I've been doing the same thing for more than a decade, and I felt like it was time to branch out and broaden my skill base."