Heroes among us
PBS's "Need to Know" and ABC's "20/20" highlight��nurses' autonomous care for patients in crisis
November 3, 2012 -- Two recent U.S. television news pieces highlight nurses' skilled and autonomous care for patients in crisis. On June 22, PBS aired a 13-minute segment as part of its "Need to Know" series called "Nursing the Wounded." William Brangham's piece profiles three nurses at the large Veteran Administration hospital in San Diego. Each profile highlights a different facet of nurses' expert care for veterans who have returned with post-traumatic stress disorder (PTSD) and other problems. Each nurse comes off as articulate and authoritative; the profile of nurse scientist Jill Bormann, who is investigating the use of mantra therapy to manage PTSD, is especially impressive. And two of the three nurses are men, underlining the gender diversity of the profession. Unfortunately, the piece's suggestion that Bormann and the other nurses who are providing holistic, self-directed care to outpatients are playing "new roles" seems to reflect the erroneous view that, until maybe a few months ago, nursing was just about custodial bedside care. And tonight, the ABC current affairs show 20/20 included an 8-minute segment about New York University neonatal intensive care nurses who transported their fragile patients to safety after power failed at their flooded hospital during Hurricane Sandy. The segment, part of a feature about dramatic rescues during the storm entitled "The Heroes Among Us," appears to be the work of producers Gail Deutsch, Marc Dorian, and Adam Sechrist. The report consists mainly of co-host Elizabeth Vargas interviewing seven of the NICU nurses. The piece does include some references to the nurses' knowledge and skill, and it never suggests that physicians were directing their work or their actions to save the babies. On the other hand, the nurses are arguably treated more like bystanders who stepped up in a tragedy rather than highly trained health professionals, and there is a strong focus on the emotional state of the all-female group, an approach the show is unlikely to have taken with physicians. So the ABC segment is not nearly as helpful in conveying the nature and value of what nurses do in their everyday work as the PBS piece is. Still, both segments give prime time television audiences an unusual look at nurses acting autonomously to save and improve lives.
Nursing the wounded
The 13-minute PBS segment, "Nursing the wounded," was broadcast as part of the public television network's "Need to Know" series. William Brangham is credited as the producer and correspondent. His brief online text introducing the segment explains that hundreds of thousands of members of the U.S. military will be veterans of the wars in Iraq and Afghanistan. Many will likely return with traumatic brain injuries (TBI) or "serious psychological wounds," posing a real challenge to the Department of Veterans Affairs (VA), which has been faulted for its mental health care capacity. The online text mentions a new effort to "train more of the nation's nurses to help care for this growing population of veterans," noting that Michelle Obama and Jill Biden recently "recently launched an initiative to create specialized training in veterans health care so nurses nationwide can better care for this coming wave of new vets." We don't hear much more about that, but, the text notes, PBS went to the large VA hospital in San Diego to "understand the myriad ways nurses are already working in veterans care."
The video segment begins with Brangham noting that the San Diego VA hospital cares for tens of thousands of wounded vets, and much of the care is provided by the hospital's more than 1,000 nurses. Brangham explains that much of that is "traditional nursing care," but nurses "are now also taking on new roles, training spouses to care for their wounded partners, exploring alternative therapies to treat trauma, and working with vets one-on-one, helping them adjust to life off the battlefield." And the remainder of the segment consists of profiles of three nurses, each playing one of these "new roles." However, although specific techniques and treatments may be new, broadly speaking these are "roles" that nurses have played for many decades--conducting research into new therapies, providing care in the community, and giving psychosocial care to patients and families. The roles may be "new" in the sense that most of the media remains unaware of them, presumably seeing nurses as just providing custodial care and following physician "orders" in hospitals, rather than thinking, managing patients, or having real responsibility. So ironically, although the segment conveys plenty of very helpful information, its apparent suggestion that the nurses it profiles work outside the nursing tradition is wrong.
The first nurse profiled is Brian McMillion. Brangham says that McMillion doesn't work at the hospital, which is evidently surprising--again, presumably reflecting the belief that nursing happens only at the hospital. Of course, public health nurses have long worked in diverse communities, from the rural areas served by the Frontier Nursing Service of Kentucky (right) to the Henry Street Settlement in New York City. In any case, McMillion reportedly spends his days driving around Southern California visiting veterans and their families. He explains that you can see a lot more visiting in person than in short clinical visits. McMillion visits Chris Goodrich, an Iraq and Afghanistan vet with chronic pain, a serious brain injury, and PTSD.
But the notable thing, according to the report, is that McMillion (right) is not actually there to visit Goodrich, who gets care at the VA, but instead to see his wife Luce, under a program apparently begun in 2010. Brangham says she's not getting medical care, but advice and support so she can do her "full-time job" of caring for her wounded husband. We see McMillion talking to Luce, asking what she's doing to care for herself. McMillion explains:
The veteran is not just a person, he's part of a family. And the caregiver of the veteran is sort of the unsung hero. They're there every night with the nightmares. They're there every day with the assistive care. They're there to keep an eye on the medications. So, we're still treating the veterans when we're taking care of their families.
Brangham says that Luce has been unable to take an outside job since her husband returned home three years earlier. But under this new caregiver program, she gets a small stipend, plus practical training on everything from managing medications to understanding brain injuries, and access to any counseling she needs. Luce explains that she's grateful to have her husband back, but things have been very difficult and she had a lot of depression in the beginning. Chris says that he spends a lot of time in his garage by himself because he doesn't want to subject people "to my anger and my attitude." Brangham explains that nurse McMillion says the return of a veteran with PTSD or a TBI can be a huge challenge for families, and that most people don't grow up learning how to deal with that kind of trauma, so it's an adjustment for everybody. In the segment McMillion comes off as knowledgeable and well-spoken, a skilled and autonomous professional providing holistic care to this family.
Back at the VA hospital, Brangham says that registered nurse Jill Bormann (right) is trying to help vets with the psychological traumas of war. She "spends most of her time conducting scientific research." Brangham explains that Bormann is now working with a group of Vietnam vets who have PTSD, studying an alternative therapy to help them deal with symptoms they've had for almost 40 years. Bormann explains that they are men and women who've experienced some really traumatic events and who may also have physical pain. Many have been through divorce, and many have lost jobs. She says they seek "a sense of peace or wellbeing."
Brangham says the therapy Bormann is studying is called mantram repetition, similar to practices used for centuries in Hindu and Buddhist traditions. We see Bormann at a white board with relevant messaging and exercises. She explains: "A mantram is a word or phrase that a person repeats silently to themselves. One definition is a spiritual formula for transformation. That's a fancy definition. A simple definition: a pause button for the mind." Brangham says that in this 6-week class, vets pick their own mantram, whether religious or not. They are then trained in how to use it whenever they need to, silently, to control overwhelming emotions or memories that plague them. We see Bormann with a group of patients. One man says he was at the hospital the day before and overheard a physician joking that he (presumably the physician) must have PTSD because he was hypervigilant. The patient says that made him angry, but using his mantram helped him deal with it. Bormann explains: "We're trying to teach them to concentrate and be able to focus . . . on whatever it is they want to focus [on], as opposed to being gripped by emotions, thoughts, or feelings, memories or dreams that they don't want to focus on." As she is speaking, we see an onscreen identifier: "Jill Bormann, RN; Nurse Scientist." Bormann explains that patients use mantram repetition to help them manage road rage, nightmares, relationship issues, and even aversions to crowds, "so it kind of helps people get their life back."
Brangham notes that vets from more recent wars have gotten mantram training also. We see Victor Ozuna, who reports that he's never had peace of mind since returning from Iraq; he's had trouble holding a job. He says mantram training has helped him hold "recurrent troubling thoughts" at bay. He says he invokes it "hourly." Bormann explains:
Nursing and nurses have always embraced the entire holistic being, mind, body, and spirit. And in the medical or health professions, that's often been overlooked. And nursing has always, I think, been on the forefront of addressing, or at least being aware of, holistic practices . . . I mean, who else would be doing this kind of research?
This is a great point, and one that seems to contradict the segment's framing concept that these nurses are venturing into new roles; Bormann is saying that nurses have always been holistic. Of course, maybe the segment is also suggesting that nurses being scientists is new, which is obviously not correct. Still, this profile is very helpful, since it presents Bormann as an articulate expert and a scholar--a "nurse scientist"--doing important, groundbreaking work that really benefits patients. It might have been even better if the segment had noted that she has a PhD and is an adjunct professor at San Diego State University's School of Nursing.
For the third and last profile, Brangham introduces Keynan Hobbs, "a nurse and psychotherapist who works one-on-one with veterans suffering from PTSD." Some of Hobbs's work is coordinating patients' care, helping them "navigate doctors, therapists, psychiatrists," but Hobbs says an even more crucial part is "helping these veterans learn how to hold onto relationships." "Hobbs cites research showing that healthy relationships are crucial to overcoming PTSD." He explains:
I see my veteran community struggle with relating. And part of the cost of incompetent relating is that I lose people in my life that are important to me: my spouse, my parents, my kids, my friends. So as these relationships fall away, PTSD will tend to get worse.
We see Hobbs talking to one patient who has "made a breakthrough" but still has trouble sleeping and other issues.
Brangham explains that Hobbs has a unique vantage point because he's a combat veteran who has struggled with PTSD himself. Hobbs notes that he served in Desert Shield / Desert Storm. When he got out of the Army in the early 1990s, he was having symptoms and was angry most of the time. Hobbs says he tried to deal with it on his own, but it was not until he was referred to a psychiatric nurse at a VA center that he started to get a handle on his PTSD. (This appears to have happened 20 years ago, so evidently it's not a "new role" for nurses to provide psychological help as Hobbs himself now does.) Hobbs says he remembers the moment he let himself cry, remembering the pain and the fear he had in combat. A year or so later, he was in nursing school. And he's been working with veterans ever since. Hobbs sums up: "I don't like to watch that suffering go on. It's important to me to be here doing something about that." And that ends the PBS report.
The portrait of Hobbs is generally helpful. It is not really about any care innovation (unless the segment is wrongly suggesting that psychiatric nursing itself is a new innovation) or even about a specific method of care, beyond the "relating" Hobbs describes. And it is a bit more about the compelling story of one of the nurses who has himself struggled with PTSD, the unique vantage point that not only helps him care for patients but also, presumably, explain PTSD from the inside out, with a professional's analytic tools. So we don't learn as much about his nursing, but why he does it, how he got there, and what PTSD is like. Nor do we learn that Hobbs is a clinical nurse specialist with a masters degree in nursing from the University of Pennsylvania. Still, Hobbs does display professional expertise about PTSD. And by presenting a skilled, focused "nurse and psychotherapist" who coordinates care and helps patients with relationships, the segment shows viewers that nurses play a key role in this aspect of the care that veterans receive.
Heroes of Hurricane Sandy
The 8-minute 20/20 segment about the New York University nurses was part of an episode broadcast on November 3 covering several groups and entitled "The Heroes Among Us." The piece began with show co-host Elizabeth Vargas giving a general introduction to the aftermath of Hurricane Sandy, with a special focus on dramatic rescues. Indeed, the text version of the nurse segment at the ABC website is headlined, "Nurses Who Saved NICU Babies Remember Harrowing, Triumphant Hurricane Night." That text is credited to Gail Deutsch, Marc Dorian, and Adam Sechrist, who are 20/20 producers and presumably were responsible for the segment. Vargas describes the 20 tiny, vulnerable babies in the Neonatal Intensive Care Unit on the 9th floor of NYU's Langone Medical Center in Manhattan. The online text says the nurses have "challenging jobs, even in the best of times," because their patients are babies who may weigh as little as two pounds and "who require constant and careful care as they struggle to stay alive."
We see seven NYU nurses seated in two rows for the interview. The nurses are not identified at the start of the segment or, as a rule, when they deliver their comments, although several are named later when it would be awkward not to do so, as discussed below. This group anonymity would be unlikely if they were physicians, and in fact, it's pretty unlikely that physicians would be interviewed in a group of seven. Of course, for those unaccustomed to public speaking--much less to speaking on network television--a group setting might be welcome. ABC's online text does identify the nurses: Claudia Roman, Nicola Zanzotta-Tagle, Margot Condon, Sandra Kyong Bradbury, Beth Largey, Annie Irace, and Menchu Sanchez.
Early on, Vargas asks what the nurses' jobs entail, but before anyone can answer, she narrows the question to whether they are constantly monitoring the NICU babies, looking at every single vital sign, and the nurses nod yes. Not letting them answer the broader question was a bit of a missed opportunity to explain nursing. Then Vargas sets the scene. As Hurricane Sandy lashed the area with wind and rain on October 29, 2012, it was time for a shift change at the NICU. Vargas notes that as part of that change, the day-shift nurses briefed the night-shift nurses. Nicola Zanzotta-Tagle explains that the briefing typically includes the settings on the ventilator, the feeding regime, and the medication regime--hints at the kind of things that an answer to Vargas's broader initial question might include. We also get a few glimpses of the monitors and other NICU technology.
Suddenly, Vargas says, there was darkness and the "machines keeping the babies alive" went silent. Of course, it wasn't just the machines who were keeping them alive, but presumably the nurses won't be forgotten given the overall context. Emergency batteries kicked in. The nurses say that after their initial shock, they used their cell phones to shine lights to ensure that the babies were all right, starting with the ventilated babies. Vargas explains that four of the babies, the most critical, needed "help from machines to breathe," explaining that "without power, the nurses rely on battery-powered respirators to pump oxygen into the babies' lungs." The nearby river was flooding the hospital. Vargas asks how much time the nurses had to get the babies to another hospital before the batteries failed; Zanzotta-Tagle estimates 4 hours, other nurses estimate 2-3 hours. Annie Irace was the nurse for the most critical baby. She explains that the 2-pound baby had just had abdominal surgery the day before, and he was on a ventilator plus "medications to keep up his blood pressure, and he also had a cardiac defect, so he was our first baby to go."
Although the report does not actually say so, obviously the elevators were not working, and the babies had to be evacuated down a stairwell. Vargas explains that each baby was surrounded by
a team of medical staff, at least five per child, security guards and secretaries joining the journey nine flights down. Unable to generate their own heat, the babies are placed on warming pads and blankets. Flashlights and cell phones light the way. They use hand-held bags to pump air into the babies' tiny lungs.
Normally when the media describes health care tasks without specifying who did what, it is part of a report that gives physicians most or all of the credit for the care provided, effectively hiding the nursing role. But here, there is no suggestion that physicians are involved. Zanzotta-Tagle explains that the teams synchronized their movements as they went down the stairs. Four of the nurses actually demonstrate on camera how they navigated the steps with what Vargas calls "their fragile cargo"; lugging a tiny baby, portable monitor, and other equipment down steps looks pretty awkward. Vargas asks if there isn't a danger of pumping too much air in manually bagging, and nurse Margot Condon says you do have to be careful because your adrenaline is going. Nurse Claudia Roman notes that they're not usually bagging a baby down the stairwell, in the dark. Vargas asks if it was "scary" to hold the tiny babies in this situation--a natural question to ask a lay person. Roman responds calmly that she was more worried about not tripping down the stairs while carrying someone's precious child. That's a pretty good answer; another might be that it was scary, but being a professional means doing your job under adverse conditions.
When the nurses emerged at the ground level, a convoy of ambulances was waiting. Vargas explains that a news video of Margot Condon cradling a tiny baby as she rode a gurney toward a waiting ambulance "struck a chord worldwide." Condon explains her focus: "I was making sure the tube was in place, that the baby was pink. I was not taking my eyes off that baby or that tube." Vargas adds that Condon did not panic, and that "her precious patient helped keep her calm." Condon does note that the baby seemed to be comforting her, with his hand on her chest. She says that babies love to be held, and the other nurses agree. That's fair enough, but was the patient really the main factor in keeping her calm and focused, or was it her professional training and strength? People who are confident in their knowledge are able to stay strong in a crisis.
Vargas goes on to say that "it was that iconic image of Margot and her tiny charge that symbolized the heroism of so many during Hurricane Sandy." Then the segment cuts to a clip of President Obama speaking, presumably soon after the storm:
Obama: During the darkness of the storm I think we also saw what's brightest in America: Nurses at NYU hospital carrying fragile newborns to safety.
Then, back in the studio, Vargas reminds the seven nurses that Obama singled out "you ladies" after seeing the image of Margot, and asks them what that was like. One notes that it gave them chills. Vargas suggests in voiceover that "President Obama's shout-out can't hold a candle to the emotional gratitude from the parents of these babies." And the segment ends with a couple clips of mothers expressing that very gratitude to nurses Sandra Kyong Bradbury and Beth Largey, giving them hugs, at the other New York hospitals to which those nurses took the babies.
The online text adds a few final notes about heroism that don't seem to have made it into the broadcast. The piece notes that many call the NYU nurses "heroes," and that when the nurses were asked what they thought made a hero, they said things like "keeping calm in the face of adversity" and "teamwork." The piece reports that Kyong Bradbury says that in "extreme circumstances" like the storm, "you step up, and I think that's what makes a hero."
There is a lot to like in this 20/20 segment. Of course, it's generally helpful to see nurses presented as "heroes" saving the lives of patients during a cataclysmic event. But it would not do much to distinguish nurses from anyone else reacting well in a time of crisis if not for a couple of other factors. First, there are references to the nurses' health care knowledge and skill. We hear about their monitoring and their actions to keep these fragile babies alive, including the delicate task of pumping air into tiny lungs while on the move, and things that lay people might not have thought of, like the heating pads. We also see the complex equipment the nurses manage and hear, at least in passing, about the medication regimens and other elements of the care the nurses provide. Of course, the references to the nurses' professional skills are limited. The note about their "constant and careful" care of the NICU babies is telling; neither of those words really suggests skill or knowledge. Thus, while viewers learn that these nurses saved babies' lives on this one night, they do not learn that NICU nurses save babies' lives every night. So it's also critical that the nurses are presented as autonomous decision-makers and doers, managing the NICU and the babies with no physician involvement. It's actually astonishing that the segment makes no suggestion that physicians were calling the shots here. Instead, it gives the realistic (but rare) impression that nurses basically run the NICU. On other ABC prime time products, like the popular drama Grey's Anatomy, physicians would likely have been shown doing this work by themselves, and if there were any nursing role, it would likely have amounted to meekly taking "orders" from the physicians.
Still, some elements of the segment might have been better. To some extent, the nurses are treated like heroic bystanders who stepped up in a tragedy rather than highly trained professionals. Although references to the nurses' day-to-day expertise are limited, the show places a great deal of emphasis on how the nurses felt, whether they were scared, how cool it is that they did not fall apart, the hugs from moms, and Obama's recognition of "you ladies." We realize that nurses may be seen as more down-to-earth and approachable than some other professionals. But there is also a sense here that these were just ordinary people caught up in extraordinary events. And because all seven nurses are female, it's hard to avoid the impression that the show is treating them as females often are in "human interest" mass media, rather than as modern science professionals. Had the segment been about physicians, of whatever gender, it seems unlikely that there would have been the same focus on emotion or the same sense of wonder that the nurses held up under pressure. Would the show really have said that a physician's "precious patient kept her calm"? On the contrary, it would probably be assumed that the physicians could handle highly stressful situations--physician characters do that every night on Hollywood dramas--and the focus would instead be more on admiring their skill and courage as well as on the technical aspects of the infants' conditions and the evacuation. We wish the NYU nurses had been presented a bit less as surprising heroes and a bit more as serious professionals.
In any case, both the ABC and PBS segments do convey valuable information about autonomous nursing in unusually high-profile settings, and we thank those responsible.
See the PBS segment "Nursing the wounded," written and produced by William Brangham, which aired on June 22, 2012 as part of the public TV network's "Need to Know" series.
Also see the 20/20 report "The Heroes Among Us" posted on ABC's website November 3, 2012, produced by Gail Deutsch, Marc Dorian and Adam Sechrist.