Leave It Better Than You Found

Emily Jacobs went to nursing school because of the months she spent caring for her boyfriend after a routine surgery went wrong. She was twenty-four, had a degree in journalism, and had never done anything like it. What stayed with her was not the wound care. It was standing in a hospital room with no idea how to help.

Twenty years later she is a hospice nurse with ten years of emergency medicine behind her and a master's degree in medical cannabis from the University of Maryland School of Pharmacy, a degree she pursued after her own rheumatologist refused to keep treating her when she became a legal medical patient.

In this episode, Emily and Chance talk about the medicines people are afraid of and what that fear costs a family at the end of a life. Why she describes cannabis as leveling rather than getting high. Why the stigma around it was built on racial and political history rather than pharmacology. And why the same conversation she once had to fight to have about her own body is the one she now walks into living rooms to have about morphine, usually with people who are certain it means the end.

Her invitation to anyone facing this: you do not have to have it figured out first. Come messy, and we will figure it out together.

Emily Jacobs, RN, is a registered nurse with Hospice of the Chesapeake.

To Know Ends is presented by Chesapeake Health Partners in partnership with Hospice of the Chesapeake.

Transcript

Copy Transcript Copied

SPEAKER_01 0:00

And the way that I used to explain it was that I don't get high, I get level. And that's really what my whole career has been about ultimately is like, hold on, we can use we use drugs in all sorts of ways. They have all different safety profiles. That's the other thing I often like to tell people too. Cannabis is the safest, safest, it has the highest safety profile of anything that you're putting in your body.

SPEAKER_00 0:27

This episode is about medicine, and specifically two medicines most of us know only by reputation. I grew up knowing exactly one thing about each of them, and what I knew was that they were dangerous. Emily Jacobs is a nurse. Emergency rooms for 10 years, mostly the night shift, academy clinic, now hospice. She also holds a master's degree in medical cannabis from the University of Maryland School of Pharmacy, which is a sentence I didn't know was possible to say out loud. This is episode 5 of To No Ends. Leave it better than you found it. Before any of the letters after her name, Emily was 24 with a degree in journalism and English, planning to go into book editing. Her boyfriend was 25 and healthy. And he went in for what everybody expected to be a straightforward surgery.

SPEAKER_01 1:35

We just he just had all these complications. So when the surgeon went in, it was, oh, this isn't what we expected. So the outcome of that surgery was completely different. We thought it was going to be like a surgery, and then now we're healing and we're good to go. It turned into he needed another surgery on his shoulder weeks after that first one. He ended up needing radiation. He needed, um, he had something called a wound vac, which is funny because even when I became a nurse, like even that is like a specialized thing. Um, which it's really cool though. It heals the wound from the inside out. So like you leave the wound open, you put a sponge over it with a vacuum attached to it. It's a wound vac, literally. And it suctions, but it makes it heal from the inside out because you have it's yeah, so right? It's science, right? Exactly. And I was like, this is so cool, right? But it was also terrifying because it would make weird noises. And I was like, is that supposed to make that noise? Is that a normal noise, or is that a something's wrong? You know, in the middle of the night, these things are always scarier too. So being home with him, and we had just moved into our apartment one month prior to all of this happening. So, you know, he was we were fully on the trajectory towards marriage, but we weren't quite there yet. And so it was like, I'm now living with this guy. Um, he can't do hardly anything on his own because his whole arm was out of commission. So he had one arm that he could use. Um, but because of the way the wound was, he couldn't rotate or turn. So, like cleaning himself, wiping himself, things like that. Um, I was doing all that stuff, and I had never done anything like that before. So it I will say this the thing that saved me was that none of that stuff was gross, and that is a big help. I all my friends were like, I can't believe you're like going through this. And I was like, but there was never there was never a question in my mind, was I not gonna do this? And I I can do it, it doesn't gross me out that much. So if I can help the person I love and I can manage it, you know, because I I get it. Some people legitimately cannot handle the smells, the the things, right? Yeah, so I get that, but I'm not one of those people, so I should be in there doing it.

SPEAKER_00 3:51

There is a version of this story where that is just a nice thing a young person did for someone she loved, but it is not. She had already been circling something. A year or so earlier, she had been sitting in a coffee shop with a journal, asking herself the question a lot of us ask in our 20s.

SPEAKER_01 4:12

I was sitting there journaling away because I was a writer, right? Like I'm a I'm a liberal arts mind, right? So I'm I was a I've been a journaler since I was a little little kid. And I was like, what am I what am I doing with my life? I need to do something more purposeful, I need to be more fulfilled, I need to help people and it call it divine intervention, whatever. But the phrase that came to me was leave it better than you found it. And that has been a mantra for me since those days, since I was probably 23. Um, and that happened well before any of this other stuff happened. Like that I was younger, but so I was in that process of trying to, that's how I had gotten to the social work. It was like, leave it better than you found it. That is what I need to do. And then when the whole thing happened with my husband, well, my boyfriend at the time, it was wait, I can do this. Like that's I think that's what it was. It was that experience of I am so driven. I have to do something where I'm helping other people. I won't be fulfilled otherwise. And this gross stuff is stuff I I'm interested in and I can handle. So what better way? Like, that's that's a no-brainer. You know what I mean? It and people are like, oh, it was a calling, right? I'm not gonna say, I mean, it what it was. I felt called to it, but it it was also this feeling of efficiency and resourcefulness. It was like, I am the person who can who can do this stuff. Like I just felt like I was designed for it. Yeah. In the same way that it was it like it called to me, but it was like I I can um I I just won't be grossed out by the grossest thing. And I and I was I was raised with an open mind, um, and and belief that all people should be treated equally and that sort of thing. And it was like, I just I think we need someone like me in healthcare, so I'm gonna jump in.

SPEAKER_00 6:04

No, I totally agree with you. She took prerequisites at a community college at night while working full-time, including a biology course she did not need, because she figured she should start at the beginning, eleven months in an accelerated program, then straight into the emergency department as a new graduate, which almost never happens. And the thing she carried in with her was not clinical, it was the memory of standing in a hospital room with nothing to do.

SPEAKER_01 6:33

I started doing this where when someone would come in and we like it was an emergency, like we truly needed to not focus on you family member, we need to focus on the patient. I would usually say to them, we're gonna have you sit over here in the corner. You're gonna be ignored for a little bit. That's because we're focusing on whatever so-and-so, right? We need you in here because if we need to ask you questions, we need you ready to answer them for us. And as soon as we're we get him or her stabilized, then I'm gonna come over and I'm gonna talk to you about what's going on and what we did. But I need you to just sit here and hold on for a little bit. And they're like, okay. And I when I I mean, I didn't start doing that right away, right?

SPEAKER_00 7:09

But once I'm like something you learn to do. Right.

SPEAKER_01 7:12

Once you realize that, you're like, okay, like it it just shows a control of the room. And I think once you did that, then people go, they would could go, okay, they're in good hands. And then they would be able to remember things better. Like this is how it went. Or like, oh, this is oh, I he does take this medicine. You need to know that. Like, just there would be that. So it was like you want to find that calm. And sometimes, like, you you can't stop and be like, everyone take a slow deep breath. That we don't have time for that. So I think it was like those elements of the of just the humanity being there and like helping people.

SPEAKER_00 7:48

10 years in the emergency room, she loved it until COVID, and then burnout caught up with her in a way she describes with unnerving precision a night when she could not hold a patient's story in her head long enough to triage them safely. That is when she started looking for the door. But something else was happening at the same time, and it was in her own body. Emily has lived with chronic illness since her early 20s. After her third child, a flare-up was worse than anything before.

SPEAKER_01 8:23

I had been dealing with chronic illness um since my early 20s, and um it was it was starting to take a toll. So I had had significant flare-ups after each of my children were born, which is common. You kind of go into remission a lot of the time, and then you have this huge flare-up when the baby's born. Okay. So I that happened, and I happened to have three kids, and the third one, it was particularly rough. And so I was dealing with a level of chronic pain and inflammation that I had not dealt with to that point. And it was really impacting my ability to do bedside work. And so I was not a stranger to cannabis. Um, but I was curious because the effects that it had on me were different from what I'd seen in other people. And the way that I used to explain it was that I don't get high, I get level. And that was the only way I could think to explain it to people. That's not to say that there's no impairment, but I could feel it in my body physically that when I would experience when I would, you know, smoke cannabis, because that's all I was doing back then, I would just feel like um level. I would just feel like things were in balance, like the pain was more manageable, but also my thinking about it was different. It wasn't as like this stressful overtaking of like, oh my God. And that's what happens with chronic pain. You feel that pain and you're like, oh my God, this is gonna be the beginning of a flair. This is gonna be, you know, it's gonna turn into something more. And so that fear amplifies it. Yeah. So having something that could also change my thinking about it was interesting. And so I was really curious about how that could happen. And I tried to talk to my medical team about it. My rheumatologist at the time, she refused, and she actually refused to be my doctor if I was gonna be a medical patient. And it was legal medical patient status at this point. Why do you think she Because she didn't understand it? Okay. She didn't understand it, and she didn't know she couldn't, she didn't know what it would how it would impact me and how it would impact what she was trying to do. And I think she just felt like, no, we're not gonna be involved in it. She just didn't want to be involved in it. And I said, Okay, well, then you're not the doctor for me, unfortunately, you know. Um, but I was like, Well, that's great. Like, what am I supposed to do? Because I I want to pursue this. So I mean, I'm kind of a nerd, right? And I was like, I'm gonna go. I'm gonna go find it.

SPEAKER_00 10:51

So she was a patient that did everything by the book and legally in a state that permits it medically, and she was still shown the door. Her physician did not have the education to have the conversation. And so Emily went and got the education herself. And when she went looking for who was already doing this work, the answer surprised her. And then not so much surprised her after all.

SPEAKER_01 11:15

That's it. What I just went like looking, and turns out there's a whole there's a nurse coalition because really cannabis education is being led by nurses in the country. It's nurses, which is really, I mean, patient education is in general is led by nurses. It's the nurses who do discharge education and and disease education, diabetes education. It's always nurses. I found this group of nurses who were interested in cannabis medicine. I ended up just connecting with them. One of them was local, and she was like, Oh, you've got a bachelor's degree, you're fascinated about this, you've got personal experience. Like, you should you should pursue this master's degree. And I was like, What do you what do you mean? Let me look into it. And I and it was it was just autumn, I was like, Yep, this is what I'm doing. Yeah, I don't know what career I'm gonna have after this, but this is what I'm gonna do. Yeah, yeah. And I think for me it was also about just like being able to put a degree, like put those letters after my name that say, like, do you want to challenge me on cannabis now? Because let's talk about it. Right. Because now I'm educated about it. So now I like shout it from the rooftops. I love telling people, but it was definitely something that I was like quiet about. Yeah, at first.

SPEAKER_00 12:19

Here is the part Emily ends up explaining most often because it lands fast, and because most people have never heard it before.

SPEAKER_01 12:27

We have something, all mammals have something called the endocannabinoid system. It's a body system just like your cardiovascular or your respiratory, whatever out. You have all these body systems. Well, all mammals also need all of these systems to work together, and so in order to establish homeostasis in the body, there's a system that does that. It's the endocannabinoid system. And so the ECS manages sleep, memory, appetite, um, mood, all of these things are comp are, and this is why people often, and I've had ER doctor colleagues of mine who I know respect me as a nurse, be like, that's a joke. Like, I mean, I had so much, so many people challenging me to my face, right? It's funny because it was years ago too. I'm like, look at us now, but okay. But they'd be like, how could it possibly be that this little plant can fix all these different things? Like that, there's no way. And it's like, but if you look at the pharmacology of it, the fact is we have receptors in our bodies. For example, you have CB1 receptors in your nervous system and your central nervous system, so your brain and in your spinal cord. CB2 receptors are more in your gut and kind of found throughout your body. So the CB1 receptors are what THC connects with, and that's where you get the euphoria and that kind of thing. But if you take THC out of the, take that away as a cannabinoid, you have hundreds of other cannabinoids that are doing amazing things in your body, and then you're not getting the euphoria. Like if people don't want to be high, we can take that part out of it. Now, I would argue there is value in having THC because it can help with pain and there's other things that can help with it. It's not just the thing that makes you feel the euphoria just to get you high, but that is the biggest thing to it. And so there's, you know, there's all sorts of arguments, but I feel like what people don't understand is that we have a body system that makes cannabinoids of our own. So those are endocannabinoids. The plant ones are phytocannabinoids. So when, so like we have something called um 2AG or nandamide and AEA, those are actual cannabinoids that our bodies make ourselves. And when we have THC or the other cannabinoids, the other phytocannabinoids, they're fitting in those same receptors. So it's like that plant was also was always something that our body could interact, how right, could interact with and should interact with.

SPEAKER_00 14:51

And then there is the social history, and that's the part that always gets me to rethink things that I may have been taught as a young person.

SPEAKER_01 14:59

In fact, this is the other piece that I tell people. Number two is cannabis was in the US pharmacopoe, which is basically the dictionary of all the medications. It was in there in the early 1900s, right? And before. So there's I in my grad school program, I learned the history of what got us here.

SPEAKER_00 15:19

Exactly.

SPEAKER_01 15:19

Yeah, but but number one, it's first of all, it was a medicine. It was well, it was a plant first that we used as medicine before it was ever an illicit drug. Number one. And number two, all of the negativity around cannabis is based in racial and political problems. Yes, yeah. We without getting too deep into 100%. But that so that's that's the other piece of my fascination around cannabis, is that number one, it is a medicine and it should be used that way. And number two, it is not right that I, as a privileged white woman and sitting here calling it a medicine, have a degree in it, but there's still plenty of black people, especially black men, sitting in jail for it.

SPEAKER_00 15:59

Yeah, absolutely.

SPEAKER_01 16:00

Yeah, this it's a plan, it's been a medicine, it's really safe and it's effective.

SPEAKER_00 16:05

And it's super effective.

SPEAKER_01 16:06

So it's a good thing. Yeah. We just have to take the stigma away from it. Stigma, yeah, and and make it more fair once again.

SPEAKER_00 16:17

The other medicine is morphine. And unlike cannabis, it does not stay theoretical when we're talking about hospice. It comes into the house. At some point, a family may have to decide whether to use it. Emily says she can usually tell what a family believes about it before anybody says a word.

SPEAKER_01 16:38

You hear morphine and mo I've had so many people be like, that's for the end, you know. They think that, you know, it's number one. I think people get this image of like, we're gonna just start like injecting them, and then they're gonna look like a a forgive the term, but like a dope addict, like a doped out, you know, and it's like that's not what we're doing. But but what exposure do they have? The exposure that people have is opioid crisis. People are overdosing, it'll, you know, turn you into a different person, it'll you know, ruin all these things. And you can't, you cannot just look at someone and go, and I've had people do I've had like family members just where they're like, well, what does it matter if they get addicted? Okay, you have a valid point there, but that's not where we're gonna start this conversation, right? So like that's the other piece that I think it's it's appreciating that people are they're coming to this with a space of their fear because they don't understand why we're using the drug, they don't understand what it's doing, right? They don't understand that we can use it safely and and and not speed things up. People often think you're gonna speed up that's not what I'm doing either. What people often need is just time to get used to the idea. And I can appreciate that because I remember like I remember the mental switch that I had to do for cannabis to go from being like, hold on, I was like, I'm a dare kid, okay? I grew up in the 80s, okay? So like dare was like all up everywhere. So it in my mind it was like weed is bad. It's not as bad as the other drugs, but like weed is bad, right? And then it was like, hold on, this is this is like a whole medicine that I'm gonna get a degree. So I've been able to do that kind of cartwheel, but it took years. So I'm not gonna expect other people to do that right away.

SPEAKER_00 18:27

And she took years to change her own mind. She does not expect the family to do it in just an afternoon.

SPEAKER_01 18:36

When people come to me, it's always out of fear and misunderstanding. So let's sit down, let's talk about what this is. Now, sometimes morphine isn't even needed in the situation. Like sometimes that's not the thing that we need.

SPEAKER_00 18:48

Yeah.

SPEAKER_01 18:48

Um, and so that's where it's just it's understanding where people are starting off. Maybe they've had a family member who had a substance abuse problem. Right. Maybe, you know, I mean, there's there's there's but the be- I think what I love about hospice is that there's room for all of that for us to consider because hospice is not looking at the patient going, we're just treating you, we don't care about anything else. That's not hospice. Hospice is we're treating you and we're walking with your loved ones, however many there are, whoever it is, we're walking with them to get you through this. So we need to be compassionate about what they've experienced. Maybe this is coming at a time in their life when like they really didn't need this kind of a life emergency to be happening and it's happening, and there's no one else who can do, okay, let's I'm here with you. Let's do that, you know? And so I think there's a lot of it, it's fear and misunderstanding, and it's just having the patience to sit down and be like, I understand why you think that way. And I'm not gonna judge you for thinking that way. Can you also hear me out? And and with morphine, nine times out of ten, if we need it, I'll say, How about I give the first dose and I stay here with you? And I won't leave until you feel comfortable. And then they end up seeing the person look more comfortable. Yeah, they don't look like they're cracked out or something. They're they're all of a sudden their brow isn't furrowed anymore. They look peaceful and relaxed, they're not breathing as fast, they're not fighting so hard to stay alive when their body is literally trying to shut down. It's it's a much more comfortable way. And so when they see that, they're like, oh, okay. Well, that wasn't what I thought. That wasn't what I thought. Exactly. So, like, we can do that. Amazing. Sometimes hospice is is that gift of time of being like, wait, we can cherish this and we can kind of like make this our own. And every hospice team member that I've worked with, whether we're nurses, that our aides, our chaplains, our social worker, everybody is here for the like because we know that hospice is special. And we love the families who let us in a little bit, who are willing to just be themselves. You can be messy, just be the family. Just be the family. Just be where you're at and and allow us to come in and help. That can be really hard to do. But if you allow us to do that, then we can get in and we can be the professionals who can help guide things. It's not it's not our place to make the choices, but it is our place to help you educate, help educate you so that you're informed making these decisions. Because we don't we don't talk about hospice until we get to hospice. And then it's like, wait, now we're at the end and now it's emotional.

SPEAKER_00 21:34

Right. And yeah, we're in crises. Yeah, we're gonna. Yeah, yeah. And like you said, it's I asked Emily what she wants families to know before they ever pick up a phone to call hospice.

SPEAKER_01 21:44

I think it's that um hospice doesn't mean that it's the end, and you don't have to have everything figured out. Um I've had I've had people where, you know, like I'm trying to schedule my first visit. To come and they're like, Well, oh, I've got to get the patient up and get them showered and get them ready. And please don't do that. Please do not do first of all, I it actually is a disservice because I want to see them in their bed in their natural state. Um and number two, like you just you f if that now if that's their process and they that's important to the patient so that they feel dignified and things like that when they're meeting someone from outside the home, um, that's a different story. Then I'm absolutely I understand. But I don't want you to feel like you have to do that for me. You don't need to do that for me, right? That's what I want people to understand. Like, I'm here because I feel like I can be useful. I feel like I was put here for a reason. And so I'm gonna do everything I can to make this better for you. So just don't feel like you need to have everything figured out. Come to me, messy, and we'll and we'll make it, we'll figure it out. I love that.

SPEAKER_00 22:50

Come come messy and we'll figure it out. I love that. I asked Emily what she knows about living that she did not know before this work. She didn't take long to think about it.

SPEAKER_01 23:03

There are no rules.

SPEAKER_00 23:04

Ooh, no rules. There are no rules.

SPEAKER_01 23:07

Whatever makes you happy, whatever makes your heart sing, whatever makes you comfortable, whatever allows you to feel like yourself in your own skin, peace, whatever helps you find peace, that's that's what matters. And I debated whether I wanted to say this or not. I'm gonna say it. I am someone who has had um a lot of privilege in my life and a lot of different experiences that have challenged my thought around what's important. But also, like, my parents are divorced and my dad came out when I was in college. Amazing. So, like, I have this gay dad who like when you have no idea that that is the case, and like that's the reality that you now have to accept. I think like talking about neuroplasticity, my brain has had to go, er, wait a minute, that's not that's not really what that's not the truth that you thought it was.

SPEAKER_00 24:04

Yeah.

SPEAKER_01 24:04

And and figuring out what I think is important. And so I I do, and I've as I've gotten older too, like raising my children. It's like I I know, I feel confident in saying I know what's important. And it's not it's not having the most money, and it's not having like the impressive cars and like going on cool vacations. Because I know people who do all that stuff. They're not any happier than any of us. Yeah, like I've seen all of that. I've involved been involved in something. Yeah, I choose this. Yeah. So I I this is where hospice is is so important to me, but this is where it's hospice is important because grabbing your life with two hands and making it yours is just the most important thing, no matter how long or short it is. And I think that that's what we get to do in hospice is like reclaim that for however much time you have left.

SPEAKER_00 24:54

Yeah. I learned more about medicine in an hour with Emily than I had in my entire life put together. And that is not the part I keep thinking about afterwards. It's actually the offer she made. She does not ask anybody to arrive informed or calm or unafraid or even showered. She just asks to be let in. Come messy. Somebody will figure it out with you. Our next and final episode closes out the first season, and there's not just one guess, it has many. We asked listeners, staff, and a lot of people in my own life questions about death, grief, and caregiving, and we are building the finale out of their voices. Um Chance, thanks for being here. To No Ends is presented by Chesapeake Health Partners in partnership with Hospice of the Chesapeake.