Chaplain Angelo Betancourt, J.D., on a new twist to an old command

Hospitality Ministry in an ED

When first appointed as the designated Emergency Department Chaplain at our hospital, I was both excited and anxious. Having only been at Harris Methodist Fort Worth Hospital (HMFW) for a little over a year and being the first designated Emergency Department Chaplain began to feel like an imposing task. I was excited to fill this role because of my exposure to a Level I ED during my residency. Also, like many chaplains who are one and do not want to admit it, I am somewhat of an adrenaline junkie.

My main source of anxiety came from my colleagues, not because of anything that they imposed on me, but because of the impressive manner in which they bring chaplaincy to the highest level everyday. I work at a facility that I think is the Rolls Royce of pastoral care departments. There are six full-time chaplains on staff which includes our director; we currently have seven CPE residents and a second year palliative care resident; there are a total of four CPE supervisors; and, because of this staffing level, we are able to have a staff chaplain and a resident in-house 24-hours a day. With this powerful presence of spiritual caregivers at our facility, we attempt to represent ourselves in every aspect of the hospital and its functions. It is not just my department that is impressive. We are a Magnet Hospital and all the work done here is of the highest quality. [1]

HMFW is a 710 bed Level II Trauma center located in Downtown Fort Worth. We are moving towards Level I Trauma certification. We seem to be always operating at capacity. HMFW is part of Texas Health Resources, one of the largest faith-based and non-profit hospital systems in Texas. So, inroads to chaplaincy and ED chaplaincy were laid long before I arrived in the position.

I hope that, in sharing my struggle with this new appointment, it will be an encouragement to all who face a new task in ministry. When faced with the adversity of a new challenge, I find it is good to go back to my roots. When working as a chaplain in a pluralistic society it is important to have a grounding that allows showing the love of God, being true to oneself, and still ministering to people of different cultures and traditions in meaningful, compassionate ways. My roots in chaplaincy have been based on one command from Jesus in Matthew 25:45: “He will reply, ‘I tell you the truth, whatever you did not do for one of the least of these, you did not do for me.’”

Who are the least and what am I to do? Anyone who has ever walked the halls of an ED and encountered suffering and hurting people, does not have an answer to that question. Am I saying that illness somehow lowers your status and all of a sudden you are not as powerful as you once were? My answer is “absolutely,” your status has been lowered because illness and suffering are the great equalizers; they do not care about economic status or affluence.

In the ED, the answer to that question was clear to me. I am to show hospitality, compassion and love. Grounded in that philosophy and faced with the new challenge of ministering to the patients, families, and staff I encountered in the ED, I found that my mission was clear; but easier said than done.

As a chaplain I am endowed with authority. Whether that authority is real or perceived depends on how it is used. I prefer to see my spiritual authority as a shield rather than a sword. My shield protects the oppressed and sheds light on injustices. Armed with my shield and grounded in my theology, I looked at our ED and asked myself: “Where can I be most effective?”; “How can I be accepted and useful to the staff and still be there for the spiritual and emotional needs of all?”

I envisioned myself as someone who could offer the “cup of cold water ministry” and be helpful to the staff at the same time. I knew that the caring and compassionate staff could not always be there to meet every need of the patients. But, as a chaplain, with time in between traumas, I could offer hospitality to patients and also minister to the stresses of the staff.

Sometimes the ED can be one of the toughest places to establish a ministry. Many EDs see a chaplain as someone they call only when they need you. So, I introduced my plan to the staff, and put my theology into practice. I went from room to room and hallway bed to hallway bed, introducing myself as the chaplain and asking patients how they were and what their experience in the ED had been like so far. This has led to many long and interesting visits and prayers. This “Hospitality Ministry,” as I call it, serves as a vital link to our pastoral care department.

Like many hospital EDs, HMFW serves as the gateway to the hospital; almost 50 percent of our hospital admissions come through the ED. Therefore, if I visit 30 patients a day and our ED sees about 250 patients a day, then I could easily see about 5 percent of the patients before they are even admitted into the hospital. As a gateway to our hospital and to its reputation, it is easy to see how the ministry of hospitality could affect patient satisfaction, employee moral, and the experiences of family members.

However, one cannot simply be hospitable and just walk around talking to people and have a “cutting edge” ED ministry. Being an ED chaplain requires so much more. Without developing trust and showing the ED staff that I could do more than just show up when the department needed me, my presence would only be wanted when they need me and not otherwise. Small steps, building trust and validation of presence are crucial in being accepted as a valuable part of the team.

Hospitality ministry provided by our staff in all areas of the hospital has led to an increase in family presence at all traumatic events. At all Code Blues, no matter where they are in the hospital, family presence is encouraged. When I began to work in the ED, family presence at full arrests was just being implemented and thus far has worked fairly smoothly.

Family presence at codes helps in so many ways. It helps the families because they can feel closer to the patient; they can also see that everything possible is being done. It helps the clinicians as well because the family has seen what was happening. If they resuscitate the patient with expectations that the patient may need to be coded again, when the time comes for the sometimes difficult DNR conversation, the family will know if they want their family member to go through that again. If family can see for themselves what the patient is going through, they are better able to make decisions for their family member. A chaplain being present with the family allows the staff to concentrate on the patient while the chaplain sees to the spiritual, emotional and even social needs of the family.[2]

The process and continuous improvement towards family presence has opened up discussions for improving family presence at traumas as well. While family presence is not encouraged during the initial resuscitation of a trauma patient, it is now on the minds of clinicians working the traumas. We have what we call the “red sheet.” This red form allows for communication between the trauma rooms, the chaplain, and the front desk. The form contains information about how the patient arrived, the preliminary condition of the patient and who might arrive at the hospital. The Primary Nurse fills out the form and the chaplain takes it to the triage desk so they are prepared when family arrives. The chaplain also notifies security of the need for a family room. This communication allows us to take care of the second victim of traumas: the family. The chaplain’s presence at the trauma allows the chaplain to tend to the family as well as the patient.

Developing a collegial relationship between pastoral care and the ED staff has led to other positive changes. For example, I was researching the topic of Emergency Department chaplaincy in order to improve the care we provide. I came across “The Chaplain’s Response to Trauma/Medical Resuscitation,”[3] an article that spoke about Army chaplaincy at Brooke Army Medical Center. It explained a unique type of chaplaincy done in their trauma bays that really excited the adrenaline junkie in me. I felt like it was a very cutting edge article.

The authors described many things that we are already doing at HMFW. It also described things that we were not doing. For example, the Army chaplain may "bag" the patient or pass medical instruments as s/he feels comfortable. This article had the adrenaline junkie in me in overdrive and I was prepared to add to my ordered chaos bagging patients and passing instruments until reality kicked in and my supervisor told me to relax and take baby steps. So, I came out of overdrive and saw that if I presented this as scholarly research something might come out of this for our ED.

One of the clinical coordinators of the ED was leading a process improvement team that was looking at who needed to be at Level I traumas, and especially who needed to be in the trauma bay itself. So, I gave him the article. It was also emailed to the Trauma Administration Department by my supervisor. They agreed to look at it because of the cooperation that already existed between our departments in the hospital.

It was decided by the process improvement team that the ED doctor would talk to the entire ED team (which included the chaplain), about the course of treatment, so that all would be on the same page. This not only helps the clinicians but helps the chaplains so that we can be informed and keep the family informed. This felt like a giant step forward for the team and the pastoral care department. It may be perceived as a baby step by some, but for our department, it was a great leap. It was an even greater leap for the patients, families, and staff that the pastoral care department serves.

Sometimes I feel that we as chaplains, in an effort to validate our presence, forget the reason why we are in the hospital in the first place. We put the integration of the pastoral care department into the institution ahead of the reason we were first invited into the facility – to be servant leaders and clergypersons. In order to be a fully integrated pastoral care department, I believe that the department must build from the ground up, taking baby steps along the way. As a result, we can then reap the rewards of being a fully integrated pastoral care department.

I love being a chaplain at Harris Methodist Fort Worth and the opportunities that it is affording me: the opportunity to do what I was called to do and that is the desire of my heart, to be a pastor. To be available, compassionate, and hospitable to all I encounter allows me to be a pastor to all with whom I come in contact. Will a cup of cold water go a long way to making that happen? It’s a start!

Footnote

[1] For more information on Magnet Hospitals, go to: http://www.nursecredentialing.org/magnet/.

[2] For more information on Family Presence at codes, see http://www.plainviews.org/AR/c/v4n10/pp.html.

[3] Coffey, Michael, Curd, Michael T. The Army Chaplaincy (Winter-Spring), 2000. To read the article, go to: http://www.usachcs.army.mil/TACarchive/ACwinspr00/coffey.htm.

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