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On a day that seemed like any other day, registered nurse Liz Zemke headed off to see patients at a rural California health clinic. A busy woman juggling a career and family, she was probably pondering the day's minutiae--reports to file, phone calls to return, dinner to make, dry cleaning to drop off, birthday cards to send.

But it wasn't a day like any other day. Around a blind curve on the mountain highway, a stranger's car careened into the wrong lane, headed straight for her. Life as she knew it was about to change forever.

As wrenching as the decision was, Zemke chose amputation. Unable to walk out to her mailbox without pain, she knew, logically, that a prosthetic limb would help her regain the mobility she'd lost.

Nevertheless, she had questions--dozens of them. On the advice of her surgeon, Zemke flew from her Fresno, Calif., home to New Orleans five weeks before her amputation was scheduled to attend a national meeting of the Amputee Coalition of America. She found answers, and much more. Zemke found reassurance that life does go on after amputation, and she found the courage to proceed.

Zemke says that having a case manager assigned to her after her injury was a particularly positive experience throughout her ordeal. Her case manager was able to "show her the ropes," put her in touch with the right specialists and help her navigate through the workers' comp process. Zemke soon became interested in pursuing a career in the field.

In April 1996, about a year after her amputation, Zemke began her case management career with the California arm of Philadelphia-based Intracorp, a division of Cigna Corp. She credits her boss, Shirlee Nickell, Intracorp case management delivery manager, with helping to guide her along her new chosen path.

"Shirlee saw my potential, I think, and took me under wing," says Zemke. "She and other case managers with Intracorp--as well as case managers with our local Case Management Society of America group and my previous case managers--helped to encourage and educate me."

JUGGLING MULTIPLE ROLES

As a catastrophic nurse case manager, Zemke directly handles cases in California's Central Valley region, and acts as consultant for catastrophic cases throughout the state, particularly amputations. She learned early on that the case manager's role is not a simple one; every case manager must wear multiple hats: nurse, case manager, workers' comp expert, claims expert, supportive friend, psychologist, cheerleader, patient advocate, guide, watchdog and resource. It can be a delicate balancing act at times, coordinating the best interests of the injured employee and his or her family with the concerns of the employer and the needs of the claims adjustor.

"We are the medical coordinators, we are the liaisons with all the parties, we are the education and support system for the injured worker, we're that one person that all the parties can call and get an idea of what's going on and where we're going," explains Zemke. "We're planning and implementing, always evaluating what we're doing as well as the outcomes. We're just trying to do the right thing at the right time, trying to save some money for the carriers and yet get the best outcomes that we can, functionally, financially and in every way."

Of course, the best outcome is getting the injured employee back to work. That's no small feat in some of the catastrophic cases Zemke has seen. Too often though, she says, there's an automatic perception that the injured party is out of work for good. In fact, a large percentage of catastrophically injured patients can return to work?and sooner than most would expect. Some just require a bit of creative modification to the employees' job description.

Case in point, Zemke relates the story of an oilfield worker whose leg was crushed by a large conduit and later amputated. Zemke worked with the employer, the injured employee and the claims adjustor, and facilitated a job modification. He was able to continue working in the field, calibrating equipment used to detect gases. He also works in the office and aids in the company's recruiting efforts. "Ultimately, he had a better job with more of a future ahead of him and more chance for advancement," says Zemke. "And the company was glad that they didn't have to give up this great employee with all these years of experience in the oil industry. It was good for everybody."

Without a case manager's careful orchestration, Zemke point out, the oilfield worker might've ended up "sitting at home dialing 1-800-ATTORNEY."

The real key to a good outcome, she says, is getting a nurse case manager on the scene right away--preferably within hours of the injury. A skilled case manager can redirect injured employees' focus from the injury to the recovery, dispelling fear by letting them know what to expect every step of the way.

"We can meet them right away at the ER or the trauma center and start working with them," she explains. "They don't have time to sit back and think, 'Oh, what am I going to do (for money) for the next few months? How am I going to pay the bills?' They just don't have that time because we move them along."

For catastrophic cases in particular, says Zemke, it's important to have a real, live case manager at the injured worker's side, interacting with all the parties--"embedded," if you will. Face-to-face, the case managers can spot and head off minor problems before they become serious--the warning signs of depression, for example.

An added benefit of having a case manager on the scene is that it puts a friendly face on the employer and the insurance carrier, reducing the chance that the relationship will turn adversarial. With hungry attorneys circling ERs and trauma centers, giving injured employees the "warm and fuzzies" can help keep everybody out of court.

"We're there saying, 'Your claims adjuster knew you were injured and sent me because they're really worried about you,'" says Zemke. "Or, 'Your company's really worried about you, so they asked to have me put on the case.' It's very positive."

A "BALL OF ENERGY"

As an amputee, one of the roles Zemke takes on when working with an amputee patient is peer-to-peer support. It's a role that dovetails nicely with her other passion: the local amputee support group, which she founded shortly after her own surgery.

There was no support group active in her area at that time, so Zemke formed her own group--the Central California Amputee Education and Support Group. The group has since grown, and what started as a small support network now boasts an extensive peer visitation program that serves patients in all of the area hospitals. Zemke alone visits more than 300 amputee patients a year, in addition to her Intracorp cases.

In nurse case management as well as her community service efforts, Zemke has found her true niche. She is known among her peers for her unparalleled passion for her field. Going above and beyond the call, she has completed extensive course work for certifications in case management, life-care planning and workers' comp claims examination. She was presented with CMSA's prestigious Award of Service Excellence in 2003, and has been recognized many times over for her tireless community service--including receiving Cigna's coveted Volunteer of the Year Award in 1997.

She is a finalist under consideration for Nurse Week's Nursing Excellence Award for Community Service, to be decided next year. A mother and grandmother, Zemke, in her "spare time," has also taught courses for the insurance education association and for California State University, Fresno, and published articles on case management.

"I'm very proud that I can practice case management with people like her in the industry," says Mindy Owen, chairwoman of the Commission for Case Manager Certification. "She's a very neat person ? just a ball of energy."

Zemke's boundless energy is a common source of awe. A writer for the ACA's Communicator newsletter, after observing a seminar she led on peer visitation networks, referred to Zemke as the "Emeril Lagasse of peer visitation."

"She has a lot of energy," says Nickell. "She's just amazing. She makes you feel like you're standing still."

It makes for a peculiar irony then, that Zemke is technically considered "disabled." She is undoubtedly more "abled" than most, which is apparent in the sometimes stunning outcomes of her patients.

Nickell says that--unofficially--she can count on Liz to return a lower-limb amputee to work in about four months' time, because she's an expert at knowing when someone will be ready for each step of the process, from fitting a prosthesis to gait training.

One more startling fact that Nickell adds as testament to Zemke's skills: "You've heard about the phantom pain that people get after an amputation? Her patients don't get that. They just don't get it. It's something that she is able to do ... execute the timing of the treatment and work with the prosthetist (in such a way that) people just don't have it.

"I've worked with catastrophically injured patients across the country, and I can tell the difference in the case management tactics; the outcomes are definitely different if it's handled by somebody who's an expert."

All the more reason why anyone would want Zemke in their corner in the event of a tragic injury, particularly a complicated one.

"Her interest in the case management process and her ability to really dig deep into problem identification and facilitating resolutions is almost like a dog with a bone," says Intracorp's Nickell. "She is going to figure it out, and that's the end of the story."

MICHELLE KERR, a former reporter, is associate editor of Risk & Insurance®.

September 15, 2005

Copyright 2005© LRP Publications