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Practice with purpose & passion
Mary Kay Bader RN, MSN, CCNS, FAHA, FNCS [email protected]
• AANN • Past Past President
• NCS BOD: Secretary • Medical Advisory Board
• Brain Trauma Foundation • Neuroptics
• Scientific Advisory Board • Cerebrotech • Sage Therapeutics
Disclosures
Concepts Practice
Essence of Teamwork Shared Decision making Communication Collaboration
Purpose
Passion
Overview
What is at the core of our work? Practice
Nurses and Team members actions are directed toward distinct goals
Assisting our patients overcome illness
or injury by assessing, implementing and evaluating our care
Takes those in our care to a better
place
Themes
What is at the core of our work? Purpose
Oxford dictionary “the reason for which something is done or created; a person’s sense of resolve or determination.”
As health care providers, our intent and
determination contributes to the quality of our patient’s recovery and experience while in our care.
Themes
What is at the core of our work? Passion
Vision Statement: The American Association of Neuroscience
Nurses (AANN), as the leading authority in neuroscience nursing, inspires PASSION in nurses and creates the future for the specialty.
It is the fuel that drives us in our work
Themes
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How do we integrate these concepts into what we do in the clinical environment and make a difference in our Patient’s Lives?
Practice
Purpose
Passion
PRACTICE What does it take come together as a Team in Clinical Practice?
Manser1 defines teams as ”two or more individuals who work together to achieve specified and shared goals, have task-specific competencies and specialized work roles, use shared resources and communicate to coordinate and to adapt to change” (p.143).
Essential Elements of the Team What is the Problem?
Making patients better is a team sport and not everyone on the team is “ON” the team.
My Team My Team Neurosurgery
Trauma Surgeon
Intensivist
Nurses/Therapists
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My Team
Physician Specialties Neuro: Trauma, Emergency
Department, Anesthesia Neurosurgery, Neurology, and Intensivist
Nursing Leadership Director/Manager from various units APNs: Clinical Nurse Specialist/NP Staff Nurses
Other disciplines Respiratory Pharmacy Social Work/Care Manager Chaplain
Working together as a Team…
Critical elements Team performance is vital to safely and
effectively implement coordinated care Many teams work in a rapidly changing
environment, i.e., Stroke Teams, with multiple specialties moving in and out
These teams work as ACTION TEAMS integrate diverse professional cultures under
conditions which are constantly changing as they care for critical, often unstable patients
Essential Elements of the Team
Action Teams: Master 3 distinct elements Team practice together
Various disciplines contribute unique interventions and skill sets to the patient care environment
Each team member must be present to provide the knowledge and skill that is unique to their profession
Provide a seamless delivery of care across different care units in a coordinated, effective manner
Essential Elements of the Team
Essential Elements of the Team Barriers to team performance
Toma9 studied 43 hospitals to identify barriers to implementing HACA Team members lacked familiarity with concrete
protocols Several process issues produced barriers including
lack of agreement within teams of the evidence supporting hypothermia
lack of interdisciplinary collaboration between ED and intensive care units (ICU)
increased workload demands for ED nurses lack of interprofessional education between nurses and
physicians Complexity of care delivered in mild hypothermia is
identified as a key concept that raises a barrier to implementation (seen in sepsis studies)
Ability of a team to successfully blend the individual member contributions require Teamwork Leadership/ Shared decision making Effective communication Collaboration
Essential Elements of the Team
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Essential Elements of the Team
#1 Teamwork Builds safer environment by decreasing
errors in the delivery of care Forming a Team takes TIME and has 4
stages Develop and learn acceptable behaviors Counter dependency and conflict where issues
such as power, competition and authority are questioned
Develop trust, increase collaboration as a team, and open discussions of each members roles and responsibilities
Effective group productivity
#1 Teamwork
Essential ingredients that produce improved patient outcomes Quality of collaboration amongst
practitioners needs to demonstrate mutual respect and trust
Strong shared goals as well as view the situation in a similar way and understand team structure and roles
Essential Elements of the Team
#1 Teamwork
Coordination of care
Communication is open with a shared frame of reference and encompasses team meetings or briefings
Leadership within the team values contributions made by all members and engages each member is participating in the decision making process Case: 43 year old SAH Transfer
Essential Elements of the Team
#2 Leadership/Shared Decision Making Successful action leaders possess the
following behaviors: encourage team input state and evaluate plans assert opinions when needed listen to staff’s comments delegate tasks appropriately prioritize the care interventions assess each team member’s ability to
perform tasks
Essential Elements of the Team
Leadership?
Lessens from the gridiron… Team + Champion = Super Bowl
=
Leadership?
Lessens from the gridiron… Team - Champion
= -
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Essential Elements of the Team
#2 Leadership/Shared Decision Making
Studies on effective leadership In video recorded resuscitation, researchers
found that a team was less dynamic and adaptable if the leader assumed a “hands-on” role… teams were not as effective (Manser et al)
When a senior nurse or physician arrives and demonstrates more directive behaviors such as coordinating the team and interventions, the team performance is evaluated as “optimal” (Reader et al)
Manser T. Teamwork and patient safety in dynamic domains of healthcare: A review of the literature. Acta
Anaesthesiol Scand. 2009;53:143-151. Reader TW, Flin R, Mearns K, Cuthbertson BH. Developing a team
performance framework for the intensive care unit. Crit Care Med. 2009;37:1787-1793
#3 Effective Communication - Open communication
Real stated “communication is the cement
which holds teams together”
Patient care team share their expertise, knowledge and experience
Nurses are integral to connecting the patient/ family to the team members
Essential Elements of the Team
Essential Elements of the Team
#3 Effective Communication by Nurses Ensure quality decisions by
seek information, process information for the physicians, individualize communication with various physicians, collaborate in the decision making, build credibility with physicians, and communicate “diplomatically”
Promote team synergy by Coordinate/mentor the team, empower lower
level team members, advocate for others, manage conflict, listen actively, foster a positive climate, manage workplace stress, and pinch hit for team members
#4 Collaboration Qualities
A relationship of two or more health care providers working together to solve patient care issues
An attempt to reach mutual agreement incorporating different perspectives to achieve mutual goals
Requires Both parties must balance the concern for others
(cooperation) with personal concerns (assertiveness)
If effectively achieved, collaborative shared decision making occurs and has been linked to improved patient outcomes
Essential Elements of the Team
“The way a team plays as a whole determines its success. You may have the greatest bunch of individual stars in the world, but if they don’t play together, the club won’t be worth a dime…” Babe Ruth
Teamwork
Scene of Accident 17 month old male run over by car
alarm 1817 physician on scene clears airway & gives
mouth to mouth paramedics arrive 1821
GCS 3; HR 100 O2 Sat 90%-suction airway & BMV with
100% FIO2
Teamwork Example: Anton
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GCS 3, Pupils L 3 R 2 - dysconjugate, no motor movement on arrival
VS: HR 142 BP 140 systolic Respirations assisted –no spontaneous
breathing Intubate, IVs, OG, Foley
Extensor posture right side
ED Phase 1840
Events in the Bader household at 1830 A shower A feeling A call A race to the hospital Another call to a friend A rush to the OR
Meanwhile back at MKBs Home
CT Scan Admit CT Scan Admit
ICP and PbtO2 probe in at 2030
See 1 Do 1 Teach 1 all in one moment….
PbtO2 3.5 mm Hg (low Normal >20)
MAP 51-73 ICP 25
OR Phase 1940
GCS 3, pupils 4 mm non-reactive Cerebral Hemodynamics
MAP 70 - ICP 13 = CPP 57 PbtO2 3.5
Orders Keep CPP > 55 Drain ICP < 15 mm Hg or 20 cm H20 Propofol 50 ug/kg/min
Peds ICU 2110
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MD: Orders for Brain Death Testing… MKB: So…Ya wanna give up?...
Peds ICU team assembled 2 peds ICU nurse 1 trauma nurse 1 Respiratory Therapist Neuro/Critical Care CNS – that’s me Oh…and 1 neonatologist Anton
Ventilator, ICP, LICOX, OG, Foley & 2 -24g peripheral IVs
Never Give Up… Never Surrender
Time FIO2/ MAP ICP PbtO2 Interventions
ETCO2
2133 .40/36 82 10 3.8 Increase Sedation
2141 .40/38 84 8 5.7 Drain CSF, FFP 50cc
2149 .40/39 85 9 6.3 Increase Vasopressor
0140 .50/41 90 8 13.2 RBCs 100cc
0205 .50/42 93 10 18.2
0400 .50/38 90 8 15.9 PaO2 87 -Inc FIO2
0615 .60/38 91 10 20.4 GCS 4-5-1T
PICU/SICU RNs, Neuro ICU CNS, & RT work as a team through the night…
Peds Intensivist gets report from Neonatologist ---grim prognosis
PICU RN begs Intensivist for a central line
6am: Enter the Peds Intensivist
CT Scan Post-op Day 1 CT Scan Day 1
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CT Scan Day 1 Nay Sayers Abound….
…but the TEAM does NOT Give Up!
Trends ICP drifts up to high of 30 Pbto2 decreases in response to certain
activities and interventions
The Team learns new technology together…shared decision making occurs between all practitioners
Peds ICU: 48 hrs-7 days
Days 7 PaCO2 normalized….40-54 Seizure @ 1300
Ativan/Cerebryx bolus
Day 9: LICOX removed and wean
Day 12: ICP removed & Extubated
Day 13: Scoots up to top of bed/moving arms Plays “where’s your tummy” with mom Sits up with OT -trunk control/no neck
Day 23: Feeds self
Weaning: Days 7-23
Gymnastics at age 5
High School student
Athlete Soccer Star
ANTON Age 14
PURPOSE “Great teamwork is the only way we create the breakthroughs that define our careers” (Pat Riley)
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1995-1996 AANS publish “Guidelines for the Management of Severe Head Injury” Paradigm shift for managing the
TBI patient population
Mission Hospital recognizes a variance in practice exists
Find a Process to Improve
Organize to Improve the Process April 1997- Trauma /Neuro Services begin
process of changing practice Conduct further R.O.L. on severe TBI
Clarify the Issue Review scientific literature Review outcomes of Severe TBI population
Understand the Source of Variation Clinical Practice divergent from the guidelines
FOCUS PDCA
Select the Process to Improve Develop multidisciplinary treatment
guidelines for use in severe TBI patients
Plan/Do/Act Develop/Implement new guidelines Train personnel Educated staff on new care practice Clinical support provided on 24/7 basis
FOCUS PDCA Check: June 1998
January 1994-June 1997 37 Patients
GOS 4-5 27.03%
GOS 2-3 29.73%
GOS 1 43.24%
June 1997-June 1998 18 Patients
GOS 4-5 61%
GOS 2-3 11%
GOS 1 27%
Check
Analyzed first year processes & issues Intubation procedure in ED Timing of SjO2 placement/PA catheter Concerns regarding intraoperative
management MAP sub-optimum in OR Propofol underutilized
Increased incidence of pneumonia/ARDS Acute withdrawal signs in patients on MS
and Ativan for > 7 days
Act
Revised Clinical Guidelines Developed protocols/procedure
Rapid Sequence Intubation Morphine/Ativan withdrawal Proner
Continued ongoing support of staff at bedside
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Check 2001 Act 2001
Outcomes gathered and analyzed Outcome data consistent
New technology approved by FDA Brain Tissue Oxygen Monitor Integrate of technology into protocol Educate all staff Rewrite all TBI protocols integrating
technology Providing 24/7 support of physicians/
nurses by Neuro CNS
Case Study LT
Intro: 29 yr old female fell or jumped from slow moving vehicle. Witnesses sate she hit her head and had brief LOC Boyfriend takes pt. back to apartment Later – unable to waken her
Calls 911
Prehospital
Exam Neuro changes from GCS 1-1-1 to
combative VS 110/50 HR 72 Unable to get IV due to combativeness Blood coming from both ears Hematoma on Left Parietal area Designated trauma
ED Phase: 0210
Admitted as neurotrauma GCS fluctuates 3 to 9 to 3
PERRL at 3 mm
Trauma MD intubates patient 100% FIO2 CO2 35 mm Hg
2 Large bore IV lines 170/120 HR 98-114 RR 24
Radiology: 0240
CT Multiple skull fractures over left
parietal and left occipital area Left basilar skull fracture Diffuse cerebral edema with
obliterations of ventricles and loss of ambient cisterns
Shift left to right Bifrontal contusions
ICU Phase - Admit
Day 1: GCS 7, PERRL ICP 8-21 and CPP 63-84 PbtO2 normal range Propofol 40-80 mcg/kg/min
CO2 MAP ICP CPP PbtO2 SjO2 Interventions
36 89 20 69 54 68 CSF; Propofol
37 91 22 79 16.9 69 CSF, 100%, Pupils ∆
3 – 6 absent; Mannitol
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ICU Day 5
Pentobarb coma – full medical support
All measures exhausted ICP > 25-30 mm Hg Pupils 6 and absent To OR for bilateral craniectomy
Day 5 Postop
CO2 MAP ICP CPP PbtO2 SjO2 Interventions
28 116 62 54 20.1 CSF; Pent @ 3mg/hr
28 132 67 65 16.7 81 CSF; Neo↓; MD talks
to family poor prog.
29 126 65 61 13.3 100 CSF; RBCs
Family decides to make patient a DNR
Say Goodbye and go home to plan funeral
ICU Day 5 – In the Heat of the Night
CO2 MAP ICP CPP PbtO2 SjO2 Interventions
36 95 58 37 10.9 95 CSF; MS/Ativan dc
100%; Wean Prop off
31 90 45 45 11.5 94 CSF; Donor service
called
31 95 40 55 15 100 CSF
29 98 38 60 14.9 97 CSF
23 88 37 51 15.7 60 CSF
Day 6: A Call from the East
Do you give up when the PbtO2 rises??
CNS and Trauma Surgeon talk Trauma and Neurosurgery talk Family called back to hospital – making
funeral arrangements Family conference held with Trauma and
Neurosurgeon
26 98 47 51 22 83
Not brain dead yet
ICU Day 7
ICP increases to low 50s…challenging the team CSF draining continuously Pentobarb/MS/Ativan/Neo/Dopa Daily Bronchs
CO2 MAP ICP CPP PbtO2 SjO2 Interventions
37 103 50 53 28.8 57 Vent changes
32 121 55 66 27.6 Mannitol
29 127 39 88 34.4 62 Neo decreased
29 100 31 69 28.9 58 Packed RBCs
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ICU Days 8-13
ICP Management requires all level of support
ICP ranges high 20s to 40s PbtO2 30s G/J tube placed; Trach done Rotation on Triadyne impossible due to high ICPs in 40s…Pulmonary worsens
ICU Days 8-13
ABGs pH 7.23 PaCO2 41 PaO2 73 on 100% FIO2 PC with pressure at 35; Rate 28 Inversed 2:1
Pentobarb off
Pulmonary Crisis Day 14
pH 7.22 PaCO2 48 PaO2 61
100% FIO2 Press 42 Inverse2:1
Gradient PaCO2 –ETCO2 =24
Pulmonary
10-11
10-12
Progress
Day 18: Normalized on ventilator Weaning MS/Ativan LICOX/ICP d/c
Day 24 Hydrocephalus begins – new ICP GCS 1-4-1 Pupils 4/brisk
Progress
Day 37 Weaning from ventilator Up in chair with helmet
Day 40 Unable to do VP shunt due to belly
probs
Day 84 - VP shunt placed Day 86 – to floor Day 105 – to Subacute facility
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Outcome Subacute 9 months
To ARU at 1 year Discharged home 14 months after accident
Check/Act- Results of Changing Practice: TBI Guidelines/Oxygen Monitoring Jan 1994 – Jun 1997
37 Patients* GOS 4-5 27.03% GOS 2-3 29.73% GOS 1 43.24%
Jun 1997 - Dec 2007 205 Patients**
GOS 4-5 72.5% GOS 2-3 13.5% GOS 1 14.0%
GOS: Odds ratio for the significant variable
(N=242)
Variable Odds Ratio
95% Confidence Lower Bound
95% Confidence Upper Bound
P Value
Post TBI 7.05 3.10 16 <0.001
Process Outcomes: Recognition 2000 JCAHO Codman Award
“Individually, we are one drop. Together, we are an ocean.” (Ryunosuke Satoro)
PASSION If there is no passion in your life, then have you really lived? Find your passion, whatever it may be. Become it, and let it become you and you will find great things happen FOR you, TO you and BECAUSE of you. (T. Alan Armstrong)
CASE: BE
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34 year old para 4 gravida 4 Admitted 2 weeks prior to event 34 weeks
pregnant due to intrauterine growth retardation
C-section on 12/1 delivered a 1247.4 gram (2
lbs 12 ounces) male baby
Collapses in hospital room after returning back to bed 24 hours post delivery
Clinical Presentation 12/2/09
Kyle Ervin writes in his book… Please God Let Them be Amazing
I turned back to her. I don’t know if I sensed something was wrong…whatever
the reason, I turned, and when I did, her head was laying back over the top of
the chair…I called the nurse….Her doctor came in to the room and his
demeanor changed instantly…
“WE need to get her on the bed!”
I helped him and the nurse lift my wife’s limp body onto the hospital bed…
“Call the code”…said the doctor
The dread built up inside me as the reality of what was happening became
clearer. I heard the words “Begin CPR”. Those words sparked a fear so
intense, so primal, that it exploded within me, shattering the dam of denial and
washing through every part of my being…It was Wednesday. It was supposed
to be a day of celebration… I was standing in the hallway, powerless…
I prayed…Please God, let them be amazing…” (Pages 38-39)
PEA arrest Cyanotic from chest up CPR initiated immediately x 95 minutes
CPR continues in CT scan Large PE in proximal portions of
bilateral pulmonary arteries
CPR continues into the OR
Cardiac Arrest 1420
CPR continues into the OR at 1506 Chest opened through sternal incision
On cardiopulmonary bypass: 1555
Cardiac Arrest 1420
1607: Aorta Cross clamped Surgeon removes multiple clots
Largest clot 10 cm x 1.7cm Multiple clots from 0.8 to 10 cm
1650: Aortic cross clamp removed
43 minutes total
1658: Off bypass 63 minutes
Cardiac Arrest 1420 In OR… A nursing team that has the PASSION
to make a difference…they place…
THE CALL Anyone can dabble, but once you've made that commitment, your blood has that particular thing in it, and it's very hard for people to stop you.
(Bill Cosby)
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Getting the Equipment Pad based system and machine
borrowed from Mission/Probe St Jude’s
Protocol and Order set from Mission
Collaborative Team Key Players
Nurses and Physicians @ Anaheim Administrative Support @ both hospitals APNs from Mission Hospital
ICU Phase: Beginning Hypothermia
2000 admit to ICU GCS 3 with pupils 8 mm bilateral & fixed VS: BP 105/64 HR 70 R 14 (V) T 99.8 F
Induction of hypothermia at 2200 Iced saline 30 cc/kg (2 liters)
Drops temperature from 37.2 to 35.6 degrees C
Pad system applied and started Hit target of 33 degrees C at 0100
ICU Phase: Post Arrest
14 Phone Calls during the night…and the dream at dawn!
“There are only two options regarding commitment. You're either in or out. There's no such thing as a life in-between.” (Pat Riley)
Maintenance Pupils begin sluggishly reacting to light at 0500 12/3
33 degrees
Rewarm 1900 12/3 to 2000 12/4 No bleeding complications/VS stable
ICU Phase: Hypothermia
Diagnostics: CT scan of Brain 12/5 Neurology Consult
Suspect hypoxic encephalopathy status post prolonged resuscitation
EEG 12/7: Severely abnormal EEG with widespread
delta activity seen in both hemispheres associated with both sharp and spike waveforms
EEG compatible with extensive bihemispheric cortical and subcortical dysfunction of an apparent encephalopathic nature
Electrocortical irritability suggested by frequent sharp and spike forms
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In Coma
Kyle Ervin writes
“I was sailing through treacherous waters…being met by fierce winds and
fiercer waves, rogue waves that would crash over my bow, flooding me, trying
to pull me under…
Why me? Why are you trying to drown me by taking from me my lover, my
best friend, my teammate? Why would you take her? Why would you leave in
her place this profound emptiness that I fall into without warning?”
Life is not only relentless. It is full of surprises…God…were you trying to teach
me something…’Cause screw you’…
I was angry with God again…And in the next breath I was bargaining with
him…The pulmonary embolism did not just take my wife from me…it took the
one person that made me a whole and complete being. Without her I am lost. I
was broken. I was less than I was…” Page 125
Medications weaned Patient demonstrates evidence of
seizures start on 12/4 and continue x 7 days
ICU Phase: 48-96 hours
In Coma
I arrived at the hospital a little later in the morning…the on-call neurologist had
already rounded…I learned the Murphy’s law of having a family member in
critical condition…no matter how many hours you spend at the bedside, you
will always miss the doctor…
The nurses were kind enough to reach the neurologist by phone…He laid it on
the line for me… “
Your wife’s EEG is showing signs of seizures. There are three
possible outcomes…One, she could die; two, things could stay the
same (persistent vegetative state), or three, miraculous
recovery…I am honestly doubtful of the third option…”
This news crushed me again… The weight of this information pushed in on me
from all sides…walking down the hallway…anger welled in my eyes…. “God,
either take her or heal her, but none of this middle-of-the-road bullshit!”
(Page 155)
Silence is medication for sorrow (Arab Proverb quotes )
Silence….for 3 weeks…
During that time… Kyle writes on 12/9
I’ve learned that Catholics pray the rosary…the rosary brings comfort and
solace when times are difficult…for me, the poster child of ADD, the rosary is
a special kind of torture—20-30 minutes of repetitive droning…On this night,
Brynn’s friends had asked a member of her church to come and pray…she
had some track record with healing…
“Lets all join hands and pray”…said the lady
“I wanted to say…that’s ok, you can leave me out…”
but knowing I was stuck, we all held hands in a circle and prayed…”
I put my hand on Brynn’s head…I chucked away my cynicism…I figured I
would have a few words with God myself…I opened myself up completely…
I reached out to that greatness, that positive energy…that hugeness I call
God…I opened myself completely….And for a moment, I believed that HIS
energy was passing through me, into her brain…Call it chi or life force or the
Holy Spirit… All I knew is that I was willing to try anything to save my wife’s
life…” (Page 170)
12/11-25 Moving non-purposefully and began to
open her eyes spontaneously
Smiling and laughing 12/21
Weaned from ventilator 12/23
Progressing through Coma
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The Call – Christmas the Day After
Never Give Up. There is no such thing as an ending.
Just a new Beginning.
12/28 Stands at bedside with
physical therapy Speaks to her husband through
passy-muir valve Says “cold” and “mom”
12/30 Tells nurse how she met her
husband in college Brings baby to bedside Able to stroke baby’s face Transferred to acute rehab Baby discharged home from
hospital
Waking Up
12/30 Walking with assistance “chatting up a storm” Cannot remember conversations
1/5 Eating oatmeal Strengthening
1/19 Home with baby
Acute Rehab One Year Later Kyle writes…
“Without divine intervention-without the exact
right people in the exact right place, at the
exact right time—medical science would not
have had its chance…Here is the simple fact
of the matter- I don’t care who gets the credit
for the ‘why’. I only care that God gets the
credit for the how”… (Page 192)
Brynn’s
Nursing
Team
Brynn’s
&
Family
YOUR CHARGE! “When work, commitment, and pleasure all become one and you reach that deep well where passion lives, nothing is impossible.” (FranÁois de la Rochefoucauld)