Family Affairs:

When Your Patient is Not the Only One Who Needs Care

Another post in the #AtoZChallenge (unfortunately not getting off to a good, consistent start!)

My friends who work as pediatric nurses often say that when you’re taking care of the “kiddos,” you are inevitably taking care of their parents as well. It is hard to separate patient from parent, or patient from caregiver. In my experience, the same could be said of the adult world: taking care of a patient is a whole family affair. 

I can count numerous times when my job as a nurse not only entailed caring for the needs and concerns of my adult patient, but also quelling the fears and fielding the queries of their spouse, children, siblings, parents, or other caregiver. Depending on the situation, I could be an intermediary between the patient and the provider, the family and the provider, the patient and their family, or even between family members themselves.  Back when there were no visitor restrictions on the unit, there were times when I would teach a patient’s wife how to administer tube feeds, times when I was flagged down in the hallway by a concerned son to explain why his dad looked like “that,” times when I would stand with hands clasped as a husband berated me about why a doctor had not seen his wife yet or why her surgery was delayed, and times when I had to give a little tough love to the family and encourage them to allow the patient to do more for themselves. 

There were also times when simply because I was a nurse, I also became a confidante of the family, a friendly face, someone whom they trusted to care for and advocate for their loved ones. This next story was one of those instances.

A couple years ago, I took care of a patient who had transferred to us from an outside hospital for additional care. Per the family, he had been referred to us by his neurologist “to get antibiotics” because he had an infection. By the time he showed up on our unit, he already looked quite fluid overloaded and his functional abilities seemed to have declined a considerable amount. He could not really talk let alone eat or move most of his extremities. We had him on tube feeds and considered him a “total care” patient, meaning he was unable to move, bathe, toilet or feed independently. 

A few days later, his family was brought in for a meeting to discuss the patient’s goals of care and the plan moving forward.

Basically, from a medical standpoint, it did not appear that any further treatment would bring about meaningful results for the patient and rather might actually hinder his quality of life. 

We had the wife, two daughters and son in the room, as well as a third daughter calling in on the phone. The attending physician, nurse practitioner, social worker and I were all present as well. The conversation started as most do, with the attending discussing some of the events leading up to the patient’s presentation, what we have done so far as well as their effects, and the direction that it seemed like the patient was going in despite further treatments. I wasn’t required to speak much, but my presence served to comfort the patient and family. The option of hospice was brought up to the family and they were given the opportunity to discuss among themselves what they believed was best for the patient. It became difficult and tense, though, when we realized there differing views among the family members on what to do for the patient. The daughters believed that hospice was an appropriate course, whereas the wife and son wanted the patient to keep fighting. They latched on to the notion that antibiotics could fix all. 

During this conversation, I noticed that the wife would periodically doze off as we were talking. She appeared to slump over in her chair at strange moments, only to suddenly spring back up minutes later. When she spoke, her speech was a bit slurred and would often meander to irrelevant topics. Prior to our meeting, the son had been visiting with the patient, but mostly he spent his time sleeping on the recliner situated in the corner of the room. He also appeared rather flushed, but I didn’t think anything of it. 

When the meeting concluded and the family got up to leave, one of the daughters gestured to me and pulled me aside. It seemed that she wanted to tell me something in secret. 

“Hey, just to let you know,” she began, “I think my mom may have been a little high. She’s had many surgeries in the past and has been self medicating” she said as the other daughter gave me a knowing look and walked the mom out. She then added, “Also, I think my brother has been drinking because his face is really red and he probably shouldn’t drive home.” (Just as a side note, the team had told me previously that they were told the son was an alcoholic who was not very helpful when not sober, so I already was aware that the family was dealing with health challenges and stressors in more ways than one). 

“Oh, really? Thanks for telling me” is all I could think of in response. What was I to do with that information now? While I was glad that the daughter felt comfortable enough to confide in me, I did not really know what I was supposed to do. What was my role in this situation?

Currently, the son had not left yet and was sleeping at the bedside. Phew, I thought. When he woke up and started packing up his things, he looked alright and awake and alert, but I felt obligated to convince him to stay. I tried using his dad as a bargaining device. “I think your dad would appreciate you being here. You could provide him moral support,” I said maybe a little too cheerfully. I didn’t want to let him know that his sisters suspected he had been drinking. As the son thought about whether to stay, I went to the charge nurse to see if she had any recommendations. But midway through our conversation, the son came up to me and with a quick fist-pump goodbye, said that he was going to leave. And just like that, he was gone. 

I remember wrestling internally about what I should have or could have done differently that shift. On one hand, I felt I was entrusted with this information by the daughter so I could look out for her brother’s safety. Patient and family-centered care is key, after all. However, after reflecting on this experience, I had to remind myself that the patient was my primary responsibility and ultimately it was the son’s choice if he wanted to go. While we certainly look out for their families too, they are not the ones here for treatment. As nurses, we tend to be problem solvers and fixers. We care (maybe a little too much, sometimes!) about our patients and their families, but there are limits on what we can do. 

While I may not have been able to help my patient’s family directly in that instance, I think that experience has taught me lessons and insights that I’ve carried on to future patient experiences. I’ve seen the difference that having a supportive family can have on a patient’s outlook on their condition and life in general. I’ve seen how one’s coping strategies, good or bad, can drastically change the course of their health.

And most of all,  I was reminded of the impact that a patient’s illness can have on their families and caregivers and that those same families and caregivers often are dealing with many life stressors and challenges of their own. 

Adjusting to a New Job

[Note: This marks Day 1 of my Blogging from A to Z challenge… here goes!]

Adjusting to a new job is a process. It can be exciting, scary, overwhelming and wonderful all at the same time. I recently started a new job last year, switching from working on a med-surg unit to the emergency department of my hospital, and I can tell you, I felt all those emotions and more. It didn’t matter that I already was a nurse for a few years. It still felt like starting from scratch. There were the more external, physical parts about the adjustment process: meeting new people, acclimating to a new workflow, learning where things were. Then there were the internal, less visible parts: setting expectations for myself, getting over my pride, fears and insecurities, slowly building confidence in my abilities and judgment. 

While nursing has been my first “real” job out of college, I have also had other jobs, volunteer roles, leadership positions and internships prior to this. And though each position was quite different, the adjustment process itself was very similar. 

So as a way to share what I have learned along the way, here are some simple tips and takeaways from my experience adjusting to a new job: 

Be willing to learn. Whether you’re as green as a gourd or a seasoned veteran in your industry, having a motivation and openness to learn is paramount. I tend to view every experience as a learning opportunity. I switched to the ED because I wanted a chance to learn something different, to see a different side of the hospital. When a critical patient would come in, even if it wasn’t my patient, I’d try and peek my head in to learn how the team responded. You can learn from success and  you can learn from failure. Even if you start a job and realize that “It’s not for me,” at least now you know and you can learn from it. The key is that you learn and find ways to improve in the future.

Know when to ask for help. We weren’t put on this Earth to live life in isolation. Nurses sometimes like to think they can wear ALL the hats and do it all, but this simply isn’t possible nor sustainable. Learning how to accept help and delegate appropriately was vital to my growth as a nurse. As the saying goes, teamwork makes the dream work. 

Be comfortable with discomfort. Change is hard and uncomfortable. You don’t need me to tell you that. But the fact that you’ve decided to put yourself out there and start a new job, whether it was out of necessity or as a step towards a higher goal or passion, that takes courage.  The best things don’t always come easy, so don’t give up. Payoff takes patience. See how you will grow as a result. 

Actions speak louder than words…but do know when to speak up.  Sometimes it’s easy to just put our head down, put in the hours, and let our work do the talking. But while being diligent and having a hard work ethic has its merits, I have learned over the years that sometimes you truly need to use your voice. When I think of the nurses and colleagues who inspire me, they all are not only intelligent, resourceful, compassionate and the hardest of workers, but they are AMAZING patient and staff advocates. They speak up on behalf of patients. They champion patient and staff safety. They empower and inspire others to not only talk the talk, but walk the walk. 

Be humble. It is important to remember that it is okay if you don’t know everything. You’re not expected to! The key here is that you acknowledge what you don’t know and ask for help when appropriate. And along those lines, always remember to show gratitude and appreciation. People don’t hear “thank you” enough! 

Be curious and ask questions. Sometimes the value of being new is that you can bring in a fresh perspective. You can see things from a different angle and ask “why.” Even if the “why” makes a lot of sense, at least now you know the answer! When I first started as a nurse, I felt like my curiosity and desire to learn helped me better understand patient conditions, plans of care, my role in healthcare, and ultimately  deliver better patient care. Additionally, be curious and ask questions of your colleagues! Get to know them and show you care.

Treat others the way you want to be treated. I feel like this one is pretty self explanatory. It’s the Golden Rule. I’ll leave it at that!

One Year and Counting

Confirmed COVID-19 Cases as Reported by Johns Hopkins University

One year ago today, the hospital at which I work encountered our first COVID positive patient. I remember at the time, things were still pretty hush-hush. As healthcare professionals, our friends, families and the general public looked to us for answers.

We tried to quell anxieties and fears, but it was apparent that we did not know what we were in for.

“There is no need to worry—the flu would be a more serious concern,” I told a friend back in February when she first heard word of this novel virus floating around in Asia. I would soon be eating my words. 

Less than a month later, most of DC shut down. I took my nursing certification exam on what would be the last day testing sites were open. That same day, I attended my final boxing class, as I said goodbye to group exercise in-person gym classes indefinitely. There was an eerie, post-apocalyptic type of feeling that permeated the air. 

Masks here, there, everywhere!

In the ensuing year, our hospital took care of countless COVID-19 patients and we learned to adapt to the situation. Guidelines and recommended workflows were fluid, as we received new information regarding the transmission and severity of the virus almost daily. Our hospital census practically came to a standstill, as many patients decided to forgo a hospital visit if they could avoid it and elective surgeries were immediately halted. Masks became the norm, and unfortunately for me, so did “mask-ne.”

Visitors were non-existent, and even when some restrictions were lifted, they became few and far between. The exceptions to our no-visitor policies were reserved for patients at the end of life, and even then, only two visitors were allowed. That meant larger families had to choose who could come see grandma or grandpa. There is nothing more devastating to witness than a patient who has to spend their last breaths by themselves. We tried to integrate families into the care of their loved ones through video chats and phone calls, but those were not perfect substitutes for in-person experiences. And when families did visit to see their loved ones at end of life, it was always tough and emotional.

“It’s just been so long since we’ve seen him,” I remember one daughter saying while in tears, standing next to her dying father. To be granted the permission to see him, only on his death bed, was tragic for patients, families and staff.

The COVID-19 pandemic has been challenging on all fronts. But during this time, I have been more than impressed by how my hospital has stepped up to the occasion and prioritized the safety of patients and staff and maintained a commitment to quality care and excellent service. On my unit, we converted all of our private rooms into negative airflow spaces. Although we may have griped about the constant rotation of various PPE—some more comfortable and breathable than others—I was nevertheless thankful that we had adequate supply. Compared to the stories I had heard from friends in New York, we never had to use a mask for longer than a week out of necessity. Rooms in the ICU were renovated so that all doors now have a glass window, allowing monitoring of patients from behind closed doors. The triage area of the emergency department morphed into an outdoor tent equipped with HEPA filters and heaters. When elective surgeries came to a halt, OR nurses were trained in other functions, some becoming respiratory therapists. Nurses were cross trained into higher levels of care to support team nursing initiatives. The hospital was determined not to furlough any clinical staff if it could be avoided. From a supply, logistics and HR standpoint, I felt like our hospital succeeded. 

I have also been impressed and blown away by the support from the community and the determination and resourcefulness of all staff. Starting from week one, signs and ribbons were visible in the neighboring community with words of encouragement and gratitude. Meals and snacks were often delivered to each unit, as a token of appreciation to frontline workers. Staff got creative in their abilities to maintain quality care and limit COVID transmission and exposure. Makeshift whiteboards and markers were hung in each room so that nurses inside could communicate with fellow staff if they needed help, since the air filters often made it too noisy for the call light system to be useful. Fanny packs were used to hold goggles and masks. Patient beds were cat-a-cornered in rooms to allow better viewing abilities from outside the room. Tablets were used for family communication and interdisciplinary rounding. Nurses came up with clever and cute ways to ease the discomfort on their ears and faces caused by wearing masks all the time.

On the day that the US reached 500 million deaths from COVID-19, flags were flown at half-mast across the country

Now that we are one year into the global COVID-19 pandemic, it is easy to look back and think about how far we have come. And while we should not discount the amount of progress we have made, we must also not become complacent or impatient in this current state. Sure, vaccine distribution has begun, but it would be premature to let down our guard and return to a mask less and pre-social distanced way of life. Time and knowledge has offered a little more freedom and a lot less fear, but there is still much work to be done.

Thus, as we all move forward in the year, I do so with tempered optimism. I remind myself of the fragility of life and the monumental effect that COVID-19 has had on people’s health, livelihoods, and families all around the world. I think about the amount of change—both positive and negative—that has occurred in this short year. And I am hopeful that we continue to make progress towards a better future and learn from the lessons of our not-too-distant past. 


The Walk Test

“Sir, sir, it’s time to wake up. It’s five in the morning. Do you want something to eat? Let me get you a sandwich and then let’s try and get you up and walking,” the script goes, often with minor variations here and there. 

When I worked on a med-surg floor, 5AM signaled the start of morning labs, meds, vitals and final checks for toileting and clean-ups. Somehow someway, whether the night was as quiet as a mouse or busy like a bee, the call lights and phones always managed to go off like clockwork when 5am hit. It was like someone set an alarm in each patient’s room instructing them to ring the call bell at exactly 5am each day.

But now as I work in the emergency room, 5am has a different significance. It’s the unofficial time to start waking up our MTF patients and getting them to walk. MTF stands for “metabolize to freedom.” In other words, these are the patients who were brought in by EMS after being found down or wandering about the streets, intoxicated. Oftentimes, these patients are homeless, unemployed and have a chronic history of alcohol or drug abuse.  When they are brought in, we make sure that there are no signs of injury, trauma or immediate life threatening emergency. In the winter, when patients are at risk for hypothermia, we often wrangle them free from their urine-soaked clothing and place a heated blanket, aptly named the Bair Hugger, over them to raise their core body temperature. Some doctors will order a full work-up, bloodwork, urine and scans. Others are more conservative in their treatment and will simply get a blood sugar, vital signs and let patients sleep it off  and “metabolize to freedom” under the close eye of clinical staff. 

How long it takes the patients to sober up and MTF depends on the patient and the amount of substance consumed. Some patients can be in and out of the emergency room within the same night, making it out the door before the buses stop running at 11pm. Others require an overnight stay in the emergency room, but the goal is still to get them out the door by the time buses start up and running again at 5:30AM. 

Thus, once 5am comes around, if the patients have not already woken up, we begin making our rounds. For some patients, a gentle nudge is all it takes. For others, it is a drawn out process and a negotiation. Attempts to wake patients up can be met with anything ranging from immediate cooperation to incomprehensible moans and groans, to complete belligerence and violent outbursts warranting a need for security to escort the patient off the premises. 

Regardless of what it takes, before the patient actually steps out the door, the one thing we make sure to do is a walk test to ensure that they can at least ambulate steadily on their feet. These patients end up getting discharged to the streets, so they need to show that they can get themselves out the door. 

One particularly cold and icy January morning, my patient exhibited much difficulty on his walk test. He was Spanish-speaking and had been brought in during the night for acute alcohol intoxication. On our first try, he could barely get up from sitting to standing. I saw his knees buckling and he repeatedly stated, “No puedo, no puedo.” In my time working as a nurse, I’ve had to fine tune my B.S. meter a lot more because so many patients will tell you that they can’t do something when they clearly can. But in this case, it did not appear that the patient was exaggerating. It looked like he had scraped up his knees (during a fall perhaps) and was having some residual pain that prevented him from bearing full weight on his legs. He tried to stand again and this time had to bend over and hold the wall just to brace himself and keep from falling. When the doctors checked on the patient, he was able to muster out a few stiff, unsteady steps, but nothing more. As I looked to the doctor for guidance, I was met with the response, “You know… it’s not great, but he can walk.” Now the onus was on me to get him out the door. I looked at my fellow nurses with concern and exasperation, but ultimately knew that we didn’t really have another option. 

Now, here is where I as a nurse struggle and sometimes find myself at a crossroads between my duties as an advocate for patient needs and safety and my responsibility to the overall purpose and needs of the hospital. While in theory they should be aligned, sometimes I feel they are at odds. On one hand, I did not think that this patient was ready to be discharged yet and believed he really did need help. He seemed to have trouble walking more than a few steps. And he had also mentioned that he had been kicked out of his apartment for drinking. Our registrar insisted that he had a home address listed in the medical record, but the patient was adamant that he did not have a place to go. It was icy and cold out, so to send him out in this weather, when I was not even certain if the buses were running, seemed just cruel. On the flip side, I knew that at its core, the issues this patient faced were socioeconomic in nature and that the hospital was not the best, nor the most appropriate, place to help him. On top of that, the hospital was full too. So, what was I to do?

Well, it was clear that the patient was ready to go from a medical standpoint. He showed he could “walk,” he was alert and oriented, and no longer warranted medical attention. I used a translator to go over his discharge paperwork, shared some resources about free medical clinics (although I still could not really answer his most pressing question, “But where will I go?”), gave him a sandwich and juice, and then brought a wheelchair to take him outside, for there was no way that this man would be able to make the trek on his own. 

Once we got to the emergency room entrance, the patient again began stating that he could not walk and that he had nowhere to go. I tried to encourage him, “Yes you can walk! Remember? You just took some small steps back there. The bus stop really isn’t that far.” The patient just looked defeated and did not want to get out of his wheelchair. I didn’t blame him. I felt guilty for even discharging him under the current conditions. I mean, I even almost slipped on ice as soon as I stepped out of the overhang.

The most I could do was wheel him to the bus stop. So, I gingerly wheeled my patient downhill, using all my weight to control the speed of the chair so he wouldn’t be ejected from his seat, and transported him down the street to the bus stop. At the stop, there was no seating and the ground was slippery, but there were some stairs that were lit by streetlights. So I used the translator to instruct the patient to sit down where it was dry and wait for the bus. By this time, snowflakes had begun to fall and daylight was starting to settle in. I probably told him ten times, “Be careful not to fall! The ground is slippery, so watch where you step!” But, I don’t think falling was his main concern.

As I returned to the emergency room, the cold air lingering on my scrubs and my breath, I felt disheartened and discouraged. Discharging a patient to the streets has never sat well with me, but it’s something that I’ve wrestled with and had to become more comfortable doing since transitioning into the emergency room. Looking back on my med-surg experience, so much of a patient’s admission behind the scenes is devoted to ensuring a safe discharge disposition. Even if a homeless patient doesn’t need rehab or skilled nursing care, the team of providers, case managers, and social workers try their damned hardest to get in touch with family members or even a shelter, before resorting to the streets. But in the emergency room, we don’t have that luxury with all patients. As part of the ER team, one must be thorough and judicious about the care and treatment that is ordered. Our primary concern is the health issues that are emergent and life threatening in nature. We recognize that there are social factors that contribute to a patient’s health, or lack thereof, but unfortunately, our hospitals are not designed nor adequately equipped to truly solve those problems. 

So what are we to do? How many more walk tests must patients take before they can truly get the help they need? When I first started in the emergency room, I think I was surprised by how many cases of acute alcohol and drug intoxication I would see. (Very naive of me, I know, considering I work at a large urban hospital. But in my defense, those were the patients I wasn’t seeing during my time on the inpatient side and now I know why.) I guess there’s no other place EMS can bring them. The hospital is their safety net, their temporary housing, a warm bed for the night. 

As I reach the end of this reflection, I realize that my rambling on this subject has already gone on for far too long, but I hope that by sharing this story and my thoughts, I have shined a little light on the limitations of our current health system and inspired others to learn more and contribute in positive manner. Social determinants of health and upstream factors, to some, have become a worn out topic and public health buzzwords. But I believe the “buzz” can stand to be amplified! What can you do, what can I do, what can we all do to improve the health of all patients, individuals and families? How can we tackle the problems of alcohol and drug abuse effectively and compassionately? Advances in public health take a collaborative, team approach. So, let’s work together to change the lives and outcomes of patients, communities at a time! 

A Year in Review

And just like that, another year is almost over.

2020 “ Zoomed” by. While it feels like big plans, adventures, and aspirations have been indefinitely on hold since March, the year was by no means uneventful. Let’s recap, shall we?

Things got off to a rough start in January, with the fires ravaging Australia and still tormenting California, the Trump impeachment underway, the death of the great Kobe Bryant. And that was only in the first month! Next came the introduction of COVID-19 in the United States, the shift to a life of quarantine with all its ups and downs, accompanied by social injustices and civil unrest all across the nation. Now with the election over and the hope for a better 2021, the ever-tenacious talons of 2020 still reel us back in. The current President is not accepting defeat. The second (or third, but who’s counting!) wave of the pandemic is here and ready to rumble. And with the winter holidays looming and the public antsy to travel, only time will tell how much damage the virus leaves in its wake this time around.

Although it is easy to look at this year as one that was marred by all things negative, I’d like to think there was a silver lining, that amidst all the uncertainty, sadness, anger, and frustration, there were lessons learned. Around this time last year, hope was in the air, as 2020 was going to be “the year of 20/20 vision.” And while it was certainly not the year we thought it would be, it still provided clarity.

COVID-19 shed light on the state of public health in our country and demonstrated how much work has to be done to improve health disparities and inequities. The virus challenged companies in varying industries, not just healthcare, to step up to the plate and respond in a timely manner. An outpouring of support and appreciation was shown to frontline workers and educators (although, why did it a require a pandemic for people to finally recognized teachers for all their worth?!) The need for change and solutions fast-tracked the development of vaccines, adoption of telehealth in many practices, and reframed what activities truly needed to be done in-person.

Life in quarantine may have been lonely for some, but it probably was a well-needed “reset” and time of respite for others. Social distancing not only became a new vocabulary in our everyday conversation, but it also triggered a mass movement of work-from-homers to indulge new hobbies. All of a sudden, every one and their grandmother had a YouTube talk show! The repeated injustices against the Black community exposed the deep divides and biases that persist today and brought together activists across all races, creeds, genders and ages to fight for a common cause. Finally, the toll and severity of the virus reminded us of the fragility of human life and the gratitude we must have for the many blessings we have.

As a nurse during this pandemic, I felt fortunate and honored to care for and be with patients when their families and loved ones could not. 2020 was also the Year of the Nurse and boy, did nurses live up to it. Seeing nurses around the nation step up to the challenge and shed blood, sweat and tears for those who were most vulnerable stoked my passion for and pride in the profession even more. As I look forward to 2021, I know there is still a long road ahead. (COVID-19 is still here, so don’t go throwing out your masks just yet.) This may be our new normal for the long term. But I am hopeful that the lessons we learned in 2020 will bear fruit in the coming year.

A New Project

2020 has been rough and unexpected, to say the least. But in times of darkness, there is light. There are lessons to be learned, metaphorical fires that are ignited. COVID-19 certainly threw a wrench into any big plans I had for this year. However, it also reminded me of the significance of “now,” the freedom that comes with leaning into fear and uncertainty, and the power of human connection.

As I sit here having turned the ripe old-age of twenty-five, part of me can’t help but think back somewhat ruefully on all the ways 2020 could have gone differently. But I also re-count all the positive moments I have had in spite of it all. COVID made me relish in the blessings of the present and not focus unrealistically on the past. It challenged me to grow, adapt, and learn. I feel proud and privileged to be working (period, really) as a nurse during this pandemic. I am thankful for the technologies that enable us to communicate with friends and family near and far.  And I am both excited and apprehensive about what’s next.

With every birthday or new year, I try to set goals for myself.  Rarely do I ever actually attain them. This coming year, I want to change that. One of those goals is to finally pursue my passion project of sharing my experiences and interests in healthcare and nursing with others. Perhaps it was the restlessness of staying in place and seeing the confidence of all these new home chefs, bakers and musicians during the pandemic that encouraged me to finally do the same and pursue my own hobby. I have always enjoyed writing, but never felt confident enough to share my thoughts and opinions in a public way. What ran through my head either stayed there, keeping me up at night, or was jotted down in pages and pages of journals, for my eyes only. I also doubted myself and didn’t think that my voice could add much value. This idea for a blog was actually hatched while in college, but fear and lack of motivation constantly drove it away. Now, six years later (when blogging is probably already an antiquated art form, haha!), I am ready to make it a reality. The pandemic has made it clear that life is short and plans can go awry. Thus we must not put our passions on hold or let our insecurities and fears of the unknown stop us from doing what makes us happy.

So, without further ado, here it is…my passion project, my creative outlet for reflecting on the past, ruminating on the current and thinking about the future, my blog: The Bedside Report. It will be a work in progress—my attempt at trying something new and becoming more comfortable with discomfort—but I look forward to embarking on this new creative journey.

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