On the Other Side of the Rails

Pediatric Resiliency in the Face of Disaster: An Interview with Jamla Rizek

Authors:
Jamla Rizek, MBA, MSN, RN, CEN, CPEN, NHDP-BC, NRP
Charlie Hawknuff, MSN, APRN, FNP-BC, CEN, TCRN
Lynn Visser MSN, RN, PHN, CEN, CPEN, FAEN

Charlie Hawknuff and Lynn Visser, co-editors of the Journal of Emergency Nursing blog, spent a few hours chatting with Jamla Rizek about her experiences as part of a federal disaster response team. As her bio reads, Jamla has experience in over 20 emergency departments and many countries as a flight nurse, emergency nurse, and disaster response nurse. Her experiences range from your typical United States emergency department to the underserved populations of the United Arab Emirates. The editors were excited to learn more about Jamla’s experience to glean what knowledge they could for readers of the blog interested in disaster response nursing, the wide breadth of opportunities afforded by the profession, and some lessons learned along the way.

Editors: Tell us a little bit about the work that you do.

Jamla: That is a loaded question. I spent 10 years on a federal disaster response team responding to events such as National Safety and Security Events (NSSE), disasters like hurricanes, and the current COVID response. We also provided care to refugees in several unique situations. We planned and prepared for many different scenarios, and it would be hard to describe them all. I also have over 10 years of experience as an emergency nurse and paramedic working in the United States and abroad.

Editors: What first drew you to this work and how did you get into it?

Jamla: I tend to have a can-do attitude and seek out opportunities for adventure. I knew I wanted to live a life of service and purpose, I just didn’t know how or what at the time. I liked the idea of being able to go on missions and still maintain a full-time job as an emergency nurse. Disaster response nursing was a way to blend exciting experiences and flexibility. One way to get into this type of program and join one of the 42 Disaster Medical Assistance Teams (DMAT) is to visit www.USAjobs.gov and create an account and profile. I highly recommend inputting all your certifications in your profile, as well as taking advantage of their resume builder. It can be overwhelming at first because the website contains all of the government jobs, but once you create a profile and job-specific alerts, you will find it is easier to navigate. From there, you can set up an alert so anytime a position is listed that falls under your professional category and under National Disaster Medical System (NDMS) you will receive a notification. NDMS is the umbrella that DMAT falls under. That is how I found my current role.

Editors: Who is on a DMAT and what can a DMAT nurse expect to do on a deployment?

Jamla: The configuration of a team is made up of physicians, pharmacists, paramedics, safety officers, respiratory therapists and nurses, of course, as well as many more. Prospective members must be patient. This is not something that is going to happen overnight or relatively quickly. There is a lot that is involved including a background check and verification of licensure to name a few.
Because of the unpredictability of some deployments, members need to be prepared for anything. In a hurricane scenario, the tent where incoming patients are to be triaged and cared for needs to be set up by the team members. This is an all hands on deck team. However, patients can start arriving before anything is prepared. In this situation, members of the team must be able to multitask and handle high-risk situations with the resources they have available at that time. Having strong emergency or critical care and interpersonal skills is essential for being a DMAT nurse. A tent can be set up in no time when team members work together. Setting up a tent (shelter or BOO, base of operation) is a priority. Team members can also expect to put in long hours and must be ready to work outside of their comfort zones.

Editors: What places have you visited doing this work?

Jamla: I can’t provide specific locations or details for safety reasons; however, we have responded to all types of events including hurricanes, inaugurations, National Safety and Security Events (NSSE), and many disasters that have come up like the COVID response teams and natural disasters.

Editors: Are there any memories or experiences that stick out for you while doing this work?

Jamla: The best part of being a part of this team is that you collaborate and work together with US Public Health Service Officers, National Guard members—you never know who will be with you. Some of my favorite memories are meeting all the new people in our preparation meetings. You get the chance to create an incredible network of people from all over the country with a common goal. Some of these relationships have developed into true long-lasting friendships that I still have to this day.

Editors: What do you love most about the work?

Jamla: The satisfying feeling—similar to working in an emergency department. You put a smile on someone’s face, or an elderly patient holds your hands and thanks you. The mission isn’t always to fix the problem, but rather it is often to provide support until other resources arrive. So, it can feel like you failed but those little impacts end up being significant for the people you are helping.

Editors: What are the hardest parts of doing this work?

Jamla: Knowing that the work is never really done and there is only so much you can do. That has got to be the hardest thing. The work is not done but you do your job and then that’s it. You have to say “I did what I was meant to. It may not have fixed the problem.” Sometimes it feels like placing a Band-Aid on a hemorrhage. Deployments are usually about 2 weeks on average—sometimes longer. I have personally done over 7 deployments in the last 2 years. Sometimes it is a little difficult to juggle the work with a full-time job. You do fall under USERRA—Uniformed Services Employment and Reemployment Rights Act—your organization will hold your job for you like they do for military duty. You have to remain open with your manager so they know a deployment is upcoming and they can be prepared. You can keep your management team supported through good communication and giving them ample advanced notice.

Editor: You talk a lot about children when we have talked about your experiences before. Do you think children have different needs and experiences in the midst of or in the aftermath of trauma?

Jamla: Yes. I have been reflecting on this with everything going on in the world. For example, the children coming from Afghanistan right now are excited and smiling when they arrive in the US—it is so humbling. The pictures we see on social media of them skipping and smiling and waving to everyone--you wouldn’t have known that they just fled the only country and home they know. We are taking them out of a dangerous situation and that is what they are feeling. Sometimes they adapt better than the adults because they are so focused on the present. Children are not worried about the long-term or what comes next.

Editor: What literature have you come across on resiliency in children?

Jamla: I participate in a large working group of pediatric specialists called WRAP-EM—The Western Regional Alliance for Pediatric Emergency Management. It is a Health and Human Services (HHS) funded grant to develop a Pediatric Center of Excellence in disaster and emergency medicine. One of the focus groups just did an extensive literature review on pediatric resiliency and was tasked to put together tool kits and pearls for health care providers. A friend of mine is a pediatric pharmacist, and he put together cheat-sheet cards so that during a disaster you can quickly look at these quick tips. I have seen tons of resources out there even for COVID. WRAP-EM is hoping to publish a few white papers in the next few months on this very topic. The teams are also working on smartphone apps and continued collaborative work with other groups as well.

Editors: What is different for kids? Do you think they adjust better than adults?

Jamla: Depending on the age of the child, they don’t initially understand every aspect of what is happening. They understand, “I am leaving one place and coming to another place,” but don’t have the foresight to know the struggles coming—struggles with language, school, housing, etc. When they have a “booboo,” they fall, they cry for a few minutes, then get up and want to go back to what they were doing. They don’t worry about whether the wound will become infected or if something is broken. They move on. Kids focus on “there is this in front of me.” They see a huge mud puddle in front of the house and say, “I am going to go play in the water.” As adults, we are thinking: What is in the water? What will they bring in the house? Will the mud stain the floor or the couch? We tend to keep the kids away from those anxieties. We shelter them away from what they don’t need to know yet and that can support resiliency. Adults often create anxieties by thinking ahead to things that may never come to fruition, but children don’t have that same tendency.

Editors: What types of resiliency have you witnessed in children during your visits?

Jamla: On one mission, we would give the kids crayons and markers. They would color away and leave them for us. We had our walls covered in these drawings. On another one, the kids had an entire base to themselves and there was this empty fenced-off parking lot. The kids were quarantined and bored, so they found chalk and started drawing in the parking lot—each taking their own space and keeping social distancing. Next thing you know, they are all talking to each other and playing, developing peer support. They did this all on their own without prompting. There is a sense of, “I know we are in this together because we are doing these things next to each other,” even if they don’t talk to each other. Later they see each other and feel a kinship—feel like they have made bonds and friendship. I remember stumbling upon the drawings and saying, “Why is this green? What is this?” Then we realized they had been drawing superheroes, and I was looking at The Incredible Hulk.
On another mission, we were processing and caring for hundreds of children a day. All of the children were given these gray sweatsuits because they no longer had clean clothing. I noticed some of the girls were signing each other’s clothes and writing “BFF.” They had been traveling together now for a while and had clearly been bonded by the experience. I knew that they were not going to change those pants. These children were very Catholic as well and relied heavily on spiritualism. They would ask you to pray with them as a way to cope. Taking the time to recognize what they need and making it happen goes a very long way. Kids will think up things on their own but might turn to you for help to make them happen. Following routines that children keep also helps with their coping strategies.
In other missions, girls would braid each other’s hair—we would ask them about it, and they would be giggling. They resorted back to activities they did outside of this situation, to recapture a sense of normalcy.

Editors: What lessons do you feel emergency nurses caring for children can take from these situations?

Jamla: Take advantage of the little opportunities for improvements. Don’t rush a situation—don’t stress. Kids feed off your energy and they are going to know what is going on based on your response. They are going to be scared if you are scared. If you can stay calm and focused, then the children will stay calm too. I love the analogy, “calm as a duck.” On the surface, they are calm and treading water, but underneath, their feet are splashing away frantically. For example, in a mass casualty event, if one nurse is panicking, the children will start to absorb that energy and get scared. The children don’t know this is a disaster. So whatever context we set them up with in the moment, they will carry with them forever. They will remember the reactions, the feelings, more than the facts or situation. They might be nervous going to the hospital forever after that—we have the power to both create and alleviate that fear.
Another important thing to remember is that just because it is a serious situation doesn’t mean you can’t distract them, get them moving, get them doing fun things. Focusing on the seriousness does not help the situation. So ask them if they want to dance or play a game. It is ok to be silly. Life is too short to be serious all the time.

Editors: What is one thing a nurse could implement in her practice today to support resiliency in a pediatric patient?

Jamla: I am very religious and believe in making an impact every day. I live by this quote: “My biggest fear in life is looking back and wondering what I did with it.” So I encourage everyone to ask themselves, “What can I do right now to make that little meaningful impact?” I remember this one time I flew into a children’s hospital with a very sick patient. It was a rough case and I knew I needed a break, so my partner and I were going up to get ice cream from the cafeteria. When we got on the elevator, this little girl got on with her parents. She had lost all of her hair from treatment, and she was carrying a baby doll that also had no hair. She kept looking at me, so I said, “Your doll is so pretty.” The little girl just kept looking at me but the mom and dad said, “Thank you.” As they got off the elevator, the girl turned back to look at me, and I could feel that the comment on her doll was a reflection on her. This moment brought what I was doing back into focus. I needed to remember, it isn’t about me. People look to us for guidance as superheroes. Sometimes we are so overwhelmed and exhausted, but we carry on. We need to remember the small things. Asking, “What can I do for you before I leave?” or “What is one more thing I can do before I go?”—just small things like shutting the curtain or giving the patient small options.

Editors: If you could tell every patient one thing, what would it be?

Jamla: In a disaster, I would say “What can I do for you?” I would just focus on them for a moment. Even if they look fine, letting them know you are paying attention to them individually, not just the family as a unit, has an incredible impact. This is so important with children. Recognize them as individuals—no one pays attention to them. We have this habit of turning to mom and dad first. I try to do the opposite. I focus on the kid first, get on their level and talk to them. Then I go back to the parents, then go back to the child. It helps to establish trust with the child by talking to the parents—it gives the children permission to talk to me. They see I am not a stranger, and I am safe. You can do the same thing in an emergency department.

Editors: If you could capture a memory of yours and play it like a video for your colleagues, which one would it be?

Jamla: Actually, during a hurricane, the mother of a 6-year-old child who I was playing with, took a picture of us. I am tickling the kid and playing peekaboo with him. He was so happy. His mother took a picture of us and his smile is ingrained in my head. The rest of the time I was there, I would walk away and come back and he would be expecting it. It isn’t always the big moments that stick with you. It is a culmination of all the little moments that impact you.