It Might Just Be Dehydration

In this episode of SNF This, we sit down with Dr. Irene Hamrick, gerontologist and Supervising Physician for VitalCare Connect, for a deep dive into one of the most underdiagnosed culprits in post-acute care: dehydration. Dr. Hamrick breaks down how something as seemingly simple as fluid balance can drive some of the most serious acute presentations in elderly patients — from kidney dysfunction and blood pressure instability to altered mental status. If you're caring for seniors and not thinking about hydration first, this episode will change how you approach the workup.

Transcript

SPEAKER_00 0:02

Welcome to Sniff This, the podcast where we pull back the bed sheets on skilled nursing facilities, educating, entertaining, and occasionally risking being reported to HR. All right. Welcome to this episode of Sniff This. Very, very excited to have now my friend, hopefully Dr. Hamrick, who also does a lot of work for vital care and terms of like supervising, and hopefully even more work in training. So very excited to have you on our podcast today.

SPEAKER_04 0:33

Thank you so much for this opportunity.

SPEAKER_00 0:35

And a fellow German.

SPEAKER_04 0:36

That's right.

SPEAKER_00 0:37

So very excited.

SPEAKER_04 0:38

There goes my accent. I'm from Wiesbaden, Germany. My uh one of my sons lives in Munich, and I get to see my grandchildren in a few weeks, which I'm really excited about. Very excited.

SPEAKER_00 0:48

How many grandkids do you have?

SPEAKER_04 0:49

I have four grandsons.

SPEAKER_00 0:50

Four grands grandsons. Yeah. No granddaughters.

SPEAKER_04 0:54

No girl among the whole family. And they tend to take care of us when we get older.

SPEAKER_00 0:58

Yeah. So well, hopefully the dice rolls with kids. Um, we're gonna talk a lot about like dehydration and hydration and kind of the impact that it has on multiple like body systems and disease course management, and a lot of the acute care calls that we get from skilled nursing facilities can be, I think, tied back to dehydration. So really excited to talk about that.

SPEAKER_04 1:22

It really is the root cause of many of the illnesses that our patients face, especially acute illnesses. So I became very passionate about this topic, and I'm really excited to teach you about this.

SPEAKER_00 1:35

Perfect. So then let's start with your background, your training, what got you into healthcare, specifically long-term care. And then I think one of the most important questions is why do you stay?

SPEAKER_04 1:47

Right.

SPEAKER_00 1:47

It's a hard place to be, so why do you stay?

SPEAKER_04 1:49

Yeah. So I wanted to be a physician since I was nine, and um, when I entered medical school, I wanted to go into surgery, but all my patients were asleep, banter over the OR table got boring. So I was like, this is not for me. Yeah. So then I did all the rotations and loved everything. So I went into family medicine, but when I was in family medicine, I was really excited about older patients. They were so appreciative of everything that I did for them. I loved the complexity because nothing ever got boring. You know, with pediatrics, you see 80% ear infections. Not very exciting.

SPEAKER_02 2:25

Right.

SPEAKER_04 2:26

But with geriatrics, it's a different issue every time you see them and every patient you see. So that's what got me into it, and that's why I'm staying too, because I like the challenge and I like learning new things. So early in my career, I learned that dehydration is at the main the root cause of so many of my patients' problems. So we'll talk a little bit about them. For example, when uh I would start an antihepotensive for my patients for high blood pressure, oftentimes they would call me within in a couple of days saying I'm dizzy, or I would call them to see if they have any side effects from the medications, and they would say, I'm dizzy. And I'm like, Well, you know, it's just because you're not drinking enough, because the vasodilation increases the capacitance, so all your blood volume goes to your lower extremities when you're standing up or sitting up. So if you don't drink enough, you're not perfusing your brain and you feel dizzy. So that's when I started recommending my patients double their fluid intake whenever I would start them on a medication for blood pressure or increase their dose.

SPEAKER_00 3:30

Oh, interesting. Plus, a lot of them, in terms of like antihypertensives, can uh escalate to like a diuretic or something. So you have a combination of like exactly polypharmacy that's impacting this.

SPEAKER_04 3:43

I'm glad you bring it up with diuretics. Blood pressure medications are diuretics only for about a year. Then after that, they lose the diuretic effect and become only blood pressure medicines and vasodilators, so not so much diuretics. So if the patient has been on the uh hydrochlorothiazide or the chlorothalodone for several years, that's not going to be the cause of their dehydration.

SPEAKER_00 4:07

It's not an uh acute change just in the recent, it's like more of a past.

SPEAKER_01 4:12

So exactly.

SPEAKER_00 4:13

I think dehydration as you like look at it across the board. So we get a lot of acute calls for like hypotension that I think can be correctly managed by giving them fluids, but we're not figuring out the reason why necessarily they're hypotensive. But they could be dehydrated, but there could be other causes related to medication, like some of their activity, like diuretics. But uh, the other thing I get interesting sometimes is dehydration can also impact your heart rhythm. Isn't that correct? In terms of like AFib or like in and out of that?

SPEAKER_04 4:50

And how does that impact in terms of where we're so dehydration can lead to hypovolemia, and then the kidneys send out norepinephrine, epinephrine, and that then raises the catecholamines in the blood, and that has effects on the receptors of the heart, increasing the heart rate, but also increasing the risk of atrial fibrillation because the SA node, which is the pacemaker of our heart, atrophies much faster than the rest of our cells in our body. Our skin cells atrophy, they about we are left with about 50% of our skin cells in age 80. The SA node cells, 90%, are gone. So our heart is much more prone to develop atrial fibrillation and other arrhythmias when we get older. But to get back to the dehydration, so um, there are several reasons why older adults are at higher risk of dehydration. Due to apoptosis or programmed cell death, our brain cells that trigger thirst are atrophy and are gone. So we don't feel thirsty when we're older. Yeah, then um we make less antidiuretic hormone in the brain when we're older, again because of apoptosis. And with less antidiuretic hormone, we don't concentrate the urine as effectively and therefore lose more water in the urine when we're older. And that's why many older adults have to get up in the middle of the night, because at night we usually make a lot of antidiuretic hormones, so we don't have to pee at night. But if we don't make as much, we have to get up in the middle of the night to go pee. So even if we made enough antidiuretic hormone, in an older person, the kidney is not as responsive to it because the long nephrons that concentrate the urine most effectively have atrophy the earliest. So we have fewer nephrons, especially the long ones, so we don't concentrate the urine as effectively, and therefore we lose more water in our urine when we get older. So even if we took the nasal spray desmopressin, which is the antidiuretic hormone, our kidneys would not be able to respond by concentrating the urine effectively, and we'd still have to pee at night. And that's been my experience. When a new drug came out, that nasal spray, many of my patients were started on it by their primary care physicians or by somebody else that they saw. And then they ended up in the hospital with hyponatremia and with delirium. And I would ask them, did it help with eunocturia? And they said, No. And I'm like, Well, it makes sense.

SPEAKER_00 7:23

That does make sense. I've never I've used desmopressin, like uh the antidiarietic, with in connection to like some of my younger patients that are struggling with like nighttime bed budding. Yeah. Um, and so that makes sense in terms of like the flip side of some of the apoptosis or the reduction of production of the antidiuretic while you're getting. I didn't actually ever know that by that. I thought it was like the prostate or there was a weakening of the pelvic floor or something.

SPEAKER_04 7:54

It's normal aging changes.

SPEAKER_00 7:56

Interesting.

SPEAKER_04 7:57

And in children, the brain is not mature enough yet. They have not developed enough of the brain cells to produce the antidiuretic hormone.

SPEAKER_03 8:04

Interesting.

SPEAKER_04 8:04

And some of our children develop it earlier, and others take a little longer, and that's okay.

SPEAKER_00 8:09

Yeah. What so talk me through. So we get a call from a patient for any myriad of reasons. Like whether that's hypotension or even altered mental status, or they're saying they have smell foul smelling urine, and this culture in the nursing home is like, oh, we just gotta get a UA or a like a urine culture. Walk me through kind of your thought process of helping rule out and identify whether this is like dehydration related versus like some sort of other calls.

SPEAKER_04 8:41

Yeah, because so many of the calls in the middle of the night is because the family says, Oh, she's got a UTI, because whenever she gets mental status changes or delirious, she's always had a UTI. And I would ask a little bit more history, what's going on? Oh, the urine smells really strong. Well, a strong smelling urine is due to dehydration, not due to an infection, because the bacteria in a UTI do not cause the smell.

SPEAKER_02 9:07

Yeah.

SPEAKER_04 9:08

So I will then ask how much has the patient been drinking? And most of the time they cannot tell me, but most of the time it's not enough. So I will tell the staff go ahead and increase the fluid intake. And uh at least this is oral intake. Oral intake, absolutely only oral intake. I'm not an advocate of IV fluids because that sends patients into heart failure.

SPEAKER_01 9:29

Yep.

SPEAKER_04 9:29

Two-thirds of IV fluids are third spaced and send them into heart failure. So just oral fluids, and you know, if they don't like to drink, figure out what they like and just urge them, encourage them to drink every few minutes a sip or two, whatever they will take. But get in at least two liters a day. That is the minimum that our older adults need.

SPEAKER_00 9:48

This is more than I probably drink in a day, too. I'm probably dehydrated too.

SPEAKER_04 9:52

Because you're younger, you can tolerate it, because you can concentrate your urine. There you go. And older adults just really can't, so we really need to push two quarts a day. And um, so what were we talking about again?

SPEAKER_00 10:06

No, just generally these nighttime calls we're getting and are like either they're halter. They're UTI or like they're hypotensive. Like, how do you make sure this is not an acute something that needs like correction immediately versus like we have another cause?

SPEAKER_04 10:23

Like we just started in diuretic or 99% of patients, it's dehydration that's causing the symptoms. Yeah. The symptoms of delirium, the symptoms of urinary frequency, and even just urea. Because the concentrated urine is irritating to the bladder, so it will cause patients to have to go more frequently or more urgently. So increasing fluid intake solves the issue in more than 99% of my patients. So I engage the families, especially because sometimes the nurses say, Oh, the families really want to get a urinalysis or to put a patient on an antibiotic because it always works, and only this antibiotic will work. And I would say, let me talk to the family. And if I'm in the building, I will walk upstairs and talk to the family, and I will say, Let's try increasing fluids for the next night overnight or the next 24 hours, and then I will re-evaluate the patient tomorrow. And if they're still not doing well, then we'll get a urinalysis. But in all of my patients, they usually do well, and even if they have a UTI, you need to increase fluid to then wash out the bacteria.

SPEAKER_02 11:33

Yeah.

SPEAKER_04 11:34

And I have convinced all of my families so far, yes, dehydration was the issue, and it gives them something to do to help the staff hydrate the patient by encourage them to drink and give them whatever they like and frequently.

SPEAKER_00 11:50

Yeah, one of the questions I always like push for our providers is like if they're calling for uh hypotension based off of one blood pressure reading, like are they are there are they symptomatic, hypotensive? Like I think culturally we also think, oh, if a patient is hypotensive, we're in crisis or in its acute nature, we have to send them to the hospital. But like, are they otherwise asymptomatic? Then we need to be pushing for fluids. And one of the trends that I see, especially in our older population, is that maybe some of these providers are acutely trained, and so they're like, oh, start an IV, give them fluid, which, like you say, is not the answer with this population, is like trying to increase this oral supplementation of fluid.

SPEAKER_04 12:35

Very important. Occasionally I will do hypodermalclysis for an acute event. Yeah, but then I have a discussion with the family about end of life. Because if the patient cannot maintain their own hydration anymore, then it's time to talk about calling it quits. And dying of dehydration is a very humane way of dying, right? And that I think is one of the reasons why we lose the sense of thirst as we get older, so that when we develop dementia and we're confused, we don't feel thirsty or s or hungry at the end of life, we just fade away.

SPEAKER_01 13:09

Yeah, and it's just kind of the natural sort of course of life of.

SPEAKER_04 13:13

But hypotension is always due to dehydration in older adults.

SPEAKER_01 13:18

Yeah.

SPEAKER_04 13:19

So what I always cringe at when then providers scale back the antihypertensives instead of increasing the fluid intake. So, yes, do your due diligence, get some labs to make sure that it truly is hypotension due to dehydration. And indicators are hypernatremia or hyponatremia, and we'll talk about that in a second. Um, elevated BU and preatin ratio, but especially if you have osomolarity, that is the gold standard for dehydration.

SPEAKER_00 13:48

So, what um, and I know you kind of outlined briefly, are you reaching more for like renal function? Are you doing a full BMP or are you doing a CMP?

SPEAKER_04 13:57

I usually get a BMP because it costs, it's the same. Yeah. And um then I get a little bit more information.

SPEAKER_02 14:04

Okay.

SPEAKER_04 14:04

And the reason I mean that is because most medications that older adults take can cause hyponatremia. And the biggest offenders are all psych drugs except for buproprium, and all the blood pressure medicine except for beta blockers and calcium channel blockers. So all the RAS medicines, renin angiotensin systems, like ACE inhibitors, ARBs, spironolactone, etc., they all cause hyponatremia. So whenever you see hyponatremia, it's always medications. Because our older adults don't drink enough to cause polydipsia as the psychogenic cause of hyponatremia. So don't worry about fluid restriction. Instead, look at the medicines. But if the patient needs a certain medicine that causes a hyponatremia, I'm fine with it. Because most patients are totally asymptomatic with their hyponatremia. So I don't even manage it. And yesterday somebody talked about CHF and about uh electrolyte management, and they also said, Oh, they have a sodium-121 and they're doing fine. I don't mess with it. So don't get excited about it. Treat the patient, not the numbers.

SPEAKER_00 15:15

I think that's always important, especially on from an acute setting where you're getting a call and they're like, ah, they're hyper hyponeatremic and they're delirious. Um, I think in an acute setting, that's an easy answer, but we often see adults, older adults, admitted to the hospital for hyponeitremia.

SPEAKER_04 15:34

And they've been living in the hospital, but they've been there forever. Exactly. So it doesn't really matter. So look back and see what is their history. Yeah. Is the patient doing okay? And then treat the patient, not the numbers.

SPEAKER_00 15:45

Yeah, and I think one of the things is we're trying to overall do what's best for the patient.

SPEAKER_04 15:51

Right.

SPEAKER_00 15:52

Rather than just sending them to the hospital, which really is not the best thing for this population of patients.

SPEAKER_04 15:57

They get confused, delirious, they climb out of bed and break a hip. Yeah, it's not a good thing.

SPEAKER_00 16:02

So I I like your approach of like, are we taking enough oral hydration?

SPEAKER_01 16:06

Right.

SPEAKER_00 16:07

Um, give increase their oral hydration, get some labs so you can source through some of this. A really important thing is like looking, is there any change in diuretics recently? Is there any change of an anti-hypertensive recently? Most of them probably haven't been touched for a year or more or looked at. And so rather than kind of acutely jumping to Ivy fluids or an acute referral to the hospital, like how much of their drinking, what is their status right now, what does the patient look like, not the numbers, and hopefully start increasing that oral hydration.

SPEAKER_04 16:43

So the other key to the reason older adults need more fluids, and especially early in the day, is because of um cross-linking of elastin and collagen that makes our tissues less elastic. It's most apparent in this on the skin. I mean, look at the difference between your skin and my skin.

SPEAKER_01 17:02

You look great.

SPEAKER_04 17:04

And I'm older, but I'm not as old as many of our patients.

SPEAKER_01 17:07

Right.

SPEAKER_04 17:08

So, due to this cross-linking of elastin and collagen, our tissues are less elastic, and that causes our veins to be less elastic so they don't bring the blood back to our heart as effectively, and we lose one to two liters of blood when we get up in the morning into our legs. Interesting. So if we don't replenish that fluid drop into our lower extremities by drinking more fluids early in the day, we're gonna get dizzy and fall on the way to the bathroom. Interesting. So I encourage my patients to drink a liter of fluids within four hours of waking up. And I tell my patients when you get wake up in the morning, you sit on the side of the bed and you drink a pint of fluid if you can, but at least a cup. And my presentation on tomorrow afternoon is going to go into greater detail on that. But um, by starting the fluid resuscitation at the side of the bed, it gives your body enough time to equilibrate that shift and it starts your fluid resuscitation, and then drink the fluids every hour until you have a whole quart or a liter in within four hours of getting up, and then another liter by lunchtime, and then you don't have to drink much the rest of the day, so you don't have to pee all night.

SPEAKER_00 18:26

Yeah, so maybe break it down uh for simpler for maybe some of our newer providers that are just out of training. Like you get your BMP back, you're concerned about dehydration, you're trying to roll out some of the big bet scary stuff. What is it that you're looking on the lab that would maybe indicate to you that there is dehydration versus oh there's something uh nefarious maybe going on the labs?

SPEAKER_04 18:48

Let's start with the B U N because it's in the left of my corner.

SPEAKER_00 18:51

Yeah.

SPEAKER_04 18:52

So the fish diagram. Yeah, yeah, exactly. So if the B U N is elevated, that gives me concern.

SPEAKER_01 18:59

Yeah.

SPEAKER_04 18:59

Um if the sodium is elevated, that gives me concern. But if the sodium is low, I'm still concerned because hyper uh hyperbolemia or dehydration can cause low sodium.

SPEAKER_02 19:10

Right.

SPEAKER_04 19:11

So our kidneys are very good at holding on to sodium because historically our diet was high in potassium with fruits and vegetables, and we didn't have any access to salt unless we live next to the ocean, and most of us didn't.

SPEAKER_02 19:24

Yeah.

SPEAKER_04 19:24

It was too dangerous. So our kidneys evolved to be very good at holding on to sodium and getting rid of potassium. Now, with McDonald's moving into town, we get much more salt.

SPEAKER_00 19:37

Or like the table salt that's like on every table. Exactly.

SPEAKER_04 19:41

We get much more salt than we ever needed, and we don't get enough potassium because we don't eat enough fruits and vegetables. So it's really critical to um reduce the salt intake in our older adults, to protect their hearts, their brains from a stroke, and to control their blood pressure, and at the same time um watch for sodium, low sodium, and it's not a salt problem. By giving salt tablets or increasing the salt at the table is not going to make any difference to hyponatremia because remember what I said? It's always due to medications, and because the aging kidney cannot hold on to sodium as good as a young kidney can, because we used to we're very good at that, but an aging kidney cannot hold on to sodium as effectively and cannot get rid of potassium as effectively. So we tend to have more hyponatremia in older adults, either because of medications or because they're not drinking enough. So if you don't perfuse the kidney enough, it cannot work to hold on to the sodium. So hyponatremia can be from low sodium, especially in combination with medications.

SPEAKER_02 20:49

Yeah.

SPEAKER_04 20:50

So I look at the BU and preatin ratio, but sometimes the creatinine can be elevated due to chronic renal failure, but it can also be due to dehydration. We did a study at our nursing home looking at the prevalence of dehydration, and we found a prevalence of 75%.

SPEAKER_01 21:07

Really?

SPEAKER_04 21:07

Yes. Over three years, we brought that prevalence down to 36%. And most of the patients with that had a diagnosis of chronic renal failure did not have chronic renal failure anymore. Once we hydrated them.

SPEAKER_01 21:23

Really?

SPEAKER_04 21:23

So just because the creatinine is elevated doesn't mean that it is chronic renal failure. So look at the hydration status of the patient, make sure they're increasing their fluid intake. If the creatinine goes down, great. And if not, then you can call it chronic renal failure.

SPEAKER_02 21:39

Gotcha. Cool.

SPEAKER_04 21:40

And usually I tell my patients to drink two quarts a day of fluid, whatever they like, including coffee. Coffee is not bad. As long as you drink it all day, every day, your receptors scale back and it doesn't be it is not diuretic anymore. If you do it intermittently, then you have to add a few extra glasses of water. Drinks two quarts a day, and then when they come back for follow-up, I ask them so how much are you drinking? When are you drinking it? If I get a good enough story that I believe they're really drinking two quarts a day, then I recheck their BUN preatmin ratio or their BMP to make sure that that's enough. Occasionally, but I can count the number of the thousands of patients I've treated over the 30 plus years. In my one hand, that patients needed more than two liters to maintain their electrolytes.

SPEAKER_00 22:29

Interesting.

SPEAKER_04 22:30

So it's not a heavy lift to get them to drink two quarts.

SPEAKER_00 22:33

Yeah, I think the other aspect, and it's every provider's favorite thing, is the documentation here, right? Right. Like we need to one thing I think we all can improve on as providers is making sure that we're documenting that we thought about all of these things. Like we we got a lab for a specific reason or we're encouraging intake of fluid, and consistently in our orders, we should be telling nurses that they need to increase their fluid intake. Right. Um, and then making sure we're documenting that we thought about medications, we thought about dehydration, we've pooled the appropriate labs, and that so we can explain our kind of medical decision making in this process, so exactly, which I as a provider need to improve on too, because sometimes you get really busy, yeah, and it's hard.

SPEAKER_04 23:22

And dehydration is only one of them. But it's really critical that we just document the medical decision making in the assessment and plan to also increase our billing. Yeah, and without appropriate billing, because if we cannot justify what we did and why we did it to increase the billing level, then we should not bill level four.

SPEAKER_02 23:43

Right.

SPEAKER_04 23:44

Because we need to make sure that it's explained. Plus, then it also explains to the nursing staff that usually read our notes why we're doing something, and that really will go a long way to improving the care of our patients and to reduce the phone calls in the middle of the night. Yeah. If the nursing staff is empowered to make some changes, like increasing fluids in somebody who's becoming deliveries.

SPEAKER_00 24:06

And it's something you can easily do.

SPEAKER_04 24:08

Yeah.

SPEAKER_00 24:08

Like it's easy. I think the other thing is providers probably are thinking about these uh these things, like good providers. There, you think about these things kind of quickly and you kind of check lists in your mind, but we're making sure we're including that in our documentation as well.

SPEAKER_04 24:24

So a couple more couple more things to finish up.

SPEAKER_01 24:27

Absolutely.

SPEAKER_04 24:27

Um so the Institute of Medicine uh says that women need 2.7 liters a day, through men, 3.7 liters a day, I say a minimum of two liters. And the Institute of Medicine also then later came out as stating that we should just use um thirst as our guide. Well, in older adults, we cannot count on thirst. So make sure your patients are getting enough fluids, and our staff and the facilities, and whenever we come to see the patients, we offer them something to drink. Make sure there is something at the bedside in the reach of the patient if they're movering around in their wheelchair, make sure they have a bomb on their wheelchair so they can drink at the time, and then we need to remind them throughout the day. The other thing is that in a few years ago, a study came out of Canada that said that too much uh uh we're not we don't need to restrict the sodium in our patients with heart failure, and that actually too much sodium restriction is actually no better than no sodium restriction.

SPEAKER_00 25:31

Interesting. What is this study?

SPEAKER_04 25:33

So it was a study out of Canada and we can link it below on the podcast okay, and it compared the average intake of sodium in Canada, which was 2.5 grams, compared to over 3.8 grams in the US. So the average US person takes in six grams of sodium a day. I mean, vastly different amounts. So the Canadian study reduced the intervention group to 1.5 grams, interesting, compared to 2.5 grams for the control group, and showed no difference. Of course not. But I would be happy if my patients got down to 2.5 grams in a day, and that would solve all of their problems with their heart failure. So that is the criticism of that study when somebody says, Oh, this study showed no difference from sodium restriction on heart failure. Oh, it does, it makes a big difference in the US where people use just a lot of salt.

SPEAKER_00 26:33

I I after the podcast, I need to go and drink more water after our conversation today. But I'm really so happy to have had you on our podcast. And we love working with you, the education you provide, and so we're excited to keep working with you. Anything else you want to say? I'm hammering home increased oral hydration, especially among our patients, and making sure we're looking at these various causes of what UTI or delirium or hypotension could be simply related to dehydration.

SPEAKER_04 27:07

Yeah, totally.

SPEAKER_00 27:08

Which is an easy kind of intervention for us to make. So exactly.

SPEAKER_04 27:12

And just encourage your patients to drink frequently all throughout the day.

SPEAKER_00 27:16

Tell us about your chapter in your book.

SPEAKER_04 27:18

Yeah, so I wrote a chapter on geriatrics in the family medicine textbook by um uh Dave Rakel, and um I'm looking forward to it coming out, but I'll be glad to uh share it with you on your education website because I have complete copyright over it.

SPEAKER_02 27:35

Yeah.

SPEAKER_04 27:35

And I plan to write a book and elaborate on the chapter, but the chapter is very concise, and since it's in digital format, you can just search something and use it as a reference in your office.

SPEAKER_00 27:45

Awesome. Well, I hope to have you on the podcast again sometime. This is a good one. So I've learned a ton uh today. So hopefully those who are listening to our podcast will hear a ton too. So thanks again, my friend, Dr. Emmerich. Good to have you. Before we conclude, huge thanks to our sponsor, Vital Care Connect. Whether you're burning the mid-night oil or just trying to survive another 2 a.m. call, Vitalcare Connect provides on-call medical director support whenever you need it. Nights, weekends, and holidays. With coverage nationwide, they're leading the way in post-acute care, elevating quality, expanding access, and supporting well-being for all. Learn more at Vitalcare.org. Thank you for joining us for this episode of Sniff This. Share this show with your favorite CNA or anyone who survived an all staff meeting fueled by cold coffee. Until next time, I'm Chance in Skilled Nursing. If you sniff something, say something.