My Scope of Practice: Enthusiasm on the Front Lines: `The Best Job I Ever Had!`
Front lines. We use the armed services metaphor to refer to clinicians directly involved in patient care. For Olga C. Rodriguez, MSN, RN, CPHQ (Colonel, Army Nurse and Deputy Commander for Nursing), the term is not an analogy.
The 25-year army veteran, now Nurse Director at The Methodist Hospital, Houston, Tex, has seen active duty in both US wars with Iraq. She utilized her administrative and clinical expertise on the true front lines, her responsibilities ranging from preparing troops for deployment to caring for the tiniest casualties of battle. She is proud of the outcomes she and her staff achieved with regard to preventing acute wounds from becoming chronic wounds and recognizes the role competent clinicians, nutrition, and pain management play in that effort. Olga’s skills were honed through a variety of experiences and employment opportunities. Several were “the best job I ever had.”
Olga is an alumnus of Syracuse University, where she earned both her Bachelor’s and Master’s degrees in nursing, the latter in Administration and Critical Care. She secured a position at the Veterans Administration Medical Center, an affiliate of the State University of New York (SUNY) system, spending 1 year in Medicine and then moving into the MICU and CCU. Soon after, she was put in charge of staff development. “I was responsible for orientation and education for all the critical care units,” Olga says. “Participation in this aspect of nursing demands that you be autonomous, independent, and resourceful. I loved it. It was the best job I ever had.”
Meanwhile, already a reservist, Olga signed on (owing to the finesse of the recruiter) to serve in the US Army and was immediately ranked First Lieutenant. “I had no idea what I was doing,” Olga admits. “But at least four nursing officers took me under their wing. The unit had excellent command leadership and provided mentoring and support. My Master’s in hand, I wanted to experience nursing in other parts of the country. I fast-tracked through Nursing Administration in my civilian job and went into active duty, serving in Columbia, SC, as a nurse representative of the SICU, as well as in Korea and at the Walter Reed Army Medical Center. I am very adventurous.”
For a time, Olga returned to civilian duty, beginning a flexible, seamless process of alternating between active, reserve, and civilian nursing. She did active and civilian duty at Walter Reed (“the best army hospital out there”) and worked in field hospitals as a Captain in the Reserve. Then came the first Iraq war in 1990. By now, Olga was a Major and Director of a coronary care unit. With many active duty nurses deployed, Reserves filled in. “Nursing management is the stabilizing force for patient care,” she says. “We go where we are needed.”
Later, her desire to travel and strong sense of obligation took Olga to Hawaii for 41/2 years at Tripler Army Medical Center and 5 years with the Hawaiian National Guard, 29th Infantry Brigade. She helped prepare the 98% male brigade for a rotation at the Joint Readiness Training Center, becoming an active participant in the war-gaming medical piece and earning the acceptance of the mostly male troops. “Usually, the Brigade Surgeon is a physician who handles combat medical planning issues,” Olga explains. “However, none of the physicians in the unit wanted the challenge, so I did it. It truly was one of the best assignments I ever had.”
More preparedness training followed. In 1999, Olga went to Texas and joined the 228th Combat Support Hospital, helping to ready a newly formed multicomponent unit comprised of 50% active duty clinicians including physicians, nurses, and physical and occupational therapists and 50% reserve soldiers. “Active duty folks don’t always appreciate reservists,” Olga says. “After a while, I told them we are a team and we need to get over the attitude that the Active Duty soldiers are better.” Eventually in 2003, she took over the unit as the Chief Nurse, completing readiness training and finally deploying just after Christmas 2004 for a 1-year tour of duty in Iraq.
Preparation addresses not only clinical but also psychological and physical issues. “The sheer volume of casualties alone is astounding,” Olga says. “The reality of combat nursing in Iraq is that trauma was five-fold more intense than any trauma you see in peacetime. The process of mobilization involves checking every detail before troops can go into the war zone — including whether clinicians are properly certified and if not, how we can give them the resources to get the necessary skills. Physically, you must deal with long working hours, sleep deprivation, and fear of the hospital coming under fire and of being kidnapped. Sharing those experiences brings the unit together.”
Olga says nothing fully prepares you for war. About 90% of the patients seen at the two major trauma centers (Mosul and Tikrit) Olga led incurred trauma secondary to Improvised Explosive Devices (IEDs) set by suicide bombers or bombs detonated in public places such as mosques. Because Individual Body Armor provided to troops covers the torso, groin, and arm, head trauma and mangled lower extremities are the more common injuries. The women, children, contractors, and Iraqi forces have no protection — they come to the hospital with half a chest gone or holes in the middle of their abdomens. According to Olga, about half of the lower extremity injuries end in amputation. Third-degree burns are common. Using the knowledge obtained from taking burn courses back in the States, Olga and her staff refined the burn care protocol.
Almost all severely injured troops are flown out by Medevac within 48 to 72 hours. Non-Americans remain in Iraqi hospitals, many for weeks. Overall, Olga says, quality and outcomes are “impressive.” Infection and mortality rates are low and pressure ulcer occurrence is no higher than in major US medical centers.
Olga has a theory, her “epiphany” she says. “Sometimes technology gets in the way of patient outcomes. We had patients with significant trauma who lacked high-tech beds and IV pumps — the bells and whistles. We worked with basic, even archaic, equipment, like portable suction, for long duration in a field environment. Some patients had as many as five suction tubes. We relied on two life-saving pieces of equipment: the rapid fluid effusion machine to quickly deliver blood and the wound vac, which I’d learned how to use as part of my orthopedic service.”
Olga’s Deployed Mobile Hospital (part tents, part self-contained unit) accommodated 44 beds — two ICUs (12 beds each) and a 20-bed step-down unit, along with a lab, radiology, and pharmacy services. The number of personnel needed to respond is determined by the level of MASCAL (mass casualty) called — Level 2 demands that everyone respond. The highest level of casualties seen in 12 hours was 32. Personnel included a triage officer and trauma teams consisting of a physician, nurse, and medic — for most part, casualties were processed in a swift and thorough manner. All neurosurgical and ophthalmic patients were automatically sent out by Medevac.
Front-line responsibilities placed heavy demands on staff. “Some nurses worked 24-hour shifts,” Olga says. “The nursing staff as a whole found it difficult to treat insurgents. We had addressed the ethics of care before deploying but the realities required the services of a chaplain who worked with staff through the difficulties. On the other hand, treating the locals brought some staff to tears. In one instance, the staff surrounded a badly injured 18-month-old to offer care and solace. Many nurses had children that age back home. It was heart-wrenching. Plus, nursing experience ran the spectrum — some had 4 years’ experience, some more than 25 years in the profession. We talked about cases to keep everything in perspective. I cannot thank them all enough for their dedication. For me, it was most rewarding. That entire year was an enriching experience.”
Another of Olga’s epiphanies was the relationship she saw between weight and healing. “Most Iraqis are underweight,” she says. “But their immune systems are intact and despite the complexity of their wounds, they healed quickly with low infection rates. I think this presents a research opportunity because overweight Americans seem less inclined to heal.” An additional part of her facility’s healing success, Olga believes, involved aggressive use of antibiotics, close monitoring, and a great deal of attention to nutrition. Clinicians also were diligent about hand hygiene, using portable gels to prevent the potential spread of infection.
Back in Houston, Olga says her Army experience, particularly in Iraq, gave her a different perspective on her daily life and a huge appreciation for her Active Duty colleagues. She says, “I am grateful and so proud of the nurses I served with and who supported me in my role as the Chief Nurse that year in my scope of practice.”
My Scope of Practice is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ.
