Add an NP to improve ER patient QT

Crowded, busy emergency rooms may find their patient loads alleviated by the addition of just one nurse practitioner to general hospital staff, according to a new study by the Loyola University Health System. The NP can curb unnecessary ER visits by serving as a first line of defense, providing preventative treatments, “improving the continuity in care, and troubleshooting problems for patients,” says a Loyola University Health System release.

Published in a recent issue of Surgery, the journal of the Society of University Surgeons, the Central Surgical Association, and the American Association of Endocrine Surgeons, the research analyzed the results of adding an NP to a department with three surgeons. The study recounted an individual experience in one hospital, following nurse practitioner Mary Kay Larson, B.S., M.S.N., C.N.N., A.P.R.N.-B.C.

Researchers examined patient records from one year before and one year after Larson joined the hospital’s staff. Both sets of patients (415 before Larson, 411 after) were statistically similar, including length of stay and readmissions. From these groups of patients, researchers monitored which ones returned unnecessarily to the ER, i.e., those visits that did not lead to an inpatient admission.

Larson credits the decrease in ER visits to her communication with patients, saying she “routinely checked on their progress and responded to their concerns by ordering lab tests, calling in prescriptions, and arranging to care for them in the outpatient setting to maintain continuity in treatment.” She was also responsible for their discharge plans. Patient phone calls increased by 64% after Larson joined the hospital team, as did other outpatient services (visiting nurse, physical therapy, or occupational therapy). Researchers say this combination contributed to unnecessary ER visits dropping from 25% to 13%.

Though further research is necessary to corroborate these results, the addition of RNs to hospital staff may be the key to measurable improvements in patient care and operations.

African American patients exhibit higher COPD readmission rates

When patients leave a health care facility, everyone hopes it will be for the last time, as they go on to lead a healthy life. But for some African Americans with chronic obstructive pulmonary disease (COPD), their return visits might necessitate a revolving door.

The Agency for Healthcare Research and Quality (AHRQ) reports readmissions among African American COPD patients age 40 and older are 30% higher than other minority groups, and 9% higher than Caucasians, where patients were readmitted to the hospital within 30 days of treatment.

Analyzing data from 2008*, the AHRQ also found 7% of those readmissions were directly related to COPD, while 21% were all-cause readmissions. Other notable discrepancies include 22% higher readmissions among patients from poor communities when compared with their affluent counterparts, and 13% higher readmissions among males when compared to females. Economically, the surveyed COPD initial admissions cost an average $7,100; readmissions were 18% higher, at $8,400. And averaging $11,100, all-cause readmissions cost twice as much as initial admissions.

* These statistics were published in a recent AHRQ News and Numbers summary, based on a statistic brief drawing data from the State Inpatient Databases for the following 15 states: Arkansas, California, Florida, Hawaii, Louisiana, Massachusetts, Missouri, Nebraska, New Hampshire, New York, South Carolina, Tennessee, Utah, Virginia, and Washington. Visit www.ahrq.govfor more information.

Putting the ER in Diversity

Putting the ER in Diversity

During her orientation as an emergency nurse at Kaiser Permanente Hospital in Hollywood, Calif., Katherine Bolden, MSN, RN, helped care for a man who had come to the ER after falling and hitting his head. The medical staff suspected that he had suffered a serious injury, and the doctor ordered tests. A CT scan revealed a brain bleed. The medical team rushed him to the operating room, and he underwent emergency surgery.

“We saved him,” Bolden says. “Later I heard he recovered and walked out of there.

” Bolden’s life was changed forever, too. From that day forward, she was hooked on emergency nursing.

Minority nurses can make a profound impact in emergency care—the front lines of today’s health care system. Emergency nurses treat an unusually diverse variety of patients and conditions, from infants with colds to elderly heart attack patients to victims of stabbings and shootings. They care for people from every walk of life and cultural background, including patients from the most vulnerable and underserved populations, many of whom come to the emergency department because they have no other access to health care services.

Emergency nurses thrive on unpredictability and variety. They don’t call themselves “adrenaline junkies” for nothing. Yet the rewards of this career come as much from comforting a patient’s family members as from saving a car accident victim.

“You’re [providing care to] patients at the worst times of their lives, when they need it the most,” says William Briggs, MSN, RN, CEN, FAEN, trauma program manager at Tufts Medical Center in Boston and president of the Emergency Nurses Association (ENA).

Briggs, who coordinates services for injured adult patients at Tufts, has been interested in emergency medicine since high school, when he taught first aid and became an emergency medical technician at 17.

“I was always kind of [drawn to] the emergency room,” he recalls. “I like taking an unsolved problem and solving it, creating order out of chaos.”

No Shortage of Opportunities

The nursing shortage hasn’t hit emergency care as hard as some other specialties, Briggs says. But career opportunities for current and prospective emergency nurses still abound. Hospital emergency departments employ clinical nurse specialists, pediatric and psychiatric nurses, transport team nurses and case managers.

Demand is also growing for emergency nurse practitioners (see sidebar), who provide care in a variety of settings, including large urban emergency departments, rural and military hospitals, ICUs, adult internal medicine units and even walk-in clinics.

Katherine Bolden, MSN, RNKatherine Bolden, MSN, RN

One of the primary reasons why emergency nurses are in such demand is that hospitals throughout the country are struggling to keep up with patient loads in emergency rooms. While emergency visits have risen by 36% since 1996, 5% of the nation’s emergency departments have closed, according to statistics from the Centers for Disease Control and Prevention (CDC).

Overcrowding is the biggest challenge emergency nurses face today, says Briggs. On busy days, patients may lie on stretchers in crowded corridors, waiting hours and hours for beds.

“It’s a national crisis right now,” he declares. “Every [emergency department] is busier [than it used to be].”

Five years ago, Massachusetts General Hospital in Boston saw 180 to 200 patients a day in its emergency department. Now it sees 260 a day, says Maryfran Hughes, MSN, RN, nursing director of the hospital’s ED/observation unit. A variety of factors are causing this surge in emergency room use: an aging population, a shortage of primary care physicians and a growing number of uninsured patients who lack access to other sources of health care.

This favorable supply/demand equation also makes emergency nursing an attractive option for career-changing nurses who are looking for a more challenging, exciting specialty. Bolden, for example, became an emergency nurse after working for more than eight years as a health educator.

“It was almost like being a new grad again,” she remembers.

“It was a little scary at first. I wondered, ‘Am I going to be able to handle everything that comes in?’ In the first six weeks I lost 15 pounds, because I went from working in an office to what I now call ‘real nursing.’”

She asked lots of questions and found support and camaraderie among her fellow emergency nurses and physicians, who trusted and consulted one another. A collegial relationship with doctors and other members of the health care team is one of the biggest benefits of the emergency nursing specialty, where nurses often have greater autonomy and more say in patients’ care than they would in other parts of the hospital.

“There’s no way you could do it alone,” says Linda M. Redd, RN, an emergency nurse at Massachusetts General. “Patients are overflowing into hallways and are constantly being moved. It would be easy to lose track of people if you weren’t working as a close-knit team.”

The Culturally Competent ED

In its position statement on diversity in emergency care, the ENA emphasizes that a diverse and culturally competent nursing staff is essential to meeting the needs of today’s multicultural patient base. The specialty has a great need for more minority nurses who can help break down cultural and linguistic barriers to provide better quality care in emergency settings.

“When [emergency] patients come in and are very anxious, it’s important for them to be in an environment where they know they’ll be comfortable and will be able to bond with someone,” says Hughes.

She cites the example of an elderly Muslim woman who came to the ED complaining of stomach pain. The doctor ordered an MRI, and the woman became upset at the idea of having to remove her headscarf. The medical staff only wanted to ensure that her clothing contained no metal fasteners, which would pose a safety hazard and ruin the images because of the machine’s powerful magnetic field. A nurse whose grandmother was Muslim talked with the patient, letting her know she understood her concerns, and explaining the procedure and safety precautions. Because she shared the woman’s cultural background, the nurse was able to make a personal connection with the patient. Together with the staff, they worked through the issue and the woman successfully underwent the MRI examination.

Bolden recalls an African American couple who took offense at a security guard’s instructions in the emergency room where she works. She intervened and talked with the couple to clear up the misunderstanding. “It helps to have a person from the same culture to smooth things over,” she says.

Redd agrees that minority patients are likely to experience less stress in the emergency care setting if there are nurses and doctors who look and talk like them. What’s more, she adds, a pool of culturally diverse nurses can help one another learn to provide better care to patients who are different from themselves.

“We teach each other,” she explains. “I’ve learned so much culturally from watching other nurses work with patients.”

Language differences can create enormous barriers. Briggs says more bilingual emergency nurses are urgently needed to bridge communication gaps with patients who speak little or no English. “If you have to find an interpreter every time you have to speak to the patient, you’re going to lose a lot of [time and] communication,” he emphasizes.

According to a study by Sharon M. Jones, MSN, RN, published in the June 2008 issue of the Journal of Emergency Nursing, five Caucasian, non-Hispanic nurses at a Midwest hospital reported that the language barrier impacted all aspects of care when they attempted to treat Mexican American patients. Only one of the nurses spoke a little Spanish, and she was the only one who described being able to establish a nurse-patient relationship.

Jones concluded that interpreter services should be available 24 hours a day and that emergency nurses should receive training to learn basic Spanish and to gain an understanding of Hispanic cultural considerations that can impact nursing care.

Ready for Anything

What does it take to be successful in emergency nursing? Nurses interviewed for this article stress that critical thinking skills and confidence are paramount.

“You’re kind of like a detective, and you have to be quick [in assessing what’s wrong with the patient], because if you dilly-dally patients can die,” says Thelma Kuska, BSN, RN, CEN, FAEN, who worked for 20 years in hospital emergency departments, including Christ Medical Center in Oak Lawn, Ill., 13 miles from downtown Chicago. “You have to be sure of yourself and be able to stand up for yourself [so you can advocate for the patient]. You need to be knowledgeable to make sure you are giving the correct care to the patient.”

She recalls a 22-year-old newlywed woman who came to the ER with belly pain. Kuska had a hunch, and after questioning the patient she quickly summoned an emergency physician, who ordered an ultrasound. It revealed that the woman had an ectopic pregnancy. Within 30 minutes, the patient was undergoing surgery. Later, when the young woman was recovering from the successful operation, the doctor pointed to Kuska and told the patient, “This nurse saved your life.”

Kuska received her nursing education in the Philippines and immigrated to the U.S. at age 20 to begin her career. Before finding her niche in emergency care, she originally worked as a surgical nurse, in an environment that was worlds away from the fast pace of the ED.

“[In surgery,] everything was laid out, you knew what the patient was coming in for, the instruments had been chosen the day before and the physician was there the whole time,” she explains. “In an emergency department, you never know what will present. It could be a heart attack patient, a car crash victim or a child with a fever. Our doors are always open, the ambulances come in, the patients come in and we treat them.”

There is no such thing as a routine day. “The emergency department is such a busy, busy place. It’s like being bombarded on all sides,” says Redd. “Emergency nursing [brings it all together] for me. I really have the chance to call my entire knowledge base into play.”

The variety can be as challenging as it is stimulating. “There are shifts where one minute you’re holding the hand of a family member whose mother has just died, and then you walk into the next room and you’re blowing bubbles with a four-year-old who’s having his chin sutured,” says Jennifer Wilbeck, MSN, APRN, CNP, FNP, CEN, assistant professor and coordinator of the emergency nurse practitioner program at Vanderbilt University School of Nursing in Nashville.

What Recruiters Look For

At least a year or two of inpatient experience is recommended for nurses who want to work in the emergency setting. However, because of the high demand, some hospitals are now hiring new RN graduates and offering internship programs in the emergency department.

When hiring emergency nurses, Briggs says, he wants to see passion. “The worst thing an applicant can say is: ‘I want to work in the emergency room because you have the hours I like.’”

Hughes says she looks for nurses who have good clinical knowledge and decision-making skills, as well as the ability to work as a team with other clinicians. Above all, she wants nurses who know how to appreciate the patient as an individual.

“Sometimes [emergency nurses] have just a few seconds to establish a relationship with somebody before we have to give bad news and ask the patient to trust us,” she notes. “You really have to be able to reach the hearts and souls of patients and connect with them immediately.”

The ability to establish bonds with patients’ family members is important, too. Redd recalls an elderly patient with urinary problems, whose wife brought him in to the emergency room.

The man was ill and mentally confused, and his wife was clearly beside herself. Redd took the time to have a heart-to-heart talk with her and helped her come up with an emergency plan so that when the couple went home, the wife would know who to call and when.

Opportunities Beyond the ED

Emergency nurses can also play life-saving roles outside the traditional emergency care setting. After caring for numerous young victims of car accidents, Kuska wanted to do something to help prevent more youths from ending up in the hospital. She volunteered for the Emergency Nurses CARE (EN CARE) injury prevention program.

Two emergency nurses from the University of Massachusetts Medical Center in Worcester, Mass., started EN CARE out of frustration and heartbreak from seeing young lives shattered or ended because of drunk driving. They began presenting alcohol awareness programs to high schools, based on the cold, hard facts of their emergency department experience. The program spread nationwide and became an affiliate of the ENA in 1995, as part of the association’s Injury Prevention Institute. EN CARE has now expanded to include other injury prevention initiatives, such as gun safety and bicycle safety.

By presenting alcohol awareness programs at elementary, junior and senior high schools, Kuska has made a difference in countless young lives. One mother told her that after seeing Kuska’s presentation, her children hid the car keys when their dad planned to go out after drinking. A high school girl who had heard one of Kuska’s talks later told her she had refused to get in the car with her prom date because he had been drinking. She found another way home from the dance.

After working as an injury prevention volunteer for several years, Kuska began doing contract work for the National Highway Traffic Safety Administration’s Region 5 office in Chicago, where she now works full time as regional program manager.

“It’s another face of the emergency nurse that I never knew existed,” she says. “When I worked in the ED, I was saving one patient at a time. Now I’m saving lives [on a much larger scale].”

Emergency Nurse Practitioner: An Emerging Opportunity

Nurse practitioners have been providing emergency care to patients for decades. But only recently have nursing schools begun to offer degree programs designed to train advanced practice nurses specifically for the emergency setting.

Currently, seven graduate schools of nursing around the country offer emergency nurse practitioner (ENP) programs, which incorporate emergency nursing courses and clinical experience into traditional family or acute care nurse practitioner programs.

The University of Texas started the first ENP program more than a decade ago, after a study showed a need for nurse practitioners with broader emergency training. Acute care nurse practitioner programs provided emergency care training but did not cover caring for pediatric patients. Family nurse practitioner programs did not include enough emphasis on emergency care.

Now, besides the programs at the University of Texas-Houston and the University of Texas-Arlington, there are emergency nurse practitioner programs at Emory University in Atlanta, Loyola University in Chicago, the University of Florida in Jacksonville, the University of South Alabama in Mobile and Vanderbilt University in Nashville. While the structure of the programs varies from school to school, the ENP schools stay in close contact to make sure their curricula are aligned with one another.

At Emory University’s Nell Hodgson Woodruff School of Nursing, ENP students take family nurse practitioner courses along with four additional classes in emergency care. They must also do clinicals in primary, urgent and emergency care. Vanderbilt School of Nursing’s program is unique because it prepares emergency nurse practitioner students for dual certification as both family and acute care nurse practitioners. “This allows them to not only care for patients across the lifespan, but also across the acuity spectrum,” explains Jennifer Wilbeck, MSN, APRN, CNP, FNP, CEN, assistant professor and coordinator of the ENP program.

The majority of emergency nurse practitioner graduates find work in hospital emergency departments. But Michelle Mott, MSN, APRN-BC, FNP, an instructor and interim program director for Emory’s ENP program, says her students have also found jobs in prisons, specialty practices and retail clinics. One graduate now works for a primary/urgent care clinic on a remote Alaskan island. “I’ve never had a student who has had trouble finding work,” Mott adds.

In addition to her academic responsibilities, Mott also works in the emergency department at Grady Hospital in Atlanta. Advanced education in the emergency nursing specialty, she says, gives minority nurse practitioners a greater opportunity to improve health care for medically underserved populations. “You’re able to provide those skills that are the foundation of the philosophy of nursing, but you’re also able to provide management and bridge some of the gaps to provide greater access to care. It’s just a wonderful career path. It uses everything you learn in all of your schooling.”

While emergency RNs can earn such certifications as CEN (Certified Emergency Nurse) and CPEN (Certified Pediatric Emergency Nurse), there is no certification yet for emergency nurse practitioners. For now, these NPs hold either FNP or ACNP certifications, or both.

Wilbeck says more emergency nurse practitioner programs are needed. She believes the number of nursing schools offering ENP programs will grow as the nursing profession increasingly recognizes the value of these practitioners and begins to formalize standards for educating and certifying ENPs. Current ENP programs, she adds, are also looking at expanding and offering distance-learning courses.

Making an Investment in Nursing

The finance industry and the nursing profession may seem worlds apart. But Juan Pineda, RN, a former investment officer for the Massachusetts State Treasury Department who is now a cardiac surgery ICU nurse at NewYork-Presbyterian Hospital/Columbia in New York City, was able to make a smooth transition from the world of number crunching to the challenging and rewarding field of nursing, thanks to a passion for patient care and a love for helping people.

Making a total career change is often a risky endeavor, but for Pineda the bigger risk was remaining in a field that he was not passionate about. “I was more afraid of staying in my investment job than I was of making such a big change,” he says. “As hard is it might be to [have to start all over] in terms of education, it was harder for me to imagine myself in that same position .” Still, he admits, making such a dramatic career shift “definitely takes guts and determination.”

Pineda is the son of Colombian parents who immigrated to the United States in the early 1970s. They settled in the Boston area, where Pineda, along with his older brother, was born and raised.

Pineda’s interest in the health care field emerged in high school when he had to complete a community service project as a Spanish-language interpreter at Massachusetts General Hospital to earn credits toward graduation.

“It exposed me to the hospital environment and I thought it was great,” he recalls. “I really enjoyed helping people. Whenever I walked in to translate for a patient or a family, their faces would light up. They were probably so afraid about what was happening, and finally [here was someone who spoke their language] and could help them understand what was going on, rather than just having people poking and prodding them.”

After graduating from high school, Pineda thought about going to college as a pre-med major. But at 18 years old, he felt he was not ready for the rigor of pursuing a medical degree. “After I did the interpreting for about two months, I went away to college thinking that I was going to major in pre-med after having that experience in the hospital,” he says. “I was really interested in science and the human body. But I don’t think I was really ready to go to college at 18. I wanted to take some time off and really think about what I wanted to do. However, my parents didn’t think that was a good idea, and they strongly encouraged me to continue [with my education].”

He ultimately decided to remain at the University of Massachusetts Amherst to complete his degree, but not as a pre-med student. “[Back then], I just didn’t have the dedication for it,” he says. The thought of having to take difficult science classes, like organic chemistry, scared him. He decided to switch gears and pursue a degree in political science, one of his other big areas of interest.

As a political science major, Pineda focused his studies on international relations, comparative politics and issues affecting Central and South America. “At that time I thought I would go to work for the UN or something,” he says. “I minored in French and lived in France for a while and thought I would go down the path of working in international relations.”

After graduating with his bachelor’s degree in political science, Pineda took advantage of an opportunity to work at the Massachusetts State Senate. The job, however, focused more on the financial side of state politics than on the policy-making side.

“I worked as a budget analyst for the Ways and Means Committee,” he explains. “Then I moved to the State Treasury and became an investment officer. I did general fund investments in bonds and long-term debt, investing up to $1 billion. This wasn’t really complicated work—I didn’t have a background in investing. But I wanted to learn more [about the field], so I accepted a position at [the financial services firm] Morgan Stanley.”

At the time, the job at Morgan Stanley seemed like an attractive offer that would give him opportunities to use his Spanish-speaking skills and his background in international relations. With the possibility of assignments that would involve traveling to South America to gain clients seeking to invest money in the U.S., Pineda thought he had finally found a way to combine some of his interests.

But by the time he had completed his training and licensing in early 2001, the economy was in a downturn. It was not a good time to be working in the financial sector, and Pineda never got his chance to travel for Morgan Stanley. He was also beginning to feel that his career path was leading him further and further away from his original interest in public service.

“I didn’t feel like I was helping people by working in investing,” he says. “I realized I wouldn’t be successful in that career, because I didn’t have enough passion for what I was doing.”

Ready for Change

After quitting his job at Morgan Stanley and taking some time to think about what he really wanted to do, Pineda finally decided to return to square one and refocus on his first love: health care.

“That’s when I decided to go to nursing school,” he recalls. “I had a friend who was in nursing school and I would flip through his textbooks. He reminded me that it wasn’t too late to change careers. I agreed, and in 2001 I enrolled at Bunker Hill Community College and began taking anatomy and physiology courses.”

Pineda’s decision to make a career change into nursing was met with some resistance from his family—and even from other nurses. “When I first decided to go back to study nursing, a [nurse] friend of mine let me tour the ER of the hospital where he worked so that I could see up close what it was like. I wanted to be exposed to the ER to see if I would get nervous about seeing blood and things like that,” he explains. “One of the nurses there told me that I couldn’t go from [a field like finance] to nursing. I ignored the comment, because I knew that I can do anything if I really want to do it.”

He says his parents “rolled their eyes” when he announced that he was returning to college full-time to pursue a nursing degree. “Because I had had so many different jobs and was in my mid-to-late 20s and still struggling to find what I really wanted [to do with my life], they didn’t believe that I would [really] do it.”

But Pineda soon proved to his family—and his peers—that he was very serious about nursing. He attended classes during the day and supported himself by working as a waiter and bartender at night. “I needed something stable that wouldn’t interfere with school,” he says.

In 2004 he completed his associate’s degree in nursing, graduating at the top of his class. Shortly after that, he accepted his current position at NewYork-Presbyterian Hospital/Columbia.

Today, Pineda has no shortage of opportunities to feel passionate about his work. “I love my job. I’m one of the luckiest people in the world,” he says enthusiastically. “I can’t believe that I get paid to do this. This is the most interesting job [I’ve ever had]. It’s always challenging—physically, mentally and emotionally. I’m very proud of what I do. I’m helping people. I get to learn so much about the human body, how to work with families and how to educate patients about their recovery. I’m providing emotional support to patients and families. It’s great.”

Communicating and Connecting

Pineda feels there is a strong need for more bilingual Spanish-speaking nurses all over the United States. The community his hospital serves, for example, has a large population of immigrants from the Dominican Republic. “Every day another nurse asks me to interpret,” he says. “I can’t imagine working [here] and not speaking Spanish.”

Although many of the doctors on his unit do speak Spanish, Pineda’s ability to communicate in Spanish is still in demand. “[Here in the cardiothoracic ICU], patients are coming out of surgery, so it’s very helpful for them to connect [with the nurses] and much more effective for everyone that I speak Spanish. There’s a comfort for the patients [knowing] that I share the same culture, language and interpersonal dynamics with them.”

One of the reasons why Spanish-speaking nurses are so underrepresented in the RN workforce, Pineda believes, is the strong emphasis on family obligations in Hispanic communities. “[We] Hispanics seem to have children earlier in life,” he explains. “But [even if you do have kids] it’s worth it in the long run to continue with your education, because it will open so many doors in the future.”

As for being a man in nursing, Pineda doesn’t feel like he’s a minority in that regard. “I’ve been in units where on some days half of the nursing staff is male,” he says. “A lot of men in nursing are drawn to the ER or the ICU. It’s a very fast-paced environment. I’ve even been told by some families that [they think] male nurses are more compassionate than female nurses. The important thing, no matter what gender or race you are, is that this is a great career with lots of opportunities for growth. You can go as far as you want to go.”
Asked what qualities are necessary for a successful career in nursing, Pineda answers that a good nurse is empathetic, hard-working and determined. “You have to love this profession,” he emphasizes. “It can be difficult if you didn’t love it. The decision to become a nurse is so personal, but if [you] have a desire to learn a lot and really help people at the most critical points in their lives, it’s the best job in the world.

“It’s a competitive field,” Pineda continues. “[When you’re in nursing school], the classes are difficult. The first year is hard and from there it only gets harder. Then you have to take and pass the exams. And then when you start your first job, the work is hard and the hours are long. But it’s the most rewarding work. I advise others [interested in nursing careers] to be dedicated and do your best.”

Continuing the Dream

Now that Juan Pineda has fulfilled his dream of becoming a nurse, he is ready to take on new challenges. This summer he began taking courses in general chemistry, organic chemistry and statistics in order to fulfill requirements needed to apply to a master’s program in nurse anesthesia.

“I already had taken many of the [prerequisite courses] during my undergraduate work as a pre-med major, so I just needed three additional classes,” he says.

Today Pineda feels he is on track to achieve the kind of career he always wanted. “Being a nurse anesthetist is my ultimate goal,” he says. “That was my original plan—to have such a special role in someone’s treatment. I’m going to apply [to CRNA programs] in November. I have been focused on getting the best grades [in my prerequisite classes], because anesthesia school is very competitive.”
And what about his long-term goals? Where does he see himself in, say, 10 or 20 years? While Pineda has given it some thought, he admits that right now he’s focusing all his energies on getting through his CRNA program.

“I’ve planned on this for the past six or seven years and it’s such a big goal,” he says. “I’ve been focused on it for so long that [at this point] I’m not sure what my goals for the future are. I have thought about teaching, though. My ultimate goal for when I retire [from nursing] is to be a teacher of English as a second language.”

Putting the ER in Diversity

Into the Ruins: Nurses in Haiti

The following nurses left their homes in the United States with no real plan in place, a limited understanding of the language, and little more than a desire to help. They traveled across the island to unknown working conditions and devastation. And they echo each other: you cannot put the destruction into words.

“What do you tell them?”

Nurses listen to the calls for help, says Rosario Medina- Shepherd, Ph.D., A.R.N.P., F.N.P.-B.C., A.C.N.P., Vice President of the National Association of Hispanic Nurses and an assistant professor of nursing at Florida Atlantic University. Within two weeks of the earthquake, Medina-Shepherd joined a medical mission through her church. “I just packed up and left,” she says.

After landing in Cap-Haïtien, a city on the northern coast, she jumped into a rundown pickup truck with 15 strangers. They drove for over 10 hours through the mountains and quiet countryside. At night, they passed people congregated by the roads, where there was light from candles. “It truly was entering a different dimension, not one I can explain,” she says. The trip exhausted her, but it gave her time to prepare mentally.

By daybreak, she began working with patients at a hospital in Saint-Marc, a relatively stable coastal area experiencing an influx of refugees from Port-au-Prince, just over 60 miles away. “The medical staff at the hospital were from different parts of the world, but it did not matter where you came from,” she says. “We were there for the same purpose.”

Medina-Shepherd had packed lightly, filling her duffle bag with gear and medical supplies leftover from a 2006 medical mission to Ghana. When her team unpacked her equipment at the hospital, “suddenly everyone who spoke Kreyol wanted to be my friend,” she says with a bit of wry laughter.

“Everything we take for granted [in the United States] was nonexistent,” Medina-Shepherd says. “We’re so spoiled.” Even hours from Port-au-Prince, food and water were very hard to find. People came from miles around with buckets on their heads looking for it, and children played in the dirty water pooled near the road.

She felt afraid at times, sleeping on a mattress on the floor, surrounded by barred doors and windows, but she trusted the people who gave her team a place to stay. “They really just wanted to take care of me so I could take care of their people,” she says.

Medina-Shepherd was made medical director after arriving in Haiti, appointed by the director of the Gulf Stream Baptist Mission Association. The chief of medicine looked half her age, and the nurses and other volunteers seemed to need guidance. After making rounds, she assisted in wards staffed by nurses and physicians from a Boston-based team. They had flown in on military planes and were relatively well equipped, but conditions remained frenzied. “There were people all over the place,” she says. “It’s not America. It’s not how we run medicine.”

People recovering from surgery, including amputees, lay on the floor without pain medications or fresh dressings for three or four days after a procedure. After receiving a dose of morphine, they were suddenly up and walking out the door. It was hard to follow up with patients post-op—the physicians only looked after the most severe cases—so Medina-Shepherd set up a post-trauma clinic on other side of hospital.

Anyone could write prescriptions. There was no oxygen in the ER; “it was a place to go lay down and wait.” There was no way to intubate dying infants. One Haitian doctor said, “Get over it. Babies die here all the time.”

Medina-Shepherd and her team also established a makeshift clinic in a school in Arcahaie, a town about 45 minutes south of Saint-Marc. They worked from about 7:00 a.m. until 2:00 p.m. and saw over 100 patients. Some just came looking for free medical care, not available before the disaster. The Haitians complained of abdominal pain but only felt it when they didn’t eat, Medina-Shepherd says. “What do you tell them?”

Yet, despite the country’s devastation and the squalor in the hospital, the Haitian people wanted her to know that they were okay. The pride and reassurance is part of their culture, she says. In the early morning hours, from her mattress, she could hear people singing praise songs and worshipping in Kreyol. “That was my backdrop,” she says.

“I think we all need to go,” she says. “I would go back in a heartbeat.”

“Makeshift everything”

Chioma Ohiri, R.N., B.S.N., first went to Haiti in October 2009 to visit her mother’s family. A telemetry med-surg nurse at Parkland Hospital in Dallas, Texas, she wanted to reconnect with her roots. “The country was alive,” she says. “A lot of color. A lot of happiness.” Ohiri left feeling “complete.”

Chioma Ohiri, R.N., B.S.N.Chioma Ohiri, R.N., B.S.N.

When she returned to Haiti in January, a week after the earthquake, the once bustling airport was empty. United Nations troops guided her team around the tarmac, and they unpacked their own luggage from the belly of the plane. “My heart was so heavy,” she says.

Ohiri went with Hospitals for Humanity, a small-scale nonprofit with limited experience responding to such disasters. They gave her some travel information, she talked to her managers, and eventually skipped a vacation in Cancun to travel to Haiti. Ohiri joined nurses and doctors from all over: New Orleans, Chicago, Las Vegas. The team stayed with one member’s family in the coastal tourist town of Montrouis. Every day, they made the two-hour commute to Port-au-Prince.

They set up a clinic in one of the remaining structures, an abandoned church. Though it did not have any walls, it protected their medicine and equipment from the heat. But the Haitians were terrified to enter a building, and the nurses and doctors had to convince patients it was safe. It was a challenge, eight days after the earthquake. Ohiri was also there for the aftershocks, quakes between 5.9 and 6.1 in magnitude.

For medical supplies, they only had what they came with. “We had to make our own makeshift everything,” Ohiri says. Patients slept on the floor, and the team used church benches to make little triage areas. Ohiri assisted in a cesarean section performed on the ground, without surgical supplies or anesthesia. She just applied Lidocaine to the woman’s stomach. Both the mother and baby survived, and he was named for the doctor who performed the procedure.

“There were a lot of things I didn’t expect to see,” Ohiri says. So soon after the disaster, their clinic was inundated with multiple fractures (as many as five in a single limb), head trauma, and deep wounds. A child came in with a gash that “looked as if a shark just ate the back of his leg.” Someone used white undershirts to stop the bleeding, and the fabric had grown into the muscle tissue. Showing the Haitians how to care for their injuries became a priority. “We had to do a lot of patient teaching,” she says, because their wounds would take weeks to heal, long after the clinic disbanded. It harkens to the overarching goal of helping Haitians back on their feet, but leaving them with the tools to rebuild themselves.

“The people, they were so appreciative, so humble. That motivated me,” Ohiri says. The Haitians understood the nurses were doing the best they could, and the nurses in turn relied on each other to keep going. Everyone had so much energy, Ohiri says, and it helped her stay sane. “You put your heads together and anything is possible,” she says. “I ended up leaving with a lot of good friends.”

Ohiri says nursing outreach should not stop at Haiti. There is a debilitating lack of nurses in China, which was hit with a massive earthquake in May 2008 that left almost 100,000 people dead or missing, then another in April 2010 that killed over 600. She urges other nurses to volunteer. “Don’t be afraid, and just use your heart,” she says. “I feel honored to actually help.”

“Lines and lines of patients”

Joyce Vazzano, R.N., M.S., C.R.N.P., landed in the Dominican Republic on March 5, then took an eight-hour bus ride to Port-au-Prince. An instructor in the Department of Acute and Chronic Care at the Johns Hopkins University School of Nursing, she had volunteered in Haiti before, but seeing the stark contrast between the Dominican Republic and Haiti as she crossed the border was a new experience. “It was just so obvious it was a different country,” she says.

Vazzano traveled with three other nurse practitioners from JHUSON and a team of volunteers to a clinic in Miragoâne, a trade city on the west coast, 58 miles from Port-au-Prince. Though there were some toppled buildings, it was in much better condition than the capital city, she says. Unlike many volunteer medical workers she knew of, Vazzano’s clinic had a traditional exam room, though it did not have electricity or running water.

People came to her clinic from all around the country, including refugees from the capital. The earthquake affected everyone she saw. All had family who died in Port-au-Prince. “Every day, there would be lines and lines of patients,” Vazzano says. She estimates she saw one person every eight to 10 minutes.

Vazzano spoke to many patients exhibiting signs of Post Traumatic Stress Disorder; they could not sleep because of night terrors, could not eat, and experienced heart palpitations and trouble breathing. Two psychologists with the International Medical Corps, a private nonprofit relief agency, trained the clinic staff to recognize PTSD and taught them basic intervention, such as relaxation techniques. With the Haitian culture dismissive of psychology, there was little other psychiatric care or medication available.

Patients also came with more common ailments and chronic diseases. Many had respiratory problems because of all the dust in the air following the earthquake and the coal used for cooking. “People bathe in streams littered with garbage alongside the pigs and cows. Or they shower in groups in the open along the streets if there is any running water,” she says. “We were seeing many patients with cholera from the contaminated water supply.” Medications were very limited. They didn’t have enough to fill prescriptions for things like asthma and hypertension, so the Haitian doctors and nurses would give small doses. Bottom line: “If they don’t have the medicine, they can’t give it,” Vazzano says.

After a week, Vazzano left for a downtown clinic in Port-au-Prince. She worked on hospital grounds in ER/ICU tents with a group of Haitian nurses. “We worked together to try and work with the equipment we had,” she says. At one point, she showed Haitian nurses and doctors how to use needleless IVs, but they chose not to implement the equipment the next day or going forward, favoring more familiar, if outdated, methods. They knew, and Vazzano quickly realized, it was more prudent to reject tools that would eventually be taken away when her team left.

Generators provided the tents with electricity, but they intermittently blacked out, so nurses and doctors kept Ambubags ready to hand-ventilate patients if necessary. During procedures, they tried to be as sterile as possible, at least wearing gloves and masks, but anxious family members would walk in and out of the hospital tents, often standing at the foot of the bed. They could not be contained.

The patients arrived in droves, from 7:30 a.m. to 6:00 p.m. The 20 cots in the ICU, spaced about 18 inches apart, were always full. They treated ailments that read like a page from a history book: cerebral malaria, typhoid, and tetanus. “Some days, there were multiple deaths of patients who probably would have lived if they were fortunate enough to have the same illness in the U.S.,” Vazzano says. “They had so little before the earthquake and have even less now, yet they always had a smile for the health care workers and thanked us for whatever little thing we could do for them.”

The nurses chatted in the evenings, trading stories from their practice settings in the United States, Haiti, and elsewhere. No Haitian nurses worried about being sued if something suddenly went wrong, while the U.S. nurses followed pages of guidelines to protect the patients, as well as themselves. At the clinic, they just needed to work together to make sense of the chaos.

One of Vazzano’s peers in the Department of Acute and Chronic Care at Johns Hopkins, Beth Sloand, Ph.D., C.R.N.P., has volunteered in Haiti one or two times each year for the past 11 years. She became a leader for Haitian relief at the University, organizing one of the first JHU trips post-earthquake.

Sloand recommends registering now with organizations like the Red Cross, so when the next disaster strikes, they can quickly dispatch more specially trained nurses. She also suggests supporting relief efforts from home rather than going to Haiti, because the country has been swamped with volunteers when it really needs money and professionals.

Three nursing schools were destroyed in Port-au-Prince, and many nursing students and faculty died when the university hospital collapsed. “There’s a need for us to help support the nursing students in Haiti,” Sloand says and mentions donating to the Haitian Nursing Foundation or National Nurses United. “The Haitian nurses did a fantastic job.”