When faced with trauma in a hospital emergency department, nurses have a myriad of tools and resources available to tackle whatever challenges come their way. But imagine being faced with a situation as the only lifesaver at the scene of a horrific accident in a remote location, dealing with 10 patients and a lack of necessary equipment. Add a language barrier, cultural sensitivities, and sweltering heat and even the most experienced nurse can be challenged.
On the afternoon of June 20, an SUV traveling a lonely stretch of highway between Las Vegas and St. George, Utah, experienced a sudden tire blow-out, overturning and flipping off the road. The event threw several passengers from the vehicle and trapped others inside.
Maria VanHart, an emergency department nurse for the VA Southern Nevada Healthcare System (SNHS), was heading home to Utah after her shift at the North Las Vegas Medical Center. Nearly 30 minutes into her commute, she happened upon the single-vehicle accident. While a few onlookers had stopped to assist the victims, none of them were trained to manage the scene.
VanHart assessed the situation, and then quickly acted. “I did what I was trained to do,” she said. “I didn’t panic… just immediately did what needed to be done.”
10-Year-Old Boy Acted As Her Translator
One of VanHart’ s first challenges was communicating with the victims. She soon learned that the family had travelled to the United States from Syria for a wedding. Of the 10 passengers, only a 10-year-old boy was able to speak English. “He was walking around with some minor bumps and bruises, but overall looked OK,” said VanHart. He would serve as translator for all her patient care questions. “The first thing I told him was ‘I need you to show me everyone who was in the vehicle.’”
The driver of the vehicle was the father, who had suffered only minor bruises. An older teenage girl holding a baby were walking around the scene, both seemingly unscathed. The boy’s immediate concern was for his brother, a 14-year-old who was trapped inside the overturned vehicle.
“He was not breathing and (based on his condition) I knew immediately that he was dead.”
VanHart quickly turned her attention to others who needed immediate care. The mother of the family was thrown from the vehicle during the accident and was laying 10 feet behind the wreckage. VanHart concluded that she had suffered a severe pelvic injury and had potential internal bleeding.
Requested Helicopter Evacuation for Mother and Infant
At the front of the vehicle were two more victims on the ground: a boy in his late teens who had a broken leg and an infant girl who didn’t initially appear to have any injuries. While bystanders told VanHart that the infant was fine, she wanted to examine her just in case. “When I did my assessment on her, I could see some facial bruising, agonal breathing, and one of her pupils was blown, so I knew she had a head injury. She may have been having some seizure activity because her eyes were fluttering. She and the mother needed to be flown to a hospital immediately.”
Soon after, the Moapa Police Department arrived on site. “The scene was very active,” said Officer Alex Cruz. “Between attempting to stop traffic, rendering first aid and requesting additional units, it was hectic to say the least. Maria was calm and knew what she was doing. She was directing people on what to do while rendering aid herself. She was like an orchestra conductor.”
Based on the severity of the victim’s injuries, VanHart asked Cruz to request immediate evacuation. “I trusted her expertise and ended calling three helicopters and four ambulances due to her triaging the scene,” he said. “You could tell that she knew what she was doing and there was no time to question her capabilities.”
Calming Syrian Father with Familiar Greeting
Another challenge facing the responders was more difficult to navigate. When paramedics removed the clothing from the woman who VanHart believed suffered internal injuries, her husband became enraged. “I know that as a Muslim, he believed it was inappropriate for men to see his wife without clothing,” VanHart said. “He was still in shock and needed someone to understand him, so I did my best to do that.”
After years of working with doctors of various nationalities, VanHart has picked up phrases in many languages. “One of the things that I learned from working with doctors from the Middle East was a common greeting, ‘As-salamu alaykum,’ which means ‘peace be upon you,’” she said. “So, I sat with the husband and I told him that and he seemed to calm down.’”
Her Own Emotional Crash
After the helicopters were loaded with patients and VanHart had briefed the receiving medical teams at University Medical Center in Las Vegas, she finally took a step back and realized what had happened. She had been on the scene for two hours in 105-degree heat and was exhausted. “When the adrenaline goes away, there’s a crash. It’s an emotional and physical crash. I was dehydrated and physically shaky afterwards. I sat down, drank some water and called my friends for reassurance.”
Breast Cancer Survivor
VanHart is a breast cancer survivor. She also had lost most of her family to illness at a young age and is married to the former head of a hospital’s trauma nursing department. Health care has always played a big role in her life.
VanHart has a unique philosophy when it comes to assessing her work: “At the end of the day, there are two things that let me know if I have done my job that day. One is ‘what was my patient-to-hug ratio?’ And the other one is ‘had my mother been the last person I had cared for, would I have done anything differently?’ Everyone out there is someone’s parent or child and they all deserve to be cared for as if they were my own.”
At thousands of VA health care centers and outpatient clinics throughout the nation, employees are committed to serving Veterans.
The Veterans Administration supports and celebrates employees who want to take this dedication to the next level – whether that’s through flexible scheduling to accommodate volunteer activities, paid time off to fulfill reserve or National Guard duties, or by participating in a program that assists other VA facilities in an emergency.
Helping in a time of need
Through the Disaster Emergency Medical Personnel System (DEMPS), both clinical and non-clinical staff can volunteer to serve in the event of an emergency or disaster. DEMPS is a key component of our fourth mission to provide back-up health services to the nation.
When VA health care providers and support personnel are pulled away from their facilities to assist in events like hurricanes, earthquakes, floods and public health emergencies, these volunteers help fill in.
Recently, a team of 40 VA employees from around the country traveled to Muskogee, Oklahoma, to help care for Veterans affected by COVID-19.
“One thing this pandemic has shown is that when things get tough, VA health care staff do not waiver in their dedication to do whatever is needed to care for Veterans,” said Mark Morgan, Eastern Oklahoma VA Health Care System director.
“We are all here at VA to pay back to our Veterans for the services they have provided for us,” said Barela. “I think the presence of DEMPS brings a sense of comfort to Veterans. They know that as a country we are stepping up and doing a great job. We make sure that no matter what is happening, they receive their care without delay.”
Another group of DEMPS volunteers, including nurse Dorothy Barrow, were called to help an understaffed medical center in Whiteriver, Arizona. The center serves members of the White Mountain Apache Tribe, and Barrow helped ease the strain on night-shift family care unit staff.
“It was a humbling experience to be accepted into their cultural traditions while being helpful at the same time,” Barrow said.
Work at VA
If you’re as committed to service as we are, consider a VA career. Our mission of caring for Veterans —and helping the nation in times of need — is second-to-none.
In the middle of Emergency Nurses Week (October 11-17), a new feature-length documentary on emergency nurses is premiering on October 14. Viewers can see 16 ED nurses coping with everything from COVID-19 to gun violence, opioid overdoses, and the plight of uninsured patients in “In Case of Emergency,” which was directed by Carolyn Jones with the support of the Emergency Nurses Association (ENA). The locations include Iowa, Kentucky, Michigan, New Jersey, Oregon, Texas, and Vermont.
ENA President Mike Hastings, MSN, RN, CEN. said of the new film, “Emergency nurses experience things on a regular basis that most people will never see, things that most of the general public would not be able to tolerate, yet ED nurses face it all with poise, professionalism and an amazing human touch. This documentary will show our communities some of the challenges that we face day to day, COVID-19 or not, and provide some insight into our care settings. Most importantly, the film gives the public a true look at what essential heroes look like.”
Some of the nurses featured include:
Sheryl Hurst, RN, Ascension St. John Hospital, Detroit, MI: a community advocate who is trying to counter gun violence through education. “The violence has to be interrupted,” she says.
Angela Garrido, RN, St. Joseph’s University Medical Center Paterson, NJ Emergency Nurse: Garrido talks about her own battle with COVID-19. Hers was a relatively mild case, but “The simple task of taking a shower was exhausting; I’d have to sleep for three hours afterward,” she recalls.
Louis Cortes, RN, St. Joseph’s University Medical Center, Paterson, NJ Emergency Nurse: Cortes says that at the height of the New Jersey outbreak “We had brand-new nurses, straight out of school taking care of critical (Covid) patients from day one.”
Nancy Pitcock, RN, Texas Health Presbyterian Dallas, Dallas, TX, Emergency Nurse: the Dallas SANE relates: “There was one group of patients I felt had been really disserviced in the emergency room, and that was patients traumatized through sexual assault.” She notes that being treated by a SANE “not only helps with the healing of the patient, but also with identifying their needs immediately… and ultimately—hopefully—providing expert courtroom testimony.”
Lauren Habel, MSN, RN, CEN, TCRN, CFRN, St. Charles Health System, Madras, OR, Emergency Nurse: Habel discusses after-care for disadvantaged patients. If a patient agrees, “The community paramedic will actually go to their house and follow up on… helping them manage their meds, or with their new diagnosis of diabetes…. So that’s been a really cool program to get the health literacy up in the community.”
Jennifer Hanks, RN, UnityPoint Health – Finley Hospital, Dubuque, IA, Emergency Nurse: Hanks reflects on the importance of empathy and sympathetic communication in nursing: “When you can talk to them and explain what’s going on, that’s the human component that really makes all the difference.”
Special previews of the film will be available at the virtual conventions of the Emergency Nurses Association (ENA) and the American Nurses Credentialing Center (ANCC). For more details on the film, click here.
The importance of board certification was a key theme when two clinical nurse educators—one from California, the other from New Jersey—received this year’s BCEN 2020 Distinguished Awards. Each year, the Board of Certification for Emergency Nursing (BCEN) honors an emergency nurse and a pediatric ED nurse for combining outstanding clinical work with successful advocacy on behalf of specialized board certification, and Lisa Chambers and Jude Lark do indeed stand out.
The 2020 Distinguished CPEN Award winner is Lisa Chambers, MSN, MPS, RN, CEN, CPEN, TCRN, an emergency services/trauma clinical educator, and clinical nurse III at CHOC Children’s Hospital in Orange, California. Described as “One of CHOC Children’s finest,” who “passionately guides frontline staff in integrating knowledge, skill, and behaviors to improve nursing practice and patient care” by Melanie Patterson, DNP, MHA, RN, vice president of patient care services and chief nursing officer at CHOC Children’s, Chambers is proud of her staff’s determination to become board-certified during the pandemic. Far from being slowed down by COVID-19, she notes that “In fact, six of our nurses got certified as soon as the testing centers reopened. We had certification after certification. To me, that just showed they were using their time to push themselves.”
The 2020 Distinguished CEN Award winner is Jude Lark, BSN, RN, CEN, CCRN, an emergency services clinical nurse educator at Atlantic Health System’s Overlook Medical Center in Summit, New Jersey. Lark is “the consummate emergency department nurse—proficient, professional and compassionate—and is highly deserving of this national recognition,” said MaryPat Sullivan, MSN, RN, CNS, the chief nursing officer for Overlook Medical Center. Lark’s team was an inspiration during this eventful year: “In 42 years of critical care nursing, I have never seen anything like what we experienced in the emergency department and critical care units across New Jersey. Our board-certified nurses used their knowledge of best practices and the most updated skills to help facilitate and drive the innovative practices and adaptations we had to quickly develop for our COVID patients, and for each other, too.” She added, “Over the past six years, we have increased our certified nurses by 52%!”
Lark also remarked upon the way board-certified nurses took the lead during the pandemic, noting that “board-certified nurses really helped with that advanced level of thinking and effective utilization of CDC guidelines and ENA current COVID practice and trends, and in collaborating with our other sites. I actually have chills, because I think of all the emergency nurses and what they went through, while also taking care of each other.”
ED nurses seeking information on becoming board-certified should visit the BCEN site. Details on preparing for emergency nurse certification and other nursing certifications are available at Nurses Get Certified.
Nurses receive some disaster training, but as one New York nurse recently remarked, “We learned about a pandemic in school maybe for one day. Like it was literally one slide in one class…” Remedying this problem is a key concern in the Johns Hopkins report, “Recommendations for Improving National Nurse Preparedness for Pandemic Response: Early Lessons from COVID-19” and educators are already taking steps to add pandemic coverage to disaster nursing curricula. DailyNurse spoke to one of these educators, a member of the reporting team, Dr. Tener Goodwin Veenema, PhD, MPH, MS, CPNP, FAAN, about her role in the effort to update disaster training and education for the COVID-19 era. Dr. Veenema is a contributing scholar to the Johns Hopkins Center for Health Security, Professor of Nursing and Public Health, and author of the textbook Disaster Nursing and Emergency Preparedness.
DN: What sort of changes are you proposing in terms of disaster education and training?
TGV: I’ve been writing disaster nursing courses since before 9/11. And of course the focus after 9/11 was much more on deliberate acts of terrorism, and there was concern over natural disasters as always—pretty much the way the book [Emergency Nursing and Disaster Preparedness] was laid out—chemical, biological, and radiation events that may be human-caused. But now, because of the pandemic, the shift has really become much more public health focused.
Clinical nurses actually have to be public health nurses as well.
[At present], nurses get infection prevention and control coverage in school, but it’s at an introductory level. It’s not to the degree of what we’re experiencing now, where clinical nurses actually have to be public health nurses as well. So, we need to give nurses a better understanding of advanced concepts in infection control and prevention, and how to implement what we call intervention and containment strategies—non-pharmaceutical interventions, which includes things like social distancing, the use of masks, and frequent handwashing; closure of schools and businesses, and parks where people congregate.
More than anything else, the pandemic reveals where nurses did not have experience with the proper selection and use of personal protective equipment. It goes beyond nursing. Some of these problems were outside of nursing, for instance, the hospitals had failed to make a real commitment to emergency preparedness—to procure adequate supplies of PPE, or ensure that they had a vendor supply chain that would allow them to ramp up if they needed to order more. So, what I am advocating—and I’m working on a course right now—is to address these issues and strengthen prelicensure and nursing schools, and also continuing education to ensure that nurses have the knowledge and skills that they need not only to participate and survive, and protect themselves in this pandemic, but in future infectious disease outbreaks as well.
DN: As you mentioned earlier, there are many different sorts of disasters. Is there some sort of tool-kit that can increase nurses’ readiness in whatever emergencies might arise?
TGV: I define a prepared nursing workforce as a workforce that has the knowledge, the skills, the abilities, and the willingness to respond to these types of events. FEMA advocates what is called an “all-hazards” approach to disaster planning, which means that communities are charged with coming up with disaster response plans to address each and every hazard that might occur in their geographical area. Now for nurses, I think that they need to have a minimum knowledge base and set of skills on how to respond in an emergency and on how to continue to provide healthcare services within an environment that may or may not be safe.
The thing about a pandemic… is that it’s characterized by uncertainty…. Also, it’s everywhere.
I think that the challenge for the pandemic is, when a tornado or a hurricane hits, the event happens, and then it’s over. We move through the phases of the disaster lifecycle in a pretty straightforward manner. So, even the most horrific hurricanes that we’ve experienced over the past three years, they end. There have been extended periods of recovery—you can make the case that Puerto Rico has not yet recovered from Hurricane Maria—but you can plan for what’s going to happen. The thing about a pandemic, though, is that it’s characterized by uncertainty. For instance, we were anticipating a second wave this fall, but what we’re seeing is, we haven’t finished the first wave, and things are spiking again.
Also, [unlike most disasters, with a pandemic] it’s everywhere; it’s not geographically isolated in one region of the country. And of course, given the total absence of leadership at the federal level, now you have [states that are] basically 50 countries that are forced to address 50 different pandemics. That’s not the way you do it, so we’re failing there.
DN: Nurses have historically been on the front lines of response to disasters. What can be done to adapt the curriculum to provide them with better training and support for nursing in emergency and disaster situations?
TGV: I’m working hand-in-hand with AACN to help write an emergency preparedness competency to go into the revised Essentials document, so that schools of nursing will have a competency to teach to. AACN does a wonderful job with the Essentials documents, which basically serve as guides for curricula for nursing schools. I’m so proud to be working with them to help revise the essentials, publish this report, and then work on developing a five-module course with a company called Unbound Medicine. I produced a disaster nursing app with them back in 2015, and now I’m working with them to produce course content that schools can use to add to their existing courses or add as a standalone certificate to help provide this important information for schools that may not have the resources or the faculty who know how to develop this content or teach it—we’re hoping to do a great service for some of these schools.
DN: You mentioned the uncertainty of nursing in a pandemic. Where are we now?
TGV: We’re not through this. You’ve got California, Texas, Florida, and Arizona on the brink of being completely overwhelmed, and the Carolinas are right behind them. So the next month is going to be very ugly in the United States.
DN: What can individual nurses do to increase their readiness for pandemics?
TGV: They can pursue ongoing education and training as it relates to pandemic preparedness and response. Some of the professional nursing organizations are now offering short courses. I developed one with the National Council of State Boards of Nursing (NCSBN), and we have more that will be coming out.
The benefits of certification can include “greater career success and satisfaction including higher pay, greater opportunity for advancement, and higher employability as well as higher self-efficacy,” according to a report by the Board of Certification for Emergency Nurses (BCEN). In sum, says BCEN executive director Janie Schumaker, “Certification instills confidence, boosts engagement and ownership, and enhances collaboration and communication, all of which contribute to better, safer care.”
The BCEN paper points to studies that indicate certified nurses tend to raise the level of patient care. Certification researcher Diane K. Boyle, PhD, RN, FAAN, a professor at the University of Wyoming’s Whitney School of Nursing, comments, “Research-based evidence shows that there is a link between certified nursing practice and better patient outcomes and increased patient satisfaction. We also have beginning evidence that the higher the proportion of certified nurses there is on a unit, the better the outcomes.” By studying for certification, explains Marianne Horahan, of the American Nurses Credentialing Center, “Nurses fill in knowledge gaps as they study the entire body of knowledge for their specialty… The employer benefits by having nurses on staff who are up to date on the latest in their specialty practice.”
The BCEN report found widespread support for the certification of emergency nurses within the profession itself and among physicians. In the largest study to date, 92% of emergency nurse supervisors stated that it was important to have Certified Emergency Nurses (CENs) in their institution and that overall, CENs were preferred for their clinical expertise, technical performance, accuracy, safety and ethics. Often, hospitals support certification by offering an honorarium. In Illinois, for example, the emergency physicians at Edward-Elmhurst Health established an honorarium program for board certified RNs in 2006, with nurses receiving $1,000 for initial certification and $500 when they recertify. The hospital’s Emergency Services Chair, Dr. Tom Scaletta, calls the cash rewards “A small investment when you look at the improved relationships, improved patient safety and the message of appreciation we’re sending. It is worth every penny when it comes to ensuring nurses have the knowledge to care for our patients.” And, high-quality care is of course the ultimate goal. With a board certified nurse, says Richard E. Hawkins, the president and CEO of the American Board of Medical Specialties, “Patients can be confident that those treating them have the skills and knowledge… and are uniquely qualified to provide the best care possible.”