When John Rivoire, MSN, RN, a reserve captain in the U.S. Air Force, landed in Oman last spring as part of Operation Enduring Freedom, he was struck by the contrast between the harsh climate outside the operating tents and the sophisticated tools he learned to use inside.

"It was almost like being on the moon, except you had blue skies," he said. "Here we are, fighting off this sand and dust in a 120-degree environment and inside we have all this state-of-the-art equipment. I've seen physicians who would love to have that kind of equipment," he said. "Here's stuff that's been on people's wish lists for years."

Rivoire learned to manipulate X-ray photographs on a laptop computer, among other skills he never would have picked up at home. At the same time, he put off an opportunity to start a health clinic in rural Louisiana.

Rivoire's trade-off mirrors that of many nurses who serve in the military reserve, which has become increasingly important to the nation's armed forces as the military adapts to the smaller skirmishes of modern warfare. In the scaled-down world of military personnel, soldiers remain on active duty, but those who back them up on the battlefield-nurses, truck drivers and medics-increasingly come from reserve forces.

Cutting edge

Most recently, the "war on terrorism" has been a call to arms for reserve nurses, either to serve overseas or to replace active duty nurses headed for wartime assignments. Reservists account for 13,000 of the country's 2.6 million nurses. So far, about 146 Air Reserve nurses, 29 Air National Guard Nurses and 20 Navy Nurse Corps members have been deployed since Sept 11. (Nearly 9,000 nurses are in the Army Reserve, but the number mobilized since Sept. 11 was unavailable.)

Potentially called away for long periods of time and at a moment's notice, absent reserve nurses can strain the staff of their civilian employers, especially in the context of the nursing shortage. On the other hand, reserve nurses often receive training that cannot be duplicated, and bring their new expertise back to their civilian jobs.

Lt. Jay Wiley, RN, was working as a nurse on helicopters and in hospital emergency rooms for the Sacred Heart Health System in Pensacola, Fla., when he was called to reserve duty this summer.

Wiley, a triage nurse, and the rest of his 22-member forward surgical unit reserve team-which includes two trauma surgeons, one orthopedic surgeon, one OR nurse, one recovery nurse, medics and enlisted soldiers-flew to Jackson Memorial Hospital in Miami to train at the Ryder Trauma Center.

"You're not only getting graded, but you get cutting-edge things brought to your attention-that's a once-in-a-lifetime opportunity," Wiley said. "I bring all that experience back."

Wiley learned emergency medicine techniques that will serve him in the military as well as in his civilian position. He and the team watched as a 13-year-old boy who suffered second- and third-degree burns across 25 percent of his body was rushed into the OR for debridement.

"In the field, we would know when you triage a burn patient, they would be at the top of the priority list to take back to the rear," he said.

Lean and light

When Wiley heads overseas in April, he and his team will travel light, which is another characteristic of modern military medical care. Forward surgical teams must move around frequently on the battlefield and Wiley's will carry just enough resuscitation equipment for 72 hours-surgical gear, a couple of OR tables, a generator, lights, cardiac monitors, a certain amount of blood, drugs and sedation medication.

"A forward surgical team carries almost everything on its back," he said. The equipment and 22 team members fit into six Humvees.

Using handheld ventilators and ICU parameters monitored on laptops, among other equipment, military reserve nurses have an opportunity to use some of the most sophisticated nursing tools. As the tools have become more sophisticated, so have the medical teams.

Brig. Gen. Barbara Brannon, the assistant Air Force Surgeon General for Nursing, creates and evaluates nursing polices and programs for 19,000 active-duty, guard and reserve nursing personnel.

"The way wars were fought has changed significantly," she said. "We've had far fewer casualties. We needed a smaller number of medics that were highly trained and highly skilled, and we needed to be able to get them there quickly. We had to get lean and light."

Brannon, who also commands the 89th Medical Group at Andrews Air Force Base in Maryland, said critical care teams now can set up within 24 hours rather than the weeks-long process of the past.

"We'd be far more likely to send a facility that might have only a 10-bed capability, but have an outstanding capability to do trauma care and emergency surgery," she said.

Reserve nurses can add a lot to the small, highly trained mobile medical teams of the modern military.

Wiley was a paramedic for 14 years and maintains his competency in that area.

"I apply everything I learned there out in the field," he said. "Most of your reserve people have an element they do in their civilian job that helps them in their reservist job."

Elizabeth Norman, Ph.D., RN, FAAN, is a professor and director of the doctoral program at New York University's Division of Nursing. She has written three books, including two on the role of nurses in the Army. She sees this increasing reliance on highly skilled nurses as a shift in strategy for military medicine since the Gulf War.

"One of the things they learned, particularly in areas like trauma, was that some reservist nurses who work at top trauma centers around the country have more experience," she said. "You would want to move those nurses to the frontline first."

A drain of specialized nurses can hit some organizations harder than others. The Department of Veterans Affairs workforce typically has included a large percentage of reserve and retired military personnel. Of the VA's 37,471 registered nurses, 1,966 serve in the Army Reserve and 165 are retired military personnel.

Areas closer to bases typically have a larger number of reservists, said Cathy Rick, RN, chief nursing officer for the Veterans Health Administration.

"It's always a challenge to balance all of our missions, one being to back up the Department of Defense, the other to serve our veterans," she said.

While VA medical centers have strategies for scheduling around reservist training in addition to the usual vacation and sick leave, she said, the real challenge is in planning for a potential massive call-up of reserve forces.

"We try to make sure we have appropriate cross-training of our staff and know who can backfill for who needs to leave," she said. "That's always a challenge, especially in a work shortage. The most significant thing regarding a solution is to think ahead and be prepared. What would you do 'if '?"

"It's not just registered nurses, it's also our clinical workforce, licensed practical or vocational nurses, health techs and OR techs," she said. "Any team member that may be gone, like a physician, affects the team's capacity to care for our veterans."

Riding the wave

A good fix for a massive call-up of reserves has not yet been identified, said Cmdr. Mary Chaffee, MS, RN, FAAN, deputy director of the Navy Medicine Office of Homeland Security [See "5 Minutes With ," Page 12]. But in the meantime, she said, reserve forces are being used more efficiently.

"There is a much more careful integration and use of our reserve assets," Chaffee said. A computer database similar to that of a dating service stores information related to specific operations open to reserve officers. The reservists then look for the best match to do their required annual active-duty training.

"The process has been streamlined in the past five years," she said.

In addition, Chaffee said, the civilian and military sectors are starting to work together on pooling resources, including nursing expertise. For example, the departments of Defense, Veterans Affairs and Health and Human Services are working together on a National Disaster Medical System.

The system has two components that can be activated in times of emergency: emergency response teams situated all around the country composed of physicians, nurses, mortuary teams trained to recover bodies, veterinary teams and more.

"Those are the groups we saw head into the Pentagon and New York after Sept. 11," Chaffee said.

The other component is a cooperative bed-sharing agreement among military and civilian hospitals throughout the country. If a surge of casualties from an overseas war overwhelmed military hospitals, the military could use civilian hospitals, and vice versa.

"We're the only country in the world with a system like this," she said. "When you think of managed care and skyrocketing costs of health care, most hospitals no longer have a boatload of empty beds and nurses waiting around for something to do."

No matter how efficient the use of reserve forces becomes, the nursing shortage remains a problem. Some branches of the military have had some shortfalls, although an increased interest after Sept. 11, coupled with strategic recruiting techniques and generous training packages, have helped alleviate the problem.

Everyone-even the military-has to work harder to get the nurses they need, Brannon said, but things may be looking up. The Air Force staff of 2,300 reserve nurses is only 140 members short, rather than the 400 projected.

"We're still riding on that wave of patriotism [after Sept. 11]," she said. "While this does disrupt their lives and civilian employment, there's a lot of folks volunteering to go."

Capt. Rivoire, a reservist since 1990, took advantage of the military's generous training packages. The Air Force gave him a health professional scholarship and assisted him during his three-year program to obtain a master's degree in critical care.

Not only did he earn his formal and field education through the military, but his superiors did an extraordinary job of taking care of his family while he was away, he said. His positive experience serving his recent reserve duties has motivated him to take another look at nursing in the military.

"This has been pretty rewarding," Rivoire said.

Reserve nurses are more likely to move around on three- to six-month assignments, which can strain a family. "I've been thinking about going to active duty for three or four years instead," he said.

Contact Heather World at h_world@yahoo.com.