L E T T E R S

state of California, which requires clinical nursing instruc-

tors to have had some medical surgical experience. I was

turned away.

The hospital where I work has a Clinical Ladder pro-

gram. Despite my advanced degrees, I am only eligible for

Clinical Ladder No. 1. In response to my request to have

this policy reviewed, the nursing directors of the hospital

voted against allowing nurses with non-nursing degrees,

such as myself, from being eligible for advancement via

the clinical ladder program. I was turned away.

Realizing I still wanted to teach, as I was finishing my

master’s degree, I contacted the School of Nursing at the

University of California–Los Angeles to obtain informa-

tion about their PhD program. I reviewed the qualifica-

tions over the phone with the recruiter. After learning

about my bachelor’s and master’s degrees, the recruiter

asked me if I was a nurse. She called me back a couple of

hours later and informed me that because I did not have

at least one of my advanced degrees in nursing I was

not qualified to even apply to their PhD program. I was

turned away.

It is estimated that by 2020 there will be a shortage of

340,000 nurses in the United States. There are a number

of theories as to why this shortage exists. In a 2006 survey,

55% of nurses surveyed said they intended to retire be-

tween 2011 and 2020. The majority of these nurses were

nurse managers. And who will fill these vacancies? Un-

fortunately, we do not have the infrastructure to train new

aspiring nurses. In fact, nursing schools turned away

42,866 qualified applicants in 2006-2007. Among the rea-

sons for this was the insufficient number of nursing faculty.

Nurses are the driving force to solve the shortage prob-

lems. Traditional views of nursing need to be abandoned.

The Board of Registered Nursing in each state needs to

review their basic requirements for becoming a nursing in-

structor. Acquiring an advanced degree in nursing does

not make someone an excellent teacher, especially when

it comes to nursing. Practical hands-on bedside experience

counts more in nursing. Advanced degrees in any field

teach the student to look more closely at the subject mat-

ter and to scrutinize it carefully with an educated eye. Lifting

the strict requirements for admission into PhD in nursing

programs can help solve the nursing faculty shortages. In

light of the pending nurse manager shortage, current nurse

leaders need to look within their facilities for nurses who

stand out with strong leadership skills and encourage them

8 J

to seek the necessary advanced education to prepare them for

future leadership roles.

Nurses: Let’s stop turning each other away and rec-

ognize our colleagues who not only have the necessary skills

to advance but also the desire to teach future nurses and be

future nursing leaders, no matter what degrees they hold.—

Tracy Lloyd, RN, MPH, Newport Beach Calif.; E-mail: tlloyd3@

sbcglobal.netdoi: 10.1016/j.jen.2007.09.015

The Look

Dear Editor:

I saw the look again yesterday. There was a copy of the

Journal of Emergency Nursing in the break room of our

emergency department. On the cover was a photo of a

young Army nurse holding an injured Iraqi child. The

child was swaddled in blankets but the exposed face and leg

bore the marks of an IED explosion, peppering as we called

it. I pointed out the picture to Chris, one of our nurses and

said, ‘‘This picture speaks volumes.’’ ‘‘Yes,’’ she agreed,

‘‘that poor child. It isn’t fair.’’ But I wasn’t talking about

the child. The nurse was what drew my attention and the

expression on her face took me right back to an ER tent in

Iraq. Her eyes were open wide with a deep and profound

sorrow and I knew I’d seen that look before. Our nurses,

techs, and docs all displayed it at some point during my

2-month deployment to the Air Force Theater Hospital

in Balad, Iraq. It’s not the brief expression of horror one

has upon viewing a tragedy such as the Indonesian tsu-

nami or a violent car crash on the side of the road. Those

are too distant and impersonal. ‘‘How terrible,’’ is all the

mind can muster and we quickly return to whatever trivia

occupies our days. No, this was the look of one whose

tragedy was intimate. She held this tiny child and her

gaze told me that her defenses were down and she was

sharing, no, absorbing, pain from her little charge.

ER types, we pride ourselves on our clinical detach-

ment and coolness under fire. ‘‘Nothing works up an ap-

petite like a good Code! I’ve seen worse. Ain’t no big

thing’’ We wash off the blood or whatever bodily f luid of

the day has stained our hands and press on. Steady strain,

no problem. I was surprised while in Iraq, that despite

the horror of the situation, I seemed to be doing rather

well, . . .steady strain, no problem. As I trained my re-

placement, a terrified Family Practice doc drafted to the

OURNAL OF EMERGENCY NURSING 34:1 February 2008

L E T T E R S

emergency department at the last minute, he asked how

I could be so calm in the midst of all this mayhem. Well, no

use getting upset at every little thing, . . .steady strain, no

problem, it’s what we do. . .right? We talked trash, planned

jokes on each other, and played Texas Hold ’em right up

until the Blackhawks landed on the pad. Anything but

admit that we were taking emotional hits every time

another victim rolled through the door. It wasn’t until I got

home and started to sort through my pictures that it struck

me. There’s the look. ‘‘E,’’ one of our techs staring sadly at

a dying soldier. His chest was opened in the emergency

department in a valiant but futile effort to save his life. Her

gaze is fixed on his pale face and the look says, ‘‘I’m here,

I’ll share your pain, help you shoulder that unbearable

load, bear witness to your sacrifice. Part of me will go with

you.’’ Next picture. Ken, an ER doc, sizes up an unseen

patient and he has the look. Shields down, the misery goes

straight into the soul. Without our knowledge, it wounds

and reworks our psyche but the damage assessment must

wait. Steady strain, no problem. Flash back to my last pa-

tient at Balad. As the radio announced their imminent

arrival I remember saying, ‘‘please, no kids.’’ But there were

kids, there were always kids. He was riding in the family

car; Mom had just picked up big brother from the main

gate when a car full of insurgents pulled alongside and

showered them with AK-47 rounds. He was an 8-year-old,

just like my first patient there, and his right femur was

shattered by a bullet. As I replay the scene, watching from

my out-of-body perspective, I have the look. Its OK little

one, we’ll help you, share your pain, comfort your mother.

And then it’s gone. Back to work, clean up, prepare for the

next wave, get some food, have a laugh or two. . . steady

strain, no problem.

I remember seeing pictures of Viet Nam vets with ‘‘the

thousand yard stare’’ but this is different. Our look is not

that of the used up or hollowed out. We weren’t burned

out by the experience. . .but we were burned. We’ve held

and stood next to the victims of unspeakable violence. We

lined the hall and saluted our f lag draped brothers at the

start of their final ride. While on duty, we bore the steady

strain and accomplished the mission, no problem. Now

I’m safely home and back with the wife and children I love,

back to work, back to church, back to everything as it was

before. Yet, I am brief ly lost in thought as I return the look

to the nurse on the journal cover, and I know I am forever

changed. Soldier on Captain, you do us proud. Keep your

February 2008 34:1

eyes open and soak up some of that pain from your young

patient, you’re strong enough. There will be time when you

get home to sort it all out, steady strain, no problem. . .

Shakespeare’s Henry V tells his men on St. Crispian’s

Day, just before the battle of Agincourt, ‘‘He that outlives

this day, and comes safe home, will stand a tip-toe when this

day is nam’d, and rouse him at the name of Crispian. He that

shall live this day, and see old age, will yearly on the vigil feast

his neighbours, and say ’To-morrow is Saint Crispian.’ Then

will he strip his sleeve and show his scars, and say ’These wounds

I had on Crispian’s day.’ But we medics have no scars up our

sleeves. If you would know us as part of that few, that

happy few, that band of brothers (and sisters), watch our

faces and you may catch for a fleeting second, our scar; the

look.—Donald Lambert, PA-C, Physician Assistant with Main

Line Emergency Medicine Assoc., Paoli, Pa, and LtCol, 175

Medical Group, Maryland Air National Guard, Baltimore, Md;

E-mail: djlambert@comcast.netdoi: 10.1016/j.jen.2007.09.018

Triage

Dear Editor:

In the distant corner of a local emergency department,

a woman lies, slumped, vomiting profusely into a plastic

bag, writhing in severe pain. Within an hour she is dead.

A month later an older man who has been sitting patiently

in a different emergency department for hours complaining

of middle abdominal pain suddenly develops a cardiac

arrhythmia and dies. These scenarios could be seen in any

emergency department throughout the United States. But

they did not take place with physicians and nurses at the

bedside, the patients on monitors, intravenous lines es-

tablished; they occurred in the waiting room before evalu-

ation. What has happened to America’s healthcare system

when a patient can die of a perforated bowel or sudden

cardiac death in an ED waiting room before being seen by

a physician? Who is responsible for deciding the level of

acuity for patients when they present initially to the emer-

gency department and who is accountable for these deaths?

Traditionally, critical decisions as to whether patients

need immediate care or can wait to be seen have been left

to well-trained triage nurses, individuals with years of ex-

perience. Using a combination of clinical gestalt as well as

presenting medical complaints and vital signs allows these

individuals to make appropriate dispositions. At times,

JOURNAL OF EMERGENCY NURSING 9