May 20, 2009

CEN Review Questions 5/19/09

Sorry for the delay folks!
Here's some more CEN Exam Review Questions for practice/review...

Here's some sample CEN like review questions. Try to answer them and write out a rationale. Try to justify why the answer you choose is correct and why the others are wrong.....

The link to the answers is at the Bottom of this page...

Category: Psychiatric/Mental Health
(1) When caring for a delusional patient, the ED RN knows that it is important to:

A) Allow the patient to freely verbalize his thoughts.
B) Provide distraction activities for this patient.
C) Acknowledge the thought disorder and orient the patient to reality.
D) Place the patient on a suicide precautions.

Category: Cardiac

(2) Which of the following is an INAPPROPRIATE route to give epinephrine by:

A) Intravenous
B) Endotracheal
C) Intraosseous
D) Epidural

Category: OB/GYN
(3) At what point during pregnancy is the fetus at most risk of injury due to trauma?

A) In the first week of pregnancy
B) In the second trimester
C) In the third trimester
D) In the first trimester

Category: Professional/Legal
(4) Which of the following sources of evidence is the BEST to establish the standard of care in a legal case?

A) The defendant's testimony
B) Nurse Practice Act
C) The plaintiff's attorney
D) An expert witness

Category: Professional/Legal
(5) A prior ED patient is suing after having complications from an IV access while in the ED previously. During that visit the pt became agitated and ripped the IV out. This went unnoticed for 3 hours as the primary RN did not do any assessment or documentation of the IV site. Based on this information, which principle of negligence is being described.?

A) Duty
B) Breach of duty
C) Causation
D) Damages

May 18, 2009

Too Many Cooks in the Kitchen?

A recent discussion over at was started in which the original poster (OP) threw out the question about what drives EMS staffing, Cardiac Arrests (ALS) or Medical Care, and what the mix of EMT's to EMT-P's should be utilized. (

An interesting discussion ensued with many people voicing their opinions and experiences. After reading through a majority of the posts I could pick up on a couple of themes which seem to predominate...

One of the strongest themes is that if we are basing our EMS staffing on ALS calls, then increased EMT-P's are needed, sometimes even dual EMT-P crews. This is further facilitated by the growing use of and demand for EMT-P qualified "first responders" as part of the fire service and a responding engine or rescue company. Unfortunately, with this increased use of EMT-P's by the fire service, it has mandated or "encouarged" many who would not otherwise consider going to EMT-P school to go to get the increased education and medical credentials. Many men/women entering the fire service are now being called up on to change/alter their career paths to incorporate this EMS training to meet the demands/desires of their municipality public safety administrators.

So the thought process goes that we need more medics (EMT-P's) to be able to effectively cover more ALS calls, more readily.

While this sounds good in principle the numbers don't pan out as well.

Having more medics on duty means each medic gets less calls. Huh you say? What's that got to do with the price of diesel?

Of those ALS calls that require medic level skills (IE: non-BLS), each medic will have less opportunities to "play" and get the ongoing job/real-life experiences which add to and build upon their experience repertoire'. When one considers critical ALS skills, like, er, uh, lets say "INTUBATION", you see where lack of "practice" can lead to lack of success.

Ultimately this leads to an EMS/Fire Service with lots of medics who each SELDOM get intubations on live (er, uh, "barely alive") patients. So when it REALLY counts, they lack the field experience and have to base their skill set on those manikins and OR rotations for recalling the psychomotor skills.

Add to this the current recommendations by the American Heart Association and the EMS/Pre-hospital system as a whole; to forego intubation if BVM will suffice. So now you have even less opportunities for intubations amongst and increasing number of medics.

It's not uncommon to read about medics in some systems these days who are lucky to get even just ONE opportunity to intubate annually - that's OPPORTUNITY, we're not even talking successful intubation yet!

So now to explore this we respectfully have to look at the other side of the equation or assume the other possible outcome - to DECREASE the number of employed medics and increase the number of EMT's (basics) out there.

Well, up front the numbers would support this. Overall, a majority of all EMS calls are BLS in nature and don't require ALS skills at all. So it would make sense to have an EMS system that is heavy on the EMT-B side of providers. This would, however, beg the question: what to do with all those medics?

Some proponents have suggested staffing with medics where they are needed, or centralized or via the QRV scheme.

Looking at demographics, transport times, distances, a service could strategically look at where to maximally staff their medics. Maybe they would put them in areas that were longer transport, higher acuity traumas or more rural where experienced providers were limited in availability.

One could conceive of even putting more EMT-B's in some of the urban areas where even with a "trauma" a load-n-go might only be 2-3 minutes from a trauma center.

Some systems have already incorporated the medic QRV concept. Contemporary implementations of this usually have a shift supervisor (medic) readily available to respond to a wider area quickly to "back up" the EMT-B's on scene and bring that higher level ALS skill set when necessary. Most systems that are using this however are using their supervisors; the new evolution of this position would consider merely a street level paramedic who is unencumbered to respond as needed to scene calls and not tie up a supervisor. If no ALS needed on a particular scene, then the medic could get back "in service" and "available" for the next one.

These are only limited solutions to bigger system problems. In an era of increasing cost containment, decreasing reimbursements, increased operating costs and increased litigation risks the overall principle is COST. The costs of labor, training and effective resource utilization all add up. New and novel ways to staff and provide effective community level EMS services continues to be a challenge even for the most experienced administrations.

It is interesting however to note that we spend way too much time focusing on "the big one" when the "big one" occurs a whole less often than previously considered. But....would anyone want to tell THEIR community that they are cutting back on Advanced Life Support (IE: Paramedic) level care???? Political suicide for sure!

~"KMG-365, Clear..."

May 9, 2009

NBC TV "Trauma" - ER Replacement?

New NBC TV Series "Trauma" trailer/preview....

I'll probably watch this just for pure entertainment purposes nothing more.

Interesting - they included HEMS in this "Emergency meets Third Watch" trauma
show. Now the public will see more mis-information and mis-use of HEMS I'm

I guess that's why the guy playing the flight medic/nurse ("The rebel") is
flying cause he says "I can't die".....!!!!

May 6, 2009

"Hopelessness" and Facilitation....

Dr Ed Leap, a well respected blogger, and author that I respect, recently posted his blog on "Hopelessness". I read through it and it was quite thought provoking.

The main point I believe Dr Leap was explaining, was that no matter how much logic, observation, rationalization or coercion we use/do - there are just some aspects of human behavior that cannot be adequately explained with the traditional models we, in healthcare, use.

His conclusion was that people will continue self-destructive behaviors, not through any particular rational process, but from a state of hoplelessness; when there is no perceived better alternative, benefit of change or motivation to do same.

In the frame of reference of the people we deal with on a daily basis in the ED setting - I can testify to this; but that is because of what they come to see us for: afflictions of mind, body or psyche.

And yes, as I agree with Dr Leap, we continue to fulfill our moral, societal obligations to "counsel" and advise with learned knowledge, the need for our patients to avert their destructive pathways; and often, until blue in the face.

But let's look for a moment at an underlying stimulus which I propose facilitates this. I believe that our health care system promotes and encourages these behaviors to an extent. And sometimes, the lack of action to prevent such behaviors, can be seen as facilitating. Now I am not a fan of poor grammar, but it does remind me of that FALSE dichotomy statement, "If you're not part of the solution, you're part of the problem". But in a sense, this IS true.

Most of you reading this are probably on the patient care side of the fence. We diligently meet our calling to help, heal and restore people to their "optimal" state of wellness. But there has to be an even stronger counter-measure on the other side of the fence to effect prevention as well.

It is an economic reality that treatment costs MORE than prevention. And it is well-known that effective prevention reduces morbidity and mortality. So the obvious question, "why don't we spend more time, money and effort on prevention?" - goes unanswered.

Without prevention or "access" to prevention (note I did not say access to health care) people are forced into a situation where they cannot gain an interface with the health care system until they enter via the "EMTALA-mandated" Ivory doors to the sacred city of "OZ" (The ED). Upon being integrated into that setting the wheels are at work trying to fit a preventable problem into an acutely ill opening - the technology, resources and costs are not designed for this.

However, we see, treat and encourage our patients - they get better and they are dismissed.

Now, the next time this "need" arises again; guess where the learned behavior is going to lead the patient. They know they got better before in the ED, they still have no "healthcare home", and they are still unchanged in their unhealthy lifestyles.

I propose that the problem is multi-faceted.
Until we can:
-Encourage our system to move towards prevention,
-Re-evalute the principles, AND the necessary/contemporary changes to EMTALA,
-Take a broader recognition of the societal themes of self-entitlement, self-indulgence, self-reward and lack of self-accountability....

...We'll be fighting the same battle over and over ad nauseum.
We need thinkers and people committed to speaking up for what is right.
We don't need a government to tell us to "CHANGE", we need ourselves to recognize the need for change, both internally and in society.

-"KMG-365, Clear..."