Recently, I was privileged to attend events with leading presidential candidates, or their surrogates. I say "privileged" because I was able to hear a pointed, whole message from these candidates. Not the fragmented sound bites or curtailed answers to debate questions. Despite the proliferation of political cable talk shows (which I admit I am a fan of for their entertainment value), I find it harder and harder to get a true picture of political "news."

So much gets lost in rhetoric and partisanship that it's easy to forget that, for the most part, politicians - even those you may oppose - are trying to improve the township, state or country where they live. Thing is, they all have different viewpoints and approaches. And since they are essentially expounding on their own values, each is passionate about their plans for political change.

When it comes to healthcare, the voices get even louder.

Some - like Republican presidential candidate John McCain adamantly oppose government control of healthcare, calling instead for the free market to bring down prices. The theory is that if Americans can see the full costs of healthcare and have options, they will shop for the best rate - like car insurance. This, in turn, will create competition and lower rates overall.

On the other hand, Democrats Hillary Clinton and BarackObama have proposed something closer to universal healthcare, but not quite there. While Clinton's plan includes a mandate for all Americans to obtain healthcare (some with government assistance), Obama's plan is to lower costs by negotiating with insurance companies, believing that if premiums are lower, more will buy insurance.

I know which way I lean based on my personal beliefs, but are any of these plans (lacking much detail at this point) realistic in the healthcare world?

Should we just bite the bullet and go to universal coverage? If so, what would that look like?

For continued coverage, go to the ADVANCE for Nurses Web site for video on the Candidates' Health Care Positions and more.

A task force of representatives from medical groups, universities, the military and government agencies is basically recommending who lives and who dies after a major disaster like pandemic flu or terrorist attack.

In essence, the group recommends the very elderly, severely injured trauma patients, severely burned older patients and people with advanced dementia not receive treatment in the event of a mass-casualty situation.

The goal is to make sure resources such as ventilators, medicine -- and of course staff -- are used fairly. All the recommendations appear in an article in the May edition of Chest and are discussed on the American College of Chest Physicians Web site.

"If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing," the report stated.

The task force recommends hospitals designate triage teams who will decide which patients will and won't get lifesaving care.

Specific recommendations regarding people who should not receive care are:

• people older than 85.
• severe trauma, i.e. critical injuries from car crashes and shootings.
• severe burns in patients older than 60.
• people with severe mental impairment, i.e. advanced Alzheimer's disease.
• people with severe chronic disease, i.e. advanced heart failure, lung disease or poorly controlled diabetes.

Some argue the recommendations smack of age and disability discrimination and could create a "political and legal minefield." The American Hospital Association says the recommendations are just that, recommendations, designed to help hospitals develop their own preparedness plans even if they don't follow all the suggestions.

A pharmaceutical marketing research corporation came out with a list of the top most commonly search health conditions.

According to comScore Inc., Reston, VA, the terms "pregnancy" and "cancer" were the two most frequently searched conditions, garnering 8.8 million and 7.7 million search queries respectively.

Five of the top 20 conditions searched online (herpes, HIV, HPV, menopause and pregnancy) may be due to a function of these conditions' highly personal nature and the anonymity the Internet provides.

Top 20 Most Commonly Searched Health Conditions

1. Pregnancy
2. Cancer
3. Flu
4. Depression
5. Diabetes
6. Addiction
7. Herpes
8. HIV
9. Anxiety
10. Stroke
11. HPV
12. Bipolar
13. Cholesterol
14. Headache
15. Menopause
16. Hepatitis
17. Arthritis
18. ADHD
19. Asthma
20. Fibromyalgia

"It's not too surprising that some of the most common health conditions, such as diabetes, depression and flu, have made the list, but it's interesting that these terms generate fewer searches than significantly less prevalent conditions like cancer and pregnancy," Carolina Petrini, comScore senior vice president, said in the news release.

"A reason for this may be due to life-changing nature of a cancer diagnosis or a pregnancy. When facing a serious illness like cancer or after becoming pregnant or considering pregnancy, consumers often turn to the Internet to search for information and educate themselves in a private setting," she added.

Read the press release here.

This might help U.S. facilities. But what is it doing to the countries from which they hail?

A news article in the Philippines' Sun Star Baguilo reports nurses on average stay about 2-3 years at a hospital on their homeland before seeking more lucrative careers oversees.

New nurses staying on board for 1-2 years after school is common in the states. But there is an interesting twist to this particular story.

Filipino physicians are now enrolling in nursing courses, according to the article. At the hospital where this occurs, an administrator reports the lack of physicians is not felt.

That might be because the country has an "oversupply of nurses." An article posted on Global Nation provides a headline most U.S. nurses can only dream of - "Oversupply of Nurses Plagues RP"

But too much or too little of one thing cannot be good.

According to University of the Philippines College of Nursing Dean Dr. Josefina Tuazon, due to the numerous nursing graduates this year at 67,728, hospitals turn to volunteer nurses - cheaper because they are unpaid - to accommodate the new grads.

Without a local demand, new grads go unemployed. And when they do get those 2-3 years in somewhere, many seek high-paying jobs in the states, Saudi Arabia and Japan.

The Philippine Overseas Employment Administration deployed a total of 13,525 licensed nurses around the world in 2006.

If it hasn't been documented, it hasn't been done. With such demands on a stretched-too-thin workforce, could information technology ease workflow?

According to a March 31 Government Health IT article, "What Nurses Want", nurses elbow-deep in paper work, do, in fact, want fully implemented electronic records instead of common hybrid systems that combine automated processes and paper.

About 10 percent of the country's healthcare providers use EMRs, according to the article.

In the Government Health IT article, author John Pulley reports the American Academy of Nursing Workforce Commission  surveyed nurses nationwide.

They found, in terms of informatics, nurses want:

• computerized order entry systems to eliminate handwriting legibility issues;
• touch-screen or voice-activated technology for documentation;
• automated networks that collect and download vital information directly into patients' electronic records;
• hands-free applications, particularly wireless technology;
• smart beds that monitor patient movements and use pressure sensors to reduce the incidence of bedsores;
• interoperable systems that allow a full view of patients' records without toggling or entering multiple passwords; and
• IT that enhances workflows rather than disrupting them.

It is believed such systems improve the workflow while making a perceived labor-intensive profession more appealing to nurse recruits.

Adopting health IT doesn't end there.

When hospitals adopt these technologies, sustaining such change is key. At the American Nursing Informatics Association Conference next week in Washington, DC, speakers Ricki Willett, MSN, RN, and Donna Franks, BSN, RN, will talk about "Sustaining Integration Beyond Implementation."

They plan to discuss how evaluating facility culture, workflow and communication are imperative in creating a solid foundation.

So it's not just a matter of adopting IT; it's a matter of ensuring it is effective, practical and worth the investment.

Every March, as we wait for the first breath of spring here in the Midwest, thoughts in our house turn to my father-in-law, who passed away on March 17, 2000, after a 3-year battle with lung cancer.

Unemployed and without healthcare insurance at the time he became ill, my father-in-law, a U.S. Navy veteran, turned to the Jesse Brown VA Medical Center in Chicago for treatment. There he received excellent and compassionate care right up to the night of his death. I will never forget how respectful and supportive the nurses and physician were as my husband and his sister made the difficult decision to remove their father from life support.  

As the presidential campaign churns on, I listen to the candidates discuss the need to care for our veterans, and I know first-hand how important this is. I often wonder what my father-in-law would have done if medical treatment had not been available to him through the VA and am glad we didn't have to find out. I think about the many Vietnam era veterans who will continue to need VA assistance. And I think about the many soldiers returning from Iraq and Afghanistan with injuries more severe and medical needs greater than veterans of any previous war.

Steps are being taken to provide for these vets. According to the Department of Veterans Affairs, veterans who served in combat since Nov. 11, 1998, including those who served in Iraq and Afghanistan, are now eligible for 5 years of free medical care from the VA for most conditions, an increase from the previous 2-year limit.

But I have to wonder if this will be enough. In the March 3 issue of The New York Times columnist Bob Herbert writes about the testimony of economist Joseph Stiglitz before the Joint Economic Committee. Stiglitz told the committee that nearly 40 percent of the 700,000 troops from the first gulf war, which lasted just a month, have become eligible for disability benefits.

Stiglitz went on to ask the committee to think about how many vets will require disability benefits and medical services after the current war which may involve more than 2 million troops and will last more than 6 or 7 years.

I worry for veterans and their families. I hope the VA medical services that were available to my father-in-law will still be available to them in their time of need.

For those readers who know me from Career Beat, the column I wrote for ADVANCE for 8 years, you may remember I am passionate about wanting to get the correct message to the public about who nurses are. I encourage all nurses to be "media watchdogs." In other words, if you notice incorrect information about nurses or nursing in the media -- newspapers, radio, television -- or any other publication or outlet, it is your responsibility to call the writer or reporter and simply question the information you heard or read.

Let me give you an example of what I'm talking about. Last evening, on a Philadelphia television station, an investigative reporter related a story about students enrolled in a $12,000, one-year training program for medical assistants. The program claimed to be accredited and advertised its graduates were eligible to take the certifying exam after graduation. I applauded the reporter's choice of this story advocating for consumer protection and specifically for these students.

My problem with the reporting of the piece was it started out with a student in the program identifying herself as a nurse. She says she had previously been a nurse and because of illness had to leave nursing and now wanted to return. In fact, this is what caught my attention. However, then the story switches to this individual then enrolling in this allegedly fraudulent medical assistant program. Of course, this makes no sense at all. I have left a message for the reporter and hopefully he will call me so I can question, first, if I did hear the piece correctly and then if I did educate him about the need to clearly identifiof nurses-RNs, LPNs or non-nursing personnel, medical assistants, in future stories.

I want to emphasize we need the press to help the public receive more accurate information about nursing. So by all means be polite and courteous. You don't want to start off with an adversarial approach that will not result in a positive relationship. As a nurse of 43 years, I want nurses to be recognized for their hard work -- and not be misidentified to the public.

I have hypertension. I'm taking meds, exercising a little more, avoiding fatty foods when I can, and doing some of the other things that are supposed to be good for my almost-40-year-old ticker - like drinking more red wine, for example.  

I'm also an editor for ADVANCE for Nurses, including this Web site. And so I've edited numerous articles and otherwise read and understand a lot about the association between high blood pressure and heart attack and stroke.

I even know that I may be a "responder," meaning alcohol might actually raise the triglycerides in my blood from those yummy fatty foods that I can't seem to cut from my diet. To find out, I'll have to quit drinking that red wine for 3 weeks and then have the triglycerides level in my blood tested. It's one of my New Year's Resolutions; I just have to decide which year.

Still, I was surprised when a survey released Jan. 31 indicated most American adults are unaware of the connection between high blood pressure, heart attack and stroke - even though heart disease is the nation's No.1 killer of both men and women. 

That's right - more than 50 percent of those who responded to a survey commissioned by the National Association of Chronic Disease Directors (NACDD) said they did not associate high blood pressure with coronary events and stroke.

The "Americans and Blood Pressure Survey: A Survey of Americans and Their Knowledge Regarding High Blood Pressure" was conducted on behalf of NACDD by TSC, a division of Yankelovich, Inc.

The survey was conducted by telephone within the U.S. between Jan. 3-6, among 1,018 adults ages 18 and over. Figures for age, sex, race/ethnicity and region were weighted to ensure reliable and accurate representation of the total U.S. adult population. The margin of error for this study was +/-3.1 percent.

This being February and therefore American Heart Month, the survey's results take on a particular significance.

For example, while 72 percent of American adults understand multiple factors contribute to high blood pressure, such as obesity and salt intake, only 42 percent of the survey's respondents associated high blood pressure with heart attack and stroke.

What's more, 76 percent aren't even worried about developing high blood pressure, including 80 percent of Americans over 55!

But according to the American Heart Association, approximately 33 percent of Americans have the condition, noted John Robitscher, NACDD executive director, in a press release announcing the release of the survey.

"In essence, about 20 million American adults are not worried about getting high blood pressure, but are likely to develop it," he said

Funding for prevention efforts a one part of the problem, added David P. Hoffman, director, Bureau of Chronic Disease Services, New York State Department of Health.

"Only 34 states and the District of Columbia receive federal funds for heart disease and stroke prevention," he said. "The rest must rely on state funding and other resources."

Another problem, of course, is high blood pressure typically has no real symptoms, which lends to it the nickname "The Silent Killer."

Some of the other interesting findings from the NCDD survey include:

• 38% of Americans do not know their current blood pressure reading, including 22 percent of adults over 55.
• 37% of black respondents and 24% of white reported being diagnosed with high blood pressure.
• 85% of Americans with high blood pressure control it with medications; 10% rely on diet an exercise alone; and 4% do nothing.

All of which begs the question: What are you doing to educate your patients about the association between high blood pressure, heart attack and stroke, be it in the doctor's office, the ED, community health clinic, long-term care facility or whichever setting you work in?

Please use this blog as the place to share your tips and suggestions with your fellow nurses today - and all American Heart Month long!

Welcome to 2008! Many of us have decided to make health and fitness a priority this year, and I'm hoping this blog will help us stay on track.

This is the place to talk about your fitness tips and healthful eating tricks, vent about your challenges and cheer for your victories, and offer each other much-needed support.

The format is open - no one has to tell their weight, body mass index (BMI) or age unless they want to.

To start, here's a little bit about me.

I'll be 38 on 1/25, and I'm about 20 lbs overweight by BMI standards -- 30 lbs by my personal standards L . I've gone up and down the scale over the past 10 years. I am a lifetime member of Weight Watchers, which has really worked for me the three times I've done it. The problem is I get cocky when I reach my goal weight and my old habits creep back.

Getting committed to a fitness routine has always been a problem for me, more so now that I am keeping up with a 2-year-old son. I am a member of my local YMCA, and I think I am finally finding a schedule that works for me. I try to go to a 6 a.m. Body Pump (weight-lifting to music) class Tuesdays and Thursdays as well as one at 9 a.m. Saturday.  The challenge is trying to fit cardio in on Mondays, Wednesdays and Fridays. It's so easy to just go to work after dropping my son off at daycare, instead of going to the Y and hitting the treadmill or eliptical trainer. At the end of the day, I just want to vegetate.

Favorite Fitness Activities:

1. Body Pump (see link above): An hour-long barbell/weight-lifting class that works your whole body.  Participants can choose how much weight they put on their bars and change them according to the exercise (i.e. lighter weights for triceps, heaviest for thighs/butt/back and hamstrings). Warning to first-timers: use the lightest weights to avoid day-after pain and to ensure proper position and technique.

2. Walking: At the mall, in the woods, around a park or on the beach, this exercise can't be beat.

3. Dancing: My cable TV lineup has a bunch of music stations, including salsa, 80s hits and dance/club music. I've started trying to get some hip-shaking moves in when channel surfing or cleaning the house on weekends. I won't be on Dancing with the Stars, but at least I'm entertaining my cats.

4. TV Exercise Shows: These have progressed way beyond Richard Simmons' sweaty oldies and leotard-wearing Jazzercisers. FitTV, an offshoot of the Discovery line of TV stations, offers a variety of programs in the morning and evening. I try to do some of these programs in the evening, and sometimes my toddler will try to work out with me!

Eating Tip:

Keep a container of finely chopped nuts (available in the baking aisle of most grocery stores) at hand to sprinkle over yogurt, cereal, salads etc. Nuts are a good source of protein and omega-3 fatty acids.

Progress report:

Now it's your turn!

My father lost his battle with congestive heart failure a year ago January 5. For the past year, I've gone over his last few months in my mind, thinking over the details of each care plan. With agonizing precision, I inspect every step, every shot, pill, ministration, looking for evidence that his passing went the way he wanted. I am sure it did, because we talked about it long before it became an issue. As a result, the battle was really more a milling about, waiting for the engine to slowly sputter out.

It was not, however, the end he would have chosen for himself. Like most of us, Daddy would rather have gone to sleep one night and simply not woken up the next morning. Instead, he made do for more than 3 years after a CABG and small stroke took his independence. A gifted surgeon, retirement without being able to do for himself left Dad cranky, anxious and depressed. When my mom suffered a dissecting AAA in early 2006, he lost what was left of his spirit as well.

He was alive, but he had no quality of life. He was marking time, simply going through the motions. He took meds for symptom management, even while his longtime CHF got worse. He was ready to go. Unfortunately, when faced with that momentous decision, we weren't ready to let him. I fussed over him like he had years to go, jollied him into going into a rehab facility with my mom "to get his strength back," and got him admitted to the hospital in early December to pump him full of fluids after he stopped eating or drinking. It wasn't until he finally moved to my home with my mom and we got involved with hospice care that I fully understood what my job was to be.

Quality of life. I didn't know what that really meant until I stopped to consider the quality of his death, what it would be like for him to have to fight us for a natural end.

In her Dec. 4 entry, Pat Carroll, MS, RN, BC, CEN, RRT, talked about quality of life in her blog, Nurses' Wisdom From Your Virtual Break Room. Titled 21st Century Healthcare: Are We Making Progress?, she shared the story of her father, of discussing with him what quality of life meant and listening to his specific desires. It's tough to hear - and understand - that the parent you love has made a decision, and you have to support it. Even if you agree with it, which I did, the result will change your life forever.

Are we making progress in the art and science of saying good-bye? As my father's last caregiver, it was my responsibility to alleviate his suffering, provide whatever he needed and champion his cause. I think I did that part fairly well, but I have to admit, I've been haunted for the past year by thoughts that I didn't quite do enough.

It all comes back to quality of life. Like Pat's dad, mine was miserable. He had no hope of any recovery, nor did he want any. He had made his peace with himself (the biggest hurdle) and was ready. Then the moment came - and it was simply a moment, hovering over us like a balloon floating into the sun - and went and he with it. The poor quality of life gave itself to a higher quality of death. I would call that progress by any measure.

One of my pet peeves is people referring to universal healthcare coverage as "free," as if it's oxygen in the atmosphere. Someone's always paying for it. It has happened on a few occasions in our magazine. The first time was several years ago in an article about a delegation of nurses who visited Cuba to learn about that country's "free" healthcare system. Perhaps I was the only one who saw irony in that reference.

Another irony is how we spend more on healthcare than any other nation, yet don't enjoy the best outcomes across the board. Costs are spiraling, and it's estimated we'll be spending 20 percent of the gross domestic product on healthcare by 2016, up from about 15 percent today.

We can't stay on this path. Is taxpayer-funded universal healthcare the answer to curb runaway spending? After a long absence from mainstream political discussion, it's back on the table. While anathema among Republican presidential candidates, universal health plans have been proposed by some Democratic contenders.

In the Jan. 1, 2008, issue of Annals of Internal Medicine, the American College of Physicians publishes a position paper  that urges universal healthcare insurance coverage so "all residents have equitable access to appropriate health care without unreasonable financial barriers." The recommendation is based on a study of the healthcare systems in 12 industrialized nations. The group offers pros and cons of a single-payer system, where the government pays all costs, versus a pluralistic system that combines the government and private entities.

I'm leery of putting my healthcare in the hands of politicians, and also skeptical of government's ability to find huge administrative efficiencies and reduce costs, so I'm closer to accepting a pluralistic model if it comes to that. However, rather than covering all healthcare costs for everyone, which inevitably leads to rationing, it makes more sense to create a program that universally covers catastrophic and chronic conditions. Those are the cases universal healthcare advocates often cite when they make their case, and those situations could be addressed without nationalizing healthcare.

While the universal healthcare debate continues, we should explore policy options advanced in "Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending" a report issued Dec. 18 by the Commonwealth Fund Commission on a High Performance Health System. Key among them is the creation of a national public-private center for medical effectiveness and healthcare decision-making, which would evaluate the cost-effectiveness of new treatments and technology. Other recommendations include promoting information technology, reducing tobacco use and obesity, establishing hospital pay-for-performance programs, and paying doctors and hospitals per episode of care instead of for each service. Total savings are estimated at $1.5 trillion over 10 years if all recommendations are enacted.

You're on the front lines of healthcare and are in the best position to know what's wrong and where we should go from here. Whatever your views, make sure they're heard by those seeking your vote.

We at ADVANCE have been invited several times to speak before nursing groups on how to get published. To preface each of these presentations, we discuss nursing's representation in the press and nursing's responsibility to express their views to the public. After all, nursing is the largest healthcare profession. Additionally, it's one of the most important healthcare professions because, as I have said before, you don't go to the hospital for physician's care, you go for nursing care.

So I was delighted to read a Regional Commentary in the Philadelphia Inquirer by Linda Gural, president of the New Jersey State Nurses Association. Gural explained the proposed legislation in NJ requiring registered nurses to earn a bachelors degree in nursing within 10 years of their initial licensing. The bill affects already licensed RNs.

In simple, clear language, Gural explained the bill should not change the way nurses enter the workforce, saying community colleges and hospitals can still be the main educators of nurses.

In simple, clear language, Gural explained the bill should not change the way nurses enter the workforce, saying community colleges and hospitals can still be the main educators of nurses.

Citing studies that have shown outcomes are improved when care is delivered in a facility with more RNs with bachelor's degrees, Gural stated she believes the RN plus 10 proposal is the best way to ensure better-educated nurses in NJ.

Kudos to Linda Gural! You had something on your mind and you took the time to educate the public about this important issue.

When my mother was researching where to do her rehab after double knee replacement surgery, she asked her doctors, nurses and friends in the area. She ultimately decided on one facility that had a great reputation. She was apprehensive about the surgery and weeks of rehab but confident she would have the right tools and people to help her.

She had her surgery on a Tuesday and was transferred on Friday to the rehab facility. When I went to visit her, I found she was very distressed by the care - or rather the lack of care--she found. The nurses and support staff put her in bed and promptly ignored her for hours. The physician wasn't expected until the next day. Her roommate cried all day. Mom was overwhelmed and in significant pain. She needed a little TLC, but everyone it seemed was too busy.

One way Mom thought she'd begin to feel better was if she took a shower. She hadn't showered since Monday before the surgery, had been catherized for 2 days and understandly felt disgusting after not being able to get up and go to the bathroom unassisted.

Once we tracked down a nurse manager, she said it was unlikely Mom would get a shower that night. Patients generally received them every 2 days and since Mom just got there, she could wait another day. Emotionally and physically drained, my mom began to tear up. She just wanted to feel normal again. Couldn't anyone understand that? I asked the staff if I could help her wash if the nursing staff was too busy. That was acceptable as long as the staff helped her walk to and from the bathroom.

On my next visit to see Mom, I was assigned (by my Dad) to take her to physical therapy. On our way, we stopped by the nurses station to get more pain meds before her workout. It took a few minutes to get the attention of the nurses & other staff members. They were huddled around a computer deciding which gift to get someone from a baby registry.

When one woman finally acknowledged us, she said she'd check and disappeared for more than 5 minutes (the med closet was 15 feet away). Meanwhile, we waited patiently (ok, maybe not so patiently) barely 3 feet from where three other staff members (at least 1 was a nurse) continued to scroll through page after page of baby gifts. No one talked to us. No one acknowledged us.

Finally, I interrupted with a polite "excuse me" and asked if the nurse was coming back as we were now late for PT. Another nurse said we should have come earlier to get the meds. It wasn't her fault if Mom was late to "class".

Both of these experiences made me wonder how this facility got so many rave reviews. In the first case, it could have simply been a matter of staffing why my mom didn't get enough attention on her first day or there was no one to give her a shower. In the second case, staffing obviously was not an issue. There were nurses and ancillary staff available--they were just otherwise engaged in personal matter.

People go to facilities like this rehab hospital because of the nurses. It would be a shame if they also decide not to go because of the nurses.

During the 9-hour flight home from Ramstein Air Force Base to the states, med techs, nurses, respiratory therapists and one physician provided seamless care.

Flight nurses provided ongoing assessment of about 43 patients. While most patients were ambulatory, about 13 of them laid in litters which resemble three-tiered bunk beds with a canvas underlay and cushion on top (pictured below). (photos by Jeffrey Leeser)

Closer to the back of the C-17, the critical-care transport team [RE: "c-cat" for short], cared for two critical patients. CCTT--comprised of one nurse, respiratory therapist and physician--monitored closely the patient's pulse ox as well as heart rate, among other indicators. One of the critical patients sustained a bullet wound to the head.

In flight, I sat with an ambulatory patient, a civil engineer with the Army who was on his way back to Georgia. He is being sent home for internal bleeding. Within view of us are the two critical patients. "It's hard for me to see the guys physically wounded and then there's me," he said. "I feel like my problems are a lot more superficial than theirs."

As far as the nurses are concerned, no injury is superficial. On board that flight, patients dealing with post-traumatic stress disorder, on-the-job injury, leg wounds, epilepsy and mild traumatic brain injury received the highest level of compassionate and skilled nursing care.

If there is ever a silver lining to injuries sustained in war, it would be this: it has greatly advanced medicine in terms of designing high-tech prostheses and honing reconstructive surgery, including facial. The demand in the U.S. is not high in these areas, and what would have normally taken 30 years to develop has taken 5 years because of the war, relayed Janet Deltuva, deputy, 79^th Medical Group Commander at Andrews Air Force Base.

"When they come back, there is tremendous need to repair and restore," she said. "And with that comes bold advancements that wouldn't be there without the need."

More on the nursing and multidisciplinary care provided for soldiers at Ramstein Air Force Base and Landstuhl Regional Medical Center, both in Germany, as well as care provided at Andrews Air Force base will appear in upcoming issues of ADVANCE. It's been an amazing journey!

Critical care transport requires the utmost in communication, planning, and, from what I learned today, total flexibility.

At Ramstein Air Force base, the medical evacuation crew described the ebbs and flows of patient transports.

Consider the following statistics: Since March 2003, the 435 Aerospace Medicine Squadron has coordinated 73,003 patient transports from "downrange," out of Iraq and Afghanistan and back to Ramstein before they went elsewhere for additional care or back to the states.

Of those, only 22 percent were actual battle injuries. The remaining injuries were classified non-battle, which could mean someone became ill due to poor sanitation or was facing a mental illness.

In a single day, the aeromedical evacuation squadron can bring back about 20-30 patients per flight. Today, the Contingency Aeromedical Staging Facility (see pictures from Balad Air Base, Iraq) crew, who is responsible for unloading patients from the plane, onto "ambuses" or ambulance-buses, had three flights scheduled to arrive and unload. Their job from that point is to take them to either Landstuhl Regional Medical Center or back to the CASF staging quarters if they are non-critical. There they wait about 48 hours for the next flight back to the states.

Their cohorts, the critical care transport team, demonstrated nothing short of enthusiasm and pride for their profession. Three captains I spoke with all got their start as civilian nurses in the states. Their backgrounds combine critical care, emergency and trauma nursing. But when they met with an Air Force nurse recruiter at their respective hospitals, were thrilled with the opportunity. Now, after going through weeks of intense critical care transport training, they may have about an hour notice before they are head to Iraq. How many patients they are picking up is unknown. They make sure they care for themselves during the 5 hours down, using the time to nap and keep hydrated. Because once they land, it is an entirely different story. One captain's greatest load was 56 patients.

Nearly everyone we spoke with today was eager to tell us what they do, how they do it and why they chose this line of work. Quick-thinking, adrenaline rush, handling the pressure might be part of the job. But they wouldn't show up if they didn't believe in what they do.

Here are some photos of my day. (photos by Jeffrey Leeser)