Vital Views

Joe Gaccione 0:02
Greetings, you’re listening to Vital Views, UNLV School of Nursing podcast. I’m Joe Gaccione, communications director for UNLV School of Nursing. On this show, we talk about a variety of nursing roles. A majority of them are in the classroom, the hospital, maybe in the lab, but this is the first time we’ll be discussing nurses in the air. I’m talking about flight nursing. And we have a very special guest with us today: Donna Miller is in the booth with us. She is not only a registered nurse and flight nurse, she also founded Lifeguard International Air Ambulance. It’s a company that transfers critically ill patients by airplanes which are basically flying intensive care units. Donna has also been involved in Nevada legislation, on emergency medical services, and natural disaster responses just to list a few of her many professional accomplishments. We’re going to dive into as much as we can, but I don’t want to speak for her. Donna, thanks for coming in.
Donna Miller 0:52
Thank you for the invitation.
Joe Gaccione 0:54
When we say flight nurse, what does that involve specifically?
Donna Miller 0:57
Well thank you for describing what an air ambulance is. Most people are familiar with a ground ambulance. Just like you convert a Ford van into a ground ambulance, we use aircraft to transform into an air ambulance. So, a helicopter for example could be seen as an emergency room, a flying emergency room. And they usually transport patients from, let’s say, the side of the highway, from an accident, to the closest trauma facility. An airplane is seen more like a flying intensive care unit, as you mentioned earlier. And that is because airplanes usually transport patients longer distances, and the types of patients that airplanes transport are very complex, critically ill patients that normally are found in local ICU, let’s say, that needs higher level of care that is not available in town, and they need to be transported to another ICU somewhere else, whether it’s another state, another country, even. So the aircraft at that point becomes a bridge between two ICUs, and the level of care on that bridge has to match, almost match, the level of care that’s provided in a hospital. And when you’re looking at the team that accompanies that patient onboard that aircraft and, therefore, on that bridge, usually it comprises by a nurse, a flight nurse, and by a paramedic, a flight paramedic. It’s very challenging, and as you can think, when you are in a hospital, you have an entire group of professionals that are caring for that patient, whether it’s nurses, doctors, respiratory therapists, perfusionists, you name it, the resources are an infinity of resources. When you’re in the airplane, you only have the nurse and the paramedic most of the time, sometimes we add an additional team member that is specialized in something, for example, a perfusionist for an ECMO transport. As you noticed, you decrease the expertise and the level of care from the hospital to the aircraft, but for the same type of patient while you transport, while you take the patient from the hospital, which is a stable environment, to now you are placing this critically ill patient onboard of an aircraft. That means that there are other conditions that are going to affect, possibly affect this patients condition and make it worse, and that is altitude, that is pressure. So, the team, the flight nurse and the flight paramedic, not only have to continue the care that is being performed in the hospital, but they have to be prepared to address any foreseen and unforeseen changes in the patient’s condition. The reason I’m saying all of that is to illustrate how important it is for that team to be very experienced, to be self-sufficient, to be able to recognize changes in the patient's condition and address it immediately.
Joe Gaccione 4:02
You not only need the basics, the essentials for being a registered nurse, but you talk about altitude and pressure, that's a whole other arena. How much additional training, like what are the intangibles you have to go through to qualify as a flight nurse on top of your health training.
Donna Miller 4:19
So, that depends from one state to another, believe it or not, and even from one area to another in one company to another. So I'm going to tell you about the state of Nevada. So in Nevada, a nurse has to obtain a secondary license through the nursing board. It's called an EMSRN, Emergency Medical Certified Registered Nurse. In order to obtain that, you have to have at least three years of experience in a critical care setting, whether it's ICU or ER, you have to be certified in ALS, BLS, PHTLS, and PALS, so most critical care nurses have the certification for the BLS, ALS and PALS, but the pre-hospital, the PHTLS Pre-Hospital Trauma Life Support, is a course that teaches you how to function outside of the hospital. In addition to that, there are courses that need to be taken that are preparing the nurses in flight altitude physiology, and it teaches the nurses how to function at high altitude. Some aircraft is pressurized and some it's not. So, how is that going to affect the critical patient that you already have on hand when you take it up in the air because up at 30,000 feet, air ambulance is the absolute most isolated medical environment that you can think of. Even though with technology today, you might think that you can reach out to a doctor or to someone to give you the resource or to help you decide on the treatment that's necessary, in reality, that doesn't happen. You do not have that luxury. You've got to know your, your, your job, you've got to know it well, you've got to understand it. You have to prevent and, and be very attuned to the situation so you actually take care of a problem before it becomes a problem.
Joe Gaccione 6:14
What made you decide to be a flight nurse and then eventually start your own air ambulance company?
Donna Miller 6:19
I always loved flying. As a matter of fact, when I was a little girl, I wanted to fly. My road took me different place and I ended up being a nurse, and I loved it. I, I loved being a critical care nurse and I loved flying. So, when I saw the opportunity to combine the two, I took it.
Joe Gaccione 6:38
We have a lot of nurse entrepreneurs that, it's not just learning the nursing side of it, but then they realize once they get into business, it's a whole new playing field. You have to basically start over and learn a totally new industry. What was that like, to go from nurse health professional to businesswoman?
Donna Miller 6:56
You know when, when I started Lifeguard International, I knew nothing about business. I had no business background. And quite often people that heard my plans, right? “You barely speak English, you don't understand the system, you have no experience in business, you have no money. How are you gonna do this? You can't do it.” So, I learned very fast to just, just think for myself and, and even sometimes I have the same thoughts myself, right? So instead of allowing that to put me down, I truly use that to fuel my energy and try so hard to prove them wrong. That may have not been the right motivation, but it definitely helped because also we had, and when I say we, I started this business with another nurse, so we had people that really saw our struggling as growing pain and they were so willing to help out and share their knowledge and, and really applaud every single progress or every single step that we did, honestly, whether it was progress or it was fail because each one of those, whether progress or fail, it had value that contributed to our, to our journey. So, if I am to, to look back, I would say being able to persevere, to not give up. That was probably one of the most important things. It's a lot of work, everybody knows that, right? So if you are doing this for the wrong motivation, it will be very difficult. So, love what you're doing, be enthusiastic about it. Learn how to embrace the challenges and really use it in your favor so you can propel your business forward instead of allowing that to, to, to make a fall back.
Joe Gaccione 8:46
In addition to the legalities of it and putting the structure in place, staffing, you have to find the planes. You know, how easy was that to acquire the actual resources, the physical resources, to do what you needed to do?
Donna Miller 9:00
So that's a great question, right? We made a plan and we had an amazing plan that we presented to amazing people, but the answer was the same. “Don't have any experience, sorry, I can't help you.” It took one person to actually think outside of the box and truly understand what we were trying, trying to accomplish. And that one person belonged to a bank, that in our mind, it was the last to actually see things differently and, and give us a chance. So it took one person to make that happen. We learned, and that was of course the last bank we went to, we, we pretty much eliminated all the, the banks on our list and, and we were considering going to private investors. We had a similar problem when we purchased the second airplane. So, buying the first airplane was not so difficult. It's like you buy a house, right? You go and, and, and you speak to the bank and you explain why, and you have an asset, so it's not as complicated as one may, may think. However, buying a second, second airplane, it was a different story altogether. In my mind, the bank knows what our history is, they know our payment processes, they understand, they trust, they, they believe. None of that counted because having an airplane, we now were a higher risk for the bank. So once again, not giving up was really important. We went out and looked for people and for banks that were willing to truly understand the mission of our, of our business and what we were trying to accomplish, and the value of allowing us the chance to make that happen. So, one thing went into another and, and we were able to, to make it happen.
Joe Gaccione 10:49
In 2017, you sold the company to AMR. Looking back, and this may be a redundant question, would you do anything differently?
Donna Miller 10:58
Absolutely. You learn so much, you, you never stop learning, right? We've done an amazing job on growing our business and I think the strengths that we had were our culture. We were very transparent to our teams, we were part of the same group and, and we were very clear with our vision. What helped with that was it wasn't my vision as the business owner, it wasn't my vision as the CEO of the company. It was a vision that we all shared and because everybody was moving in the same direction, it made us all successful because of everybody pulling in the same direction.
Joe Gaccione 11:37
We mentioned before in the intro, you played a role in disaster responses, multiple hurricanes. Can you talk about that role?
Donna Miller 11:44
So, after Harvey, I landed in Texas. That was my first experience with FEMA. And the email, one of the emails that I received while I was on the ground, it was simply telling me that I'm in charge of logistics and I'm thinking, “I've never done FEMA deployments before. I have no idea what that means.” But, after two minutes later, you, you, you, you take that and turn it into, “Wow, that's a pretty awesome opportunity. That means that I get to do this and I get to work with this team of people.” So, you fast learn to be very adaptable, to be very flexible, to understand the mission that you have and figure out how do you accomplish that. So, that time we had, I had about 400 nurses, medics, pilots under my logistical power to coordinate their, all their needs, not only to be functional as people, but they have to be functional as professionals. So, for example, a pilot requires to rest for 10 hours. In order for that pilot to have an uninterrupted rest, they have to have the proper conditions. Imagine being in the middle of a disaster. There are no hotels. There's no restaurants open to provide you with the food and nutrition that your teams need. So, that challenge was pretty amazing. And the team that I was driving and the, the community around us, everybody was willing to go above and beyond to make it happen. And after Irma, it became even more obvious to me how important collaborating with others and, and working together as a team, it was not only with our industry, but with other industries. When I first landed in St. Croix Airport, the Air Force was there and their job was to build a temporary hospital, and our job was the same, where at first we saw each other as competitors trying to accomplish the same goal, in reality, we worked with each other and fast realized that the tools that we had, the skills that we had, it was so different than the skillset that they had. So while we taught them and helped them certain things, they taught us how to be prepared just on time because in our industry, we are lucky to have certain pieces of equipment that in the field you don't get to have. So, they taught us how to utilize their equipment in ways that we wouldn't have known otherwise. Then when we went during that time, we transported about 400 people that we collected from all the Virgin Islands and transported by air ambulance, whether helicopters or airplanes to Puerto Rico. And then Maria came, and Maria destroyed all the hospitals in Puerto Rico. So after Maria, we had to take those very same patients and more, and now transport them in Georgia. The challenges were different in so many ways, but yet the same. Distance is a big deal when it comes to airplanes because you have a certain, very strict timeline that you have to follow and there is no, there's no room to wiggle on that. So, making sure that everything was just right and everybody was timely, it was really important in order not to lose our assets.

Joe Gaccione 15:20
Your leadership experience is lengthy, previous roles included vice president of the Nevada Nurses Association, you were on the Nevada State Board of Health, EMS Advisory Committee, President-Elect for the Nevada Ambulance Association. How did these roles shape you where you, where you are now?

Donna Miller 15:36
Entrepreneurs are trailblazers, and they're not afraid of changes. However, you learn that you cannot accomplish as much as you want to by yourself. You've got to have a tribe. You've got to have a community. So, it is common sense to join the organizations that you relate to in order to be able to make a difference. And joining the Nevada Ambulance Association and joining the Nevada Nurses Association was very important to me. As a matter of fact, at some point as a business owner doing air ambulance, I learned that there was something that I wanted to change in the legislature and while at first I thought that I could do it by myself, I realized that that was not the case. And I, as a matter of fact, I remember it was the day before I was supposed to do the, to testify and I called the Nevada Nurses Association, they have a legislative committee, so I called the chair, asking for advice and feedback, was I prepared, was I doing it right? I've never done it before. And she patiently, Betty Razor was her name, still is, she patiently listened to my presentation and at the end of it said, “You're doing it all wrong. You are going to speak to a group of people whose goals are to protect the patient. You are speaking from a business owner perspective. You need to change the way you approach this in a way that they, it, it aligns with what their beliefs are, it aligns with their mission. This way they have a better understanding of, of what to do and how to help the situation.” That taught me a lot because without her help, I wouldn't have known any different. So shortly after that, I joined the Nevada Nurses Association and I became one of the co-chairs for the legislative committee.

Joe Gaccione 17:40
Are there misconceptions about emergency medical services that you've encountered that you want to dispel?

Donna Miller 17:47
Yes, absolutely. The one big misconception is that EMS is a public entity, and in reality, while EMS is part of the public safety, EMS, most EMS agencies are actually privately held. What that means is that the funds that they receive to run their operations are not coming from tax collections. They're actually coming from the fee for service, the transports, the business that they perform. The other misconception is that EMS gets paid for its preparedness, and that's incorrect. Today, and hopefully that will change soon, but today, EMS only gets paid if they transport a patient. So, if you respond to a call and the patient decides not to go, or there is no reason to go to a hospital, that call does not get reimbursed. So there is no payment for the preparedness. And think about it, you have to have the ability to respond. That means that you have to have the, the, the assets, right? You have to have the ambulance ready to go and respond within a very short amount of time. You have to have the nurses, the paramedics, the EMTs, all be on standby, positioned just right in order to respond timely. However, none of that gets paid. They do not, EMS does not get paid unless they transport a patient. Another thing that I would love to see change and I would love to, to, I'm actually making it one of my goals, is to educate the public on the proper utilization of EMS. It is not unusual for the, for, for the community to call on reasons that really have nothing to do with EMS. I had a call once where a woman called because she had a breakdown in her bathroom, not kidding. As an air ambulance that was stationed in rural, yeah, in rural Nevada because the hospital closed down, I remember once having a patient that simulating sickness in order to be transported to Las Vegas and on the way to Las Vegas literally said, “Actually, I'm not sick. I just didn't have a way to get down to, to town, so I needed a ride. This is an example of misuse of the, the assets in ways that it's so much more than financial, right? We had one airplane in Tonopah that was caring for patients that had real problems. So it was the only way to access healthcare in Las Vegas or in Reno, and that one asset was now utilized for the wrong reasons.

Joe Gaccione 20:49
You recently spoke at the fall 2022 recognition ceremony for our graduating students, and what I really appreciated about your speech was, at times, you didn't pull any punches. You kept it very much grounded in reality in talking about the hardships out there. And while you were encouraging, you, you didn't fluff up the speech either. You, you told the students exactly what they needed to hear as it's not a perfect world, but you can make it better. When shaping new nurses, how important is it to balance optimism with realism? How challenging is that?

Donna Miller 21:26
So, you first have to, to love what you're doing, right? So if you are not having enthusiasm for what you're doing, you are in for a hard road. If you are going to spend 12 hours, 10 hours, 8 hours a day on anything, you might as well make the best of it. So, having enthusiasm and loving, finding love in what you're doing, it's very important. Being flexible, knowing where you wanna go, but being flexible on how you get there, that's really important. You have to see the changes coming and you have to adjust your trajectory based on that change. I'd like to say that the way you manage, the way we manage change is no different than surfing. And I'm not a surfer, but I heard that once and I had to, it, it clicked and I had to look into it. So, a surfer sees waves coming from far away and a surfer gets to, by experience, know when, when that wave is ready to, to it, it will come close enough where they have to engage and they, they position themselves just right. So when the wave is close enough and just at the right time, they actually start paddling, and when they start paddling, they paddle really hard, right? They're not indifferent about it. They paddle really hard and when they think they paddled enough, they paddle some more. And when they paddle some more, they take six more strokes. Then they have to commit to jump on the, on the, on the, on the board and, and take the wave. Being in business or doing business, or even simply your, your job, is no different than that, right? We need to see the changes coming. We need to embrace it. We need to figure out how do we use that energy in order to propel ourselves? If we are going to be afraid of any change, if we are going to be negative about the change, change is not a punishment, right? It actually is the ability, it's to, to make a, it's, it's the opportunity to make a decision that is right for you. Today, the world is full of disruptions, is volatile, is uncertain, and this is not going to change tomorrow. We cannot hope for things to go back to normal because things will not go back to normal. This is a new normal. A new normal will require new rules of engagement. When you were to have a career, the same career for 75 years, where for 35 years, where all your life, in the past you used to have one career and get really good, used to become an expert. Nowadays, change happens so fast that you don't have that luxury. You have to be able to move with the changes. You have to be improving yourself. You have to reinvent yourself and what you're doing all the time. You know, we talk about being innovators. Not everybody's an innovator. As a matter of fact, they say that there's 2.5% of us that actually are innovators. However, a hundred percent of us are, are reinventors. They're born reinventors. We learn how to walk, we, we learn how to eat. We learn how to choose our profession, and we know how to do best at it. So, reinvention is really something that we need to bring back because, I say bring back, we sometimes are trained out of it. Like when you go to school and they tell you, “Be quiet, don't, don't, don't move from your, from your chair, stay still.” That's when we learn to follow rules, but forget about doing what we feel is right. So, bringing back reinvention, putting ourselves in a position where we can see the change coming and prepare for it and embrace it. Learning how to change resistance into buy-ins. Those are qualities that, that I think will serve well whether you are a nurse at the bedside, whether you're an entrepreneur, whether, whatever it is that you put your mind to it will help you get there.

Joe Gaccione 25:42
That is all the time we have today. Donna, thank you so much for coming.

Donna Miller 25:44
Thank you for, for the invitation. I'm excited for the nurses that are about to enter the nursing profession. I'm excited for what they will have, bring to the table and the eagerness and the enthusiasm and the new eyes that they will bring to our profession so we can all be better prepared for tomorrow.

Joe Gaccione 26:05
Everyone out there, thank you for listening and I hope you have a great day.