Dialysis Nurse, David Wilson

[00:00] Michelle: It was such a pleasure to talk with my longtime friend and colleague, dialysis nurse David Wilson. In this episode, he discusses the intense training dialysis nurses get,  emergencies in dialysis, and the emotional connections that are formed with these chronic long-term patients. I love his empathetic approach of meet the patient where they are, not where we think they should be. When you hear his story of why he became a nurse, you'll understand divine intervention. In the five-minute snippet, will somebody please get Dave some Blue Cod? Here is David Wilson. You're listening to the Conversing Nurse podcast. I'm Michelle, your host. And this is where together, we explore the nursing profession, one conversation at a time. Well. Hi, David. Welcome to the show.
[01:01] David: Good morning. Thank you for having me. It's a privilege to be able to talk to you today.
[01:07] Michelle: Thank you, David, I've been excited to talk to you because I know very little about dialysis nursing, and nephrology nursing. So the way I like to do things is just kind of jump right in. So tell me about what a dialysis nurse does.
[01:27] David: Well, basically just that we are assigned patients. We have orders written by the nephrologist who may have standing orders, but we will in the acute setting in the hospital, we had an area where we had six beds. That's two beds for one nurse. And then we had a dialysis technician which would help set the machines up. We'd look at the orders, we would access the patient, and then we would dialyze the patients. And generally, dialysis treatments went from three to 4 hours every other day. But in the acute setting, sometimes we would do it once daily for several days, depending on the patient's condition. So we sit and monitor the patients very closely because we're taking unstable patients and making them more unstable to make them stable, so to speak, because we're removing probably about 300, 400ml's blood at a time going through the machine and the dialyzer and then putting it back in the patient. So we're recirculating and doing basically we're filtering in a three-and-a-half-hour treatment, depending on how fast you run the machine. Usually, it's about 65 to 80 liters of blood are filtered. Now, bear in mind, we only have, what, five or six liters of blood. So we're constantly refiltering. The kidneys can filter thousands of liters of blood a day. So they're very active little organs. So we watch the patients closely because there are things that can happen, such as blood pressure can drop rapidly. If we pull off too much fluid too fast, they can start to have muscle cramps, which means we're pulling up too much fluid. Or we've taken perhaps the electrolyte levels have dropped. So we're constantly monitoring them every 15 minutes, taking vital signs, and keeping an eye on them and their accesses. It could be scary. Something I learned early on in my career with renal patients is they're basically walking Murphy's law. What can go wrong will go wrong with them. So you've got to kind of just keep an eye on the various things that happen during dialysis.
[03:36] Michelle: You worked in an inpatient setting. What other settings can dialysis nurses work in?
[03:43] David: Dialysis nurses can also work in chronic units, which they're all over the place. And those are patients who actually come in on their own or they're brought in by wheelchair or whatever, depending on their mobility. They have standing appointments. They come in at a certain time. Usually Monday, Wednesday, Friday, or Thursday. Saturday and Tuesday. At the chronic units, we use more technicians to put the patients on. But in the state of California, techs aren't allowed to access Central Venous catheters or tunnel catheters. And so the RN is responsible for that. But the RN'S are also responsible for monitoring the patients given the medications during treatment, that being maybe antibiotics for the end of the treatment or giving EpiGen or iron to help facilitate blood production in the body. There's also peritoneal dialysis, which is a different form of dialysis, and that is monitoring the patients because they do that at home on their own. They're trained to do that.
[04:51] Michelle: So with that nurse be like a home health nurse? Or is the nurse like will a dialysis nurse but just sees them in the home setting?
[05:02] David: No, typically, the patients come into the office to the nurse's office at the chronic unit, and they're followed up there.
[05:13] Michelle: Well, let's talk about the patients for a second. So is there a certain demographic that you see and talk about the comorbidities that dialysis patients have?
[05:25] David: Yes. Typically what we see with patients in the acute setting are people who are either chronic kidney failure, and that's due to the number one cause in the United States anyway, is uncontrolled diabetes. And we see that in so many age groups, from young people all the way up to older people who develop diabetes in their older years. We also see people with uncontrolled hypertension, which will ruin the kidneys, people with chronic heart disease, heart failure, and things like that. Or it might also be hereditary, such things as polycystic kidney disease, where the kidneys develop these oversized cysts and the kidneys get huge and cease to function. And the only way to cure that or take care of that is for them to either get a kidney transplant or go on dialysis. So there are a number of comorbidities to do that, but number one is diabetes. Number two is hypertension. Three is congestive heart failure. In the United States, the three groups we see more within their own demographic is African American, Native Americans, and Asian Americans have higher rates of kidney failure.
[06:51] Michelle: Okay, so these patients are pretty sick, but they're stable because the dialysis is making them somewhat better with all these other comorbidities, I guess.
[07:05] David: You could say dialysis does about 15% of what our kidneys can do. So it's not curing them. It's keeping them stable, keeping them at a certain state of homeostasis. It's working in removing fluid, it's working in removing electrolytes that build up urea.
[07:29] Michelle: So I would think that your patients need a lot of education. So how do you go about doing that? I guess in each setting, is there a certain time that is set aside for education? Or is it just as you're accessing their port and you're just chatting and asking them about what they've been doing or how they've been feeling? How does that go?
[07:59] David: In some cases, if it's an acute onset of kidney injury or renal failure, the doctors will explain to them they need to be on dialysis and what's going to happen. But pretty much it's up to us to educate the patients about what we're doing and what's going on because it is kind of a big mystery, I think, to patients and to their families. So it's up to us to explain to them, this is what happens during dialysis. This is what we want you to look out for if you start feeling this way or that way. But I tried to always ensure them that even though they feel terrible now because of the toxins build up in the body or the excess fluid they may have and give us time, give us a couple of weeks and you will start feeling better. It's a scary situation for them.
[08:48] Michelle: Oh, yeah. I was kind of going to touch on the emotional side for them. So some of the patients that you get are patients that are newly diagnosed and they're coming, so they're just starting their treatment. And I could imagine how I would feel if I got told you're, in kidney failure and you need dialysis. So a lot of times when you're seeing the patients, are they still kind of in shock and maybe not believing or talk to me about how some of those are managing their new diagnosis.
[09:29] David: I wouldn't say they're in shock. They just don't understand the whole process of what's going on. And you need to be reassuring to them, as I said, that this is something they're going to need to do probably the rest of their life. And they need to follow certain rules, so to speak, of dialysis, because their life changes. They have to change their diet, they have to change the amount of fluid that they take in. And a lot of times they'll say, but I'm still making urine. Yes, you're making urine, but it's filtrated. It's not urine. Your kidneys aren't clearing the toxins, it's just getting rid of fluid. But as time goes on, they stopped making urine altogether and so water has nowhere to go. That's when they get themselves in trouble.
[10:19] Michelle: I would imagine that you see quite a few patients that are non-compliant in terms of their diet and maybe their medications and so forth. How do you approach that with a patient?
[10:34] David: I learned early on when I was taking care of doing bedside and nursing care with renal patients, and I learned that really the only control they have in their life is their non-compliance. Many are compliant, but the ones that we would see frequently if the hospital were noncompliant, they come in fluid overloaded. They would come in with potassium at eight or nine when normally it's three and a half to four and a half or five. So we would see that. But it's a sudden change, especially with people who might grow up on different ethnic diets, and they have beans, potatoes, tomatoes, citrus, things that are high in potassium, and suddenly you come along and tell them you can't have that anymore. And they're saying that I grew up on this, and you try to educate them in that. And we do have dietitians, we work closely with them on that. But just suddenly your life has turned around and it's a big shock to them. And a lot of people, because of their demographic situation, may not understand exactly what's going on, no matter how much we tried to tell them, yeah.
[11:50] Michelle: Gosh, I would imagine those cultural dietary practices are so ingrained, it would be very, very hard to change. I guess you would have to feel so bad that making such a huge change in your life would be worth feeling better and living longer. So gosh, I would think that would be really difficult. And I think as nurses, we get really frustrated when our patients aren't, I guess, receiving our education or taking it to heart or understanding. And we're so good at saying things in so many different ways to help them understand and giving them printouts and just all these different ways that we educate them. And we get so frustrated as nurses and providers that they're not getting it and they're not making those changes to help themselves and make themselves better.
[12:57] David: Well, that's where we, I think not just dialysis nurses, but as nurses all in general, we really take to heart that we want to help these people, help our patients to do the best they can in their situation. And in this situation, it's going to be for the rest of their life. Even if they get a kidney transplant, they're still going to have to be very careful with what they do. And you've got to have empathy for these people because we're not in their shoes. We don't live in their situation. And so we have to come to an understanding of where they are, meet the patient where they are, not what we expect them to be, where we are.
[13:40] Michelle: I love that. That's such a great philosophy, especially in nursing and medicine, but just in life in general, I love that because you did talk about transplants for a minute and I wanted to talk about kind of the emotional toll. Do you have patients that are set up to get a transplant, like, maybe they're on a transplant list? Would you know that? How does that work?
[14:11] David: Just about every patient that goes on dialysis, they pretty much get put on the list. And of course, there's not enough kidneys. There's not enough kidneys to go around, depending on where they are. Because of what I have witnessed in the years I did dialysis or 30 years I've taken care of renal patients, the transplant centers look at the patient's compliance. And I would stress to the patients, look, your doctor's going to put you on a transplant list, but you have to show up for your appointments. You have to take your medications. You have to lift things. Right. Because if you're coming in every other week to the hospital because your potassiums are up or because your fluid  overloaded, those are strikes against you. And the transplant centers aren't going to put a kidney into somebody who's going to blow it out in a year or so. They're going to get somebody who's going to be very compliant and hang on to that kidney for 12, 15 years.
[15:11] Michelle: Yeah. So just another reason, another motivation to really take care of yourself and be compliant and follow what is recommended for you. So that's a really good point. How do you, as a nurse manage a patient's death? Like, say they pass away or maybe they pass away, like during dialysis. I would imagine that you guys get pretty familiar with these patients, with their lives. They talked about their grandkids and so forth. So how do you manage that as a nurse?
[15:53] David: That's a really good question because we do get to know these people on a personal basis and their families. We talk with them during those 3 hours. And you know me, I'm kind of a verbose person. I do like to talk to people. You don't have to laugh about it, but anyway but you get to know these people and you do talk to them and you do personal things. And they'll ask me, hey, how are your grandkids? You went on vacation. So it's almost like they're a neighbor, so to speak. And when you do see them declining, it is sad. It is hard. I had one patient one time who I've come to find out I went to high school with her son. I never knew that until he came in to visit one day. But a couple of years ago, I was dialyzing her, and she kept coming in more and more frequently. And I was hooking her up one day, she had a fistula, and I was putting the needles in and such. And she asked me, she said, David, she said, what if I don't want to do this anymore? And I told her, I said, it's your life. It's your right. You don't have to be on dialysis anymore. But I said I would strongly suggest you talk to your children and family about this because this is a big decision. And she said, okay. I went to check on her when I got back to work a couple of days later, and she had gone home on comfort care. She talked to her family and they agreed with her and they let her go. And that was a sad day for me because not that I looked forward to her coming in, but when she did come in, I looked forward to talking to her because she had a real sharp quick wit, so it was fun to talk with her. And that's been a number of patients we've dealt with, and then we have other patients who are just horribly non-compliant. I had one throw a tray across the room at me one day because he didn't get what he wanted for breakfast. Just so many different personalities you have to deal with. But that, again, is every nursing situation, not just dialysis.
[18:03] Michelle: Yeah, absolutely. And I just could imagine that you're spending so much time with them that yeah, you would get to know them and their families and the same for them. So that's got to be hard. David, do you guys see any pediatric patients?
[18:23] David: No. There are protocols in the hospital. If there is a child that comes in an acute kidney failure and we can't get them up to Valley Children's, we can dialyze them. But a nephrologist has to be there with us the whole time.
[18:37] Michelle: Okay.
[18:37] David: So otherwise, normally we work autonomously. But the only one I remember is when I was a student nurse in pediatrics, when you and I were working together before I graduated, there was a young man who was twelve years old that had a genetic disease. And I remember it was Dr. Smith put a line in him and he was dialyzed until they got him up to Valley Children. That's the only pediatric patient I've ever seen.
[19:02] Michelle: That sounds like a very familiar scenario that you just talked about. I think I remember that. And wow, Dr. Smith, what a great guy.
[19:14] David: He's a character, all right.
[19:16] Michelle: Yeah. Indiana Jones, right? Well, let's talk about your Peds days because of course, I know you because we worked together way back in the day, but what is your background? Talk a little bit about that.
[19:33] David: I didn't go to nursing school until I was about 33 years old. I never planned to be a nurse. I worked at a factory that made carbon paper. Carbonless paper in business forms. And they were big, they were national. But with the onset of computers and such, I was working on quality control. Now, I saw that there was not going to be a need for business forms like there was back then so I came home one day after work in the graveyard shift. I told my wife, and she asked, what's wrong? And I was getting the kids ready for school, and I said, well, you know, we got this new computer at work in the lab, and I said, it does so much stuff. I said I don't think I'm going to have a job in two years. And of course, the loving woman she is, she says, I'm so tired you of bitching about work. Do something about it or shut up. When I went to bed that morning after getting the kids to school, I just said, Lord, if there's anything I can do that I can say at the end of my life that I did something for somebody else other than myself, show me the way. And over a period of a few months, I started thinking more and more about nursing. My mother was an RN. My grandmother was an RN. So it was in the family, but I never thought it would appeal to me. But it just seemed more appealing as I thought about it. So I talked to Dr. Lynn Mirviss at COS, and a lot of my wife's clients were RN'S, and they were saying, we need more men in nursing. And so I explored it, and I thought, what the heck? Went and took some prerequisite classes just to see if I was a better student than I was in high school and found that I was doing okay. And so my wife and I planned for it. I went three semesters and quit my full-time job and became a full-time student and got through it and realized I really did like it. That's when I learned nursing, I believe, anyway, is truly a calling. It's a ministry of sorts. It's not just a job. I don't think people just choose nursing just because I'll be a nurse. I think we're kind of led into that, be it spiritually or emotionally, I don't know. But it's something that I wish I would have gotten into earlier because it's been a fulfilling job career.
[21:50] Michelle: Wow. I love your story, and I had no idea. It reminds me, I interviewed Dr. Dianthe Hoffman, and she said the very same thing, that you're called to nursing. It's not just a job. And I think many nurses and many of our you know, a lot of the nurses in our audience can totally attest to that. And I would say that nursing really fits you, or you really fit nursing. So I think it was a really good call on your part.
[22:24] David: I certainly enjoy it. That's why I went back to the Chronic Unit. Although I was ready to get out of the hospital at 65, I wasn't quite ready to get away from patients, and so I volunteered with the County, giving Covid shots out of the AG Center, doing drive-by shootings. They never got out of the car. We just gave the shot, and they took off. And that's why I worked with a number of retired nurses and just realized I like the camaraderie of nursing friends that you have. You develop special friendships with people and, you know, you miss that. And so that's why I went back in a chronic unit, just to do a day, a week keeping out of trouble and just to stay with it.
[23:13] Michelle: Well, you're absolutely right. I'm newly retired and what I miss the most about nursing is those relationships, of course, the patients and their families. But yeah, that is really difficult and it takes some getting used to. Do dialysis nurses need any kind of special education? So obviously you have to be a nurse. But then what kind of training do you get?
[23:43] David: That's a good question because it's pretty intense training. I was fortunate. I worked with some really good nurses. Chris Rogers and Cynthia Shire. Larry Yoda, Gloria Vincetti. They were all really good at helping me. But they would assign one experienced dialysis nurse and we would work in tandem and we would do a full eight weeks of hands-on. And then after that, they kind of left the leash out and let you start working more on your own rather than being under their umbrella to develop autonomy. But then after six months, you are on your own. And we started taking calls. But it's about a six-month training period to be able to do that. Because dealing with machines, knowing what the different alarms are, how to set them up, how to troubleshoot what happens, what's going on, looking at the different pressure gauges, if a patient's blood is clotting in the filter, which can be a problem, because if the circuit clots, you lose about 3400 MLS of blood. And you can't let that happen too often. Typically dialysis patients are anemic anyway. Their hemoglobins run generally anywhere from eight to ten. They live in that neighborhood. It's true for, us, normally it's around 13, so they can't afford to lose much blood. So there is a lot of training with that. But once you get that done my biggest fear after learning the machines, because that's all technical, was learning how to access the grafts and fistulas. And I think every new dialysis nurse, that's a really scary thing to deal with.
[25:25] Michelle: Yeah. Wow. We'll talk about some of the emergencies that happen during dialysis.
[25:33] David: The biggest one is the patient becomes hypotensive. Suddenly their blood pressure drops to 60 systolic. You'll be talking to them, their eyes roll at the back of their head, and they become unconscious. You do emergent blood pressure, you turn off the ultrafiltration so you don't stop pulling water, slow the machine down. And if the blood pressure is down, generally we'll give them a bolus, like 200 MLS of saline through the machine rapidly and they wake up. It's just a lack of volume. I remember Dr. Haley saying the number one reason why dialysis patients code during or after dialysis is because we pull too much fluid. And although they have a heartbeat, there's just not enough volume to circulate the blood so we give them 500 saline, and generally, most of the time they come back.
[26:32] Michelle: Yeah, well, that would be very scary.
[26:34] David: It is very scary. Or a patient will code that suddenly they'll go into a bad heart rhythm, and the first thing we're trained to do is immediately give the blood back, you know, get that volume back in them and let's see what happens there. And of course, you would call a rapid response to call the code blue, but we would keep the needles and things hooked up in case they needed to give the medications. We could give it through their central lines rapidly rather than peripherally in the arm or something.
[27:10] Michelle: Is there a reason why patient dialysis would get canceled? Like, if they were scheduled on a certain day, why would it be canceled?
[27:20] David: Typically, we didn't see them canceling it. The doctors might look at the labs and say, they don't need it today. We'll do them on their next scheduled date because the labs look good, that's going well, and it might be because we're too busy. We don't have the staff, we have too many patients. And so we'll ask the doctor to look doctors so and so he was done yesterday, or she was done two days ago. Her labs look good today, and they'll say, okay, go ahead, and we can pull them to tomorrow, the next day. So that's generally the reason why we see them will cancel a treatment. Or if they happen to start to recover from acute kidney injuries, which is a different form of kidney failure, they may start to recover, and the doctors want to see which way the kidneys are going to go and not mess with dialysis.
[28:10] Michelle: Okay, so, like, rationing of care, that's a real thing. When we don't have the resources, whether it's people or machines or whatever it is.
[28:21] David: It comes to the point where sometimes you have to just triage your patients like they would in the emergency room, which one needs it worse or what have you. When we used to have to take call, now we have night nurses, but when we have to take call, we get called in. And generally, it was people who would come in who had missed their chronic treatments for a day or two or maybe even a week or two, and the electrolytes are all messed up, or they're just full of water. I've pulled as much as six and a half liters of fluid out of a patient or the same as Kilos. You're talking almost a gallon and a half of water you pull out in a matter of few hours.
[29:03] Michelle: So along those lines, are there certain times that you're busier, like after Thanksgiving and those kinds of things?
[29:16] David: Holidays. And it's kind of funny because it seems like in the wintertime we were busier, and in the summertime, we weren't quite as busy. Things slowed down in the spring, and summer for some reason. But yeah, after the holidays, 4 July, Thanksgiving, Christmas. And I know where people are going to have parties and stuff. We see patients coming in with fluid overload, generally fluid overload or high potassium. We have to explain to dialysis patients that potassium is a very important electrolyte. Intracellularly extracellular is bad for you. I bring it home to them. That when a patient goes in for open heart surgery, of course, they have to stop the heart once they're on the bypass pump. And the way they stop the heart is with a huge bolus of potassium chloride and that stops the heart. And so it causes horrible arrhythmias, low potassium, and high potassium can cause really bad arrhythmias in the heart and could be fatal.
[30:21] Michelle: Dave, can a patient consume alcohol when they're getting treated like a patient with chronic kidney failure? Can they consume alcohol?
[30:33] David: Yes, they can. Remember that it's the liver that metabolizes the alcohol and turns it into sugar. So it's not a renal function. But if they're going to drink alcohol, I would recommend to them that they, I had recommended maybe go to vodka, hard liquor, because, well, it's higher in alcohol, so you're not consuming as much fluid.
[30:56] Michelle: Okay.
[30:57] David: It's all a fluid balance and you drink a couple of cans of beer, you're getting up there as far as fluid goes. So you got to be careful with that. Typically the doctors will have patients or try to put them on like maybe 1200 MLS a day of fluid-free fluid. And that's if they're not making urine at all. And the only way you're going to lose fluid is through insensible, loss of sweating, and breathing. And that's only, what, about 800 ML a day?
[31:27] Michelle: Gosh, those fluid restrictions, I would not do very well on those. I drink a lot of fluid, so.
[31:35] David: You need to keep those kidneys washed.
[31:37] Michelle: There you go. Right. Okay, well, let's talk for a second about California Proposition 29. This is a bill that is now on the ballot for the third time. Just tell me what you know about this and if you think it's a good idea or not.
[31:59] David: Last time I voted no on it. I voted no again. I read through it and I try to read all the propositions, but this of course touches home with me because of what they want to do. Prop 29 is saying that they want to have a physician, a nephrologist, or a nephrology-trained PA or nurse practitioner be at the clinic during operating hours is how I understand it. Now, these chronic clinics go from four in the morning to sometimes ten at night. And I don't know of any physician who is going to sit there all day and hope that maybe something happens. Because dialysis nurses were highly trained. We can troubleshoot, we know the patient's starting to get in trouble and we know how to deal. With that. We don't need a doctor there. And the only thing the doctor could do probably also because we have limited drugs to be able to run a code, we have crash cards, and we still have to call 911 and get them to the hospital. So to have a physician there is just a very costly thing. And dialysis is covered under the Medicare Act. And so the reimbursement is not something where these companies make a lot of money. Yes, they are for profit, a lot of them are, but it's a narrow profit margin. And this would really cause, I think, clinics to shut down like the ads are saying. I think there's a lot of truth to that.
[33:22] Michelle: Like you, I read all these propositions and one of the things that I thought was really silly was that this proposition says that the clinic needs to report their data to the state, to the Centers for Medicaid and Medicare. And they already do that.
[33:43] David: Yes.
[33:44] Michelle: So, you know, I don't understand why they're pushing for this. There's a severe shortage of physicians for providers. So hopefully this will be the last time that this gets on the ballot because I do think that it's going to be a big no. But thank you for your take on it.
[34:09] David: Certainly.
[34:11] Michelle: What kind of hours do you work if you're a dialysis nurse in a clinic? Are you there that whole time?
[34:17] David: We would only do typically 12 hours, like in the hospital.
[34:22] Michelle: Okay.
[34:23] David: And do three days a week, just like in the hospital. Now, up until, I don't know, four or five years ago at the hospital, we would do our three days a week, but we would have to take call and of course, most of us would take call on maybe the last day we worked in a week. Let's say I worked on Monday, Tuesday, and Thursday. I would take calls Thursday night. Now, if we were slow enough, we'd go home, that we could punch out early, go home, maybe take a nap and get prepared in case we had called in. Sometimes it was busy enough to where we were there maybe from six in the morning till 10 or 12 at night. Or there are some cases where we are 24 hours. So that's where your training comes in because you have to be able to react even when you're a little bit fatigued. But there's just some innate thing built into us. I think it's something in nurses and firemen and policemen and soldiers, whatever. There are just mechanisms in our body that allow us to do that.
[35:27] Michelle: Yeah, I remember those twelve-hour shifts and I look back and I go, god, how did I do that? But I think you just explained it so well. There's just something where you just keep going. Right? Yeah. Well, this has been so informative for me today. I hope our listeners can say the same. I started with very little knowledge of what a dialysis nurse does, and you've explained everything really well, so I thank you for being here. Thank you. So you know that at the end, I do this little thing called the five-minute snippet. Right.
[36:09] David: Okay.
[36:10] Michelle: And it's just fun. It's a chance for our listeners to kind of know the off-duty side of David Wilson. So are you ready for the five-minute snippet?
[36:22] David: We'll give it a shot.
[36:25] Michelle: I'm going to set my timer. Here we go. A favorite activity to do with the grandkids.
[36:33] David: Oh, gosh. Just about everything they want to do. They love to go for walks. They like to play little games. My granddaughter loves to draw on her chalkboard, and I draw with her. My oldest grandson loves nature and loves to go on walks and learns about birds and such. And so I go with him. And we take my binoculars so he can look at things. And I've got two other little ones who are nine months old, and the other is two and a half. And of course, the two-and-a-half-year-old, he's just exploring everything, and so he keeps us active. Yeah. We just got back from three days in Disneyland and just watching the joy on their face to see the characters, to go on the rides and whatnot, it's just an absolute blast. They're just so much fun.
[37:22] Michelle: Yes. Being a grandparent is such a special relationship. There's just none other, there's no saying that.
[37:31] David: If I'd known grandkids were so much fun, I would have had them first. So true.
[37:37] Michelle: Wow. I know you love to travel. What's the first thing you do when you get to your destination?
[37:44] David: Unpack and then explore. We've learned that when you get somewhere, especially if you go overseas and the time change is really radically different, we've learned that try to stay up as late as you can with the people in the area to get on their time zone quicker. Instead of going to the hotel and hopping in bed trying to catch up on your sleep in your old time zone.
[38:10] Michelle: Yeah, I love it. Okay. Can you impersonate any accents?
[38:18] David: Oh, gosh. Well, I used to do impressions of some of our doctors, but I won't do that.
[38:29] Michelle: Probably a good time. Yeah. Right.
[38:32] David: Because we worked with, basically the United Nations of doctors with nephrologists. We had Irish and Chinese and Indian Vietnamese. We had quite a few different doctors.
[38:47] Michelle: Yes.
[38:48] David: I enjoyed working with them all.
[38:50] Michelle: Yes. What is the most widely planted grape in the world?
[38:58] David: That I don't know, you stumped me. Because what I have learned is every country, and every region has a grape that prospers really well. It's prolific, and so that's what they grow. So in France, it would be mainly a Cabernet grape or a Merlot grape., the Bordeaux area. In the Burgundy area would be Pinot Noir's,  Chardonnay. Rome would be another type,  and England is actually making wonderful sparkling wines. Now they're winning international competitions partly because of climate change, they have a longer growing season now.
[39:39] Michelle: What my source said was Cabernet.
[39:42] David: Okay.
[39:43] Michelle: I know you would know a lot more about wine than I do. What's your favorite country to drink wine in?
[39:52] David: Well, our first trip was also with your brother Chris, and Mary,  was France. But I think Italy would probably be at the top of the list, partly because it has more of a Latin influence. And I love that kind of culture. It's very familiar, and so you just feel more at home. And the wines there are very good.
[40:23] Michelle: Well, I know you also like food, so what food can you not find near you that you wish you could? 30 seconds.
[40:34] David: What food can I find near me? When we were on a wine trip in New Zealand, I had blue cod in the waters there, and it was a delicious fish, the way they prepared it and such. And I was talking at the meat market, I was talking to the fish man, and he said he can't get blue cod. He'd never heard of it, but they have it down in New Zealand, Australia. It's absolutely wonderful.
[41:04] Michelle: Well, it sounds awesome. I love fish, so I guess I might have to go to New Zealand to get it.
[41:13] David: New Zealand is a beautiful country.
[41:16] Michelle: Well, thank you so much, David, for coming on today and talking all things dialysis nurse. I really appreciate it.
[41:26] David: Thank you. I appreciate you asking me. It's been a privilege.
[41:30] Michelle: Yes, well, thank you. And have a great rest of your day.
[41:34] David: Thank you. You too.
[41:35] Michelle: Okay, take care.
[41:36] David: Bye now.