Alan Zmek, RN is a Home Based Primary Care (HBPC) nurse at the Martinez campus who additionally volunteered to help start the Caregiver Support Program (CSP) in his spare time on nights and weekends. In his capacity as a CSP nurse he facilitated admission to East Bay HBPC, an early twenties OIF/OEF/OND married veteran living with his wife and mother-in-law. While in Afghanistan on deployment this Marine veteran sustained a sprained ankle while trail running to help a fellow Marine get into shape due to weight waivers.

This simple sprained ankle cascaded into a series of multiple events over several years; most recently leading to Complex Regional Pain Syndrome (CRS) of lower extremity with allodynia. Eventually, this veteran elected to have a below the knee amputation despite the fact that there was a very minute chance that he could have pain relief from this amputation. Over the course of several years of treatment the veteran did not feel heard and understood by caring providers.

After admission to CSP and HBPC and several home visits, Alan's welcoming smile worked its way into the hearts of this young injured veteran and his wife, who now welcome him into their home as a trusted confidante and provider.

We conducted an extensive literature review of CRS, which included consultation with our VA pain specialist, national VA HBPC list serve, and other VA and non-VA multidisciplinary treatment providers prior to the veteran's decision to have a BKA. Alan scoured the literature and provided important salient points to the veteran and his spouse. The literature and consultation with others did not recommend amputation. Despite the veteran electing this option, against VA provider's recommendation to avoid the BKA, Alan was supportive of this veteran's decision to make his own health care choices.

In fact, in his role as the CSP nurse he visited the veteran and his wife in a local non-VA hospital status post BKA when the veteran was suffering from excruciating post surgical pain. Staff at the local hospital were not aware of CRS and were flummoxed by the post surgical pain reactions and were having great difficulty managing his pain. Alan provided them with an in-service training and literature review on CRS, which helped the facility staff better understand the source of the veteran's pain, which led to improved care and eventual improvement in post surgical pain management.

Alan did an exemplary job of coordinating with the disparate pieces of a VA and non-VA health care providers while communicating effectively with the veteran and members of his VA and non-VA treatment teams. This veteran was admitted to HBPC twice. The first admission was before the BKA and the second was status post BKA. In the pre-BKA admission Alan helped cobble together a hybrid HBPC treatment team that included two additional members of the HBPC treatment team (occupational therapist and psychologist) and a non-HBPC VA primary care physician at a VA outpatient clinic near the veteran's home. He helped orchestrate coordinated care via CPRS and secured email between these VA providers across the normal HBPC continuum of care. However, he also helped coordinate the possibility of specialty VA pain management care and with the Federal Recovery Coordinator who is in another VA system. The degree of difficulty in care coordination with the Federal Recovery Coordinator was increased because the Federal Recovery Coordinator does not have direct access to CPRS so all clinical communications needed to be coordinated by telephone or secured email.

During the second admission to HBPC Alan again performed exemplary in facilitating the collaboration of HBPC providers with outside non-VA pain specialists including helping in the coordination of a pain referral to UC Davis Medical Center at the request of the non-VA pain specialists.

Alan stands 6'4" and is a gentle presence in the homes and hearts of veterans, veterans' families, VA staff, and non-VA staff alike. He is optimistic and realistic in easy to understand concrete terms. He effectively uses humor to infect others with his enthusiasm and professionalism.

Alan exemplifies best practice of the VA Mission "To fulfill President Lincoln's promise "To care for him who shall have borne the battle, and for his widow, and his orphan" by serving and honoring the men and women who are America's veterans." He unequivocally inspires, cajoles, and spirits all who come in contact with him to put veterans first by cutting through bureaucracy and largess of business as usual. Instead, he works collaboratively to coordinate the best possible care both within, outside, and among VA and non-VA providers.

I am continually impressed by Alan's outstanding mental health observations that enhance veteran's care and interactions. In the USAF they say "When you are solo no one can hear you scream." HBPC is a solo and team pursuit. We communicate on many different levels to team members and veterans who are geographically spread throughout a large catchment area. Depending upon the circumstances some decisions need to be made in the moment and others are able to wait for further consultation with treatment team members. Alan is able to walk that fine line knowing when he is able to make a decision in the moment or when he needs to seek consultation and authority for treatment orders.

HBPC is unique in many ways. Seeing veterans in their homes often affords us the opportunity to better distinguish between what veterans and their family say they are doing versus what they are actually doing. Alan does not shame or blame veterans for non-adherence. He uses humor and easy to understand homespun language to help veterans weigh the risks and benefits of adherence and the consequences of choices.

Hopefully, the above commentary on Alan Zmek's outstanding interpersonal skills with VA and non-VA staff speaks volumes about his effective interpersonal skills. Being a nurse requires great communication skills particularly in navigating cultural schisms of power within and between a fast array of professions ensconced within interdisciplinary treatment teams that crosses VISN barriers, treatment teams, and non-VA providers. The ability to successfully navigate this divide is exemplified by the daily care, honor, respect, and actions that Alan Zmek, RN demonstrates to veterans, their families, and staff.

I encourage you to hear my heartfelt recommendation to consider Alan Zmek for the honor of receiving the first DAISY Award for extraordinary nurses. He is more than an extraordinary nurse - he is a remarkable and outstanding human being who I have the distinct pleasure of calling my VA colleague - Mr. Alan Zmek, RN a.k.a. by veterans and staff alike as "The Big Man."