Feb 18th 2010 ~ National Critical Care Transport Nurses Day~

Study questions the standard of C-Collars

Baylor study doubts neck brace standard
In some cases, device might hurt accident victims

By TODD ACKERMAN
HOUSTON CHRONICLE

1/25/10

   Applying a brace to the neck of a trauma patient, standard procedure for many decades, can worsen the injury and lead to severe paralysis or death, according to a new study by Houston researchers.

   Baylor College of Medicine doctors used cadavers to confirm that so-called cervical collars can be counterproductive, a finding that could upturn the way emergency medical personnel and doctors act to stabilize and protect the upper spine in potentially fatal neck injuries, such as those that commonly occur in bad automobile accidents.

   "This study is a proof of concept that in cases of severely unstable neck injuries, cervical collars are not only not helpful, but harmful in many situations," said Dr. Peleg Ben-Galim, a professor of orthopedic surgery and the study's lead author. "More research needs to be done, but it might be that we can prevent some of the deaths and quadriplegia that occur in these injuries."

   The study appeared this week in the Journal of Trauma.

   Dr. David Persse, medical director of Houston's Emergency Management Services, called the study "compelling" and "concerning" and said it will come up for discussion at the annual meeting of the nation's 30 largest EMS departments in Dallas next month. But he also said he doesn't want to overreact.

   "We need to look at this thoughtfully before we change the standard of care," said Persse. "It concerned a particular kind of injury. It may apply to other injuries as well, but we don't know that yet."

   But Persse added that he understands the need to act quickly, that "it's not like a lot of areas where there's not as serious downside to waiting for the next study."

Car-crash victims

   Ben-Galim said cervical spine injuries are found in the autopsies of up to 94 percent of people who die in car crashes, which claim about 44,000 U.S. lives annually. There are about 11,000 people annually who survive spinal cord injuries.

   There is no obvious alternative to cervical collars, though hospitals often place sandbags under the back of the patient's head and, less commonly, some EMS teams at the scene of the crash wedge the head of the patient between foam bolsters on the backboard.

   The injuries in question involve the area where the brain connects to the spinal cord. Doctors treating such injuries work to stabilize the ligaments, muscle and bone to prevent secondary injury and to protect the brain stem and cord.
  
   Baylor researchers undertook the study after a case in which a broken jaw precluded the use of a cervical collar on the survivor of a car wreck brought to Ben Taub. When the doctors started to put a collar on the patient, fluoroscopy showed two of the patient's vertebrae separate, causing doctors to immediately remove the collar. The treated patient ultimately walked out of the hospital on his own.

   Ben-Galim noted that there are other such case histories in medical literature.

   To study the phenomenon, Baylor researchers made an incision in cadaver neck ligaments based on patient X-rays, then simulated clinical scenarios by applying cervical collars and putting the bodies in ambulances and driving a distance.

   In all of the cadavers, imaging technologies found that the collar increased the rupture.

   In effect, the collars pushed the head away from the shoulders, Ben-Galim said.

   He said the rupture stretching occurs because of both the application of the collars and their continued use.

   One national expert called the study interesting but said he wasn't sure it would one day change the standard of care.

   "There are certain cases, like the ones in this study, that can be dangerous, but they're rare -- most people who suffer high neck injuries die immediately," said Dr. Tom Scaletta, the past president of the American Academy of Emergency Medicine. "I think the study's importance will be to raise awareness about the special care that must be taken -- preserving patients' normal head position, making sure they're not having difficulty breathing."

Anecdotal cases

   Dr. Walter Lowe, director of the Memorial Hermann Sports Medicine Institute and team physician for the Houston Texans football team, said the study wouldn't change the care of injured football players removed from the field in collars and on stretchers because those injuries tend to involve lower areas of the spine.

   Ben-Galim said that since the study was undertaken, Ben Taub doctors have saved patients with severe neck injuries by loosening or removing cervical collars early and rushing them to the operating room, but he acknowledged such cases are anecdotal.

   He said the research team looked at 400 articles and found no scientific evidence that cervical collars can stabilize severely unstabilized spine injuries.

Original source: http://www.seattlepi.com/health/414631_Neck25.html

Pain Scale - "Zero to Ten"...!

In this business of ER/EMS/Healthcare, we have been tasked with an attempt to objectify a patient's "pain".  Apparently many bean-counters and doctoral candidates have done research on how to do this, and as such the "Zero to Ten" scale was born.

Now most of you reading this are undoubtedly of the ER/EMS genre' and are all too familiar with this "scale".  Our instructors, mentors, preceptors, managers, educators (ad nauseum); pound it into us to use this scale.  It's pretty easy for them to say that because on paper it looks good, but as most of you, my readers know, it is haphazard at best to apply effectively...  Oh, wait, let me also throw in what they told us in feel-good-nursing-school, "pain is whatever your patient says it is".   So, we are asked to unquestioningly document "whatever" the patient says about their pain.

By itself, this is not too bad, however, it is when the patient is savvy to this whole pain scale thing that they begin to manipulate it to suit their own needs and wants.  We are left to unquestioningly just "write it down" with no practical attempt to help the patient understand what we are trying to measure.

So we write what the patient says, then we spend the next 5-10 minutes charting all those "little things" that we observe about the patient's behaviors - those things that seem to make the patient's self-assessment inconsistent at best....

"patient talking/texting/IM'ing on cell phone..."

"patient laughing, joking with friends..."

"patient walks to room with steady, coordinated gait..."

"patient smiling..."

"patient resting (sleeping) on stretcher spooning with boyfriend...!"

...and on and on

Sometimes we go further to note more objective findings such as the vital signs:

-reported pain score "10"

-Pulse rate: 56....???

However, in an attempt to further quantify this pain scale, and maybe to help the patient understand what we're looking for, I came across this table (see below) which strives to put some defining characteristics to the different pain levels....

Comparative Pain Scale
	0	No pain. Feeling perfectly normal.
Minor Does not interfere with most activities. Able to adapt to pain psychologically and with medication or devices such as cushions.	1 Very Mild	Very light barely noticable pain, like a mosquito bite or a poison ivy itch.
	2 Discomforting	Minor pain, like lightly pinching the fold of skin between the thumb and first finger with the other hand, using the fingernails.
	3 Tolerable	Very noticable pain, like an accidental cut, a blow to the nose causing a bloody nose, or a doctor giving you an injection.
Moderate Interferes with many activities. Requires lifestyle changes but patient remains independent. Unable to adapt to pain.	4 Distressing	Strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe real hard
	5 Very Distressing	Strong, deep, piercing pain, such as a sprained ankle when you stand on it wrong, or mild back pain. Not only do you notice the pain all the time, you are now so preoccupied with managing it that you normal lifestyle is curtailed.
	6 Intense	Strong, deep, piercing pain so strong it seems to partially dominate your senses, causing you to think somewhat unclearly. Comparable to a bad non-migriane headache combined with several bee stings, or a bad back pain.
Severe Unable to engage in normal activities. Patient is disabled and unable to function independently.	7 Very Intense	Same as 6 except the pain completely dominates your senses, causing you to think unclearly about half the time. Comparable to an average migraine headache.
	8 Utterly Horrible	Pain so intense you can no longer think clearly at all.. Comparable to childbirth or a real bad migraine headache.
	9 Excruciating Unbearable	Pain so intense you cannot tolerate it and demand pain killers or surgery, no matter what the side effects or risk. Comparable to throat cancer.
	10 Unimaginable Unspeakable	Pain so intense you will go unconscious shortly. Most people have never experienced this level of pain. Those who have suffered a severe accident, such as a crushed hand, and lost consciousness as a result of the pain and not blood loss, have experienced level 10.

So, now, here's your clinical story to illustrate the use of this scale...

Dr: "Between zero, being no pain and 10 being the worst you can imagine, how would you rate your pain?"

Pt: (calmly)..."a 10"....

Dr: "Okay, at 10 would be you getting hit in the face with a 15 pound sledgehammer, and unconscious from the pain, not the head injury.  Most people have never and will never experience this pain level ~ and if they do, will undoubtedly be unconscious..."

Pt: (again calmly)..."okay, 9-and-a-half..."

National Emergency Nurses Week Oct 11-17, 2009

Emergency Nurses "Prepared for the Unexpected"

Emergency nurses across the US will be celebrating Emergency Nurses Week, Oct. 11-17, and Emergency Nurses Day on Oct. 14. This year’s theme is "Prepared for the Unexpected," a perfect theme as every day brings the unexpected. There is no "usual" or "typical" day in an emergency department.

Emergency patients are just that — emergencies requiring acute, episodic care. We care for patients across the lifespan, with a vast range of problems. It is not uncommon to care for a two-year-old boy with a fever, a 75-year-old woman with a fractured hip and a 22-year-old man involved in a car crash, all in the same hour.

We are frontline health care providers, often a person’s first and only interaction with the health care system. Every day, we interact with other disciplines — including physicians, paramedics, respiratory therapists and police officers. We do not work alone, but as part of the health care team, relying on each other’s skill and expertise. Each day, we touch people’s lives, from providing CPR, to explaining the signs of infection to a mother whose child just received stitches for the first time. We are there for our patients and families during happy and sad times — we are also there for each other.

We need to acknowledge the great work done by all our emergency nurses across the US. We are truly a unique specialty, caring for a multitude of diseases and injuries from infancy to adulthood. Every day, we are faced with increased demands, from violent patients, short staffing to overcrowding, but we do our best to provide safe and competent care.

*****
Since 1989, the Emergency Nurses Association has celebrated the second Wednesday in October as Emergency Nurses Day, a day set aside to honor emergency nurses for their commitment to patient care. Starting in 2001, ENA expanded the celebration to devote an entire week to honoring emergency nurses, because it was felt that one day was not enough to recognize all contributions made my emergency nurses.

ENA is the only professional nursing association dedicated to defining the future of emergency nursing and emergency care through advocacy, expertise, innovation, and leadership. Founded in 1970, ENA serves as the voice of more than 36,000 members and their patients through research, publications, professional development, injury prevention and patient education.

"A 98.8% passing rate...?"

While promoting and publishing my own CEN review course and CEN Review Manual, I have been keeping abreast of what others are doing out there.

One "competitior" company is Med-Ed. On their website they boldy proclaim a "98.8%" passing rate.
While they do not specific which exam that refers to, they do print it on their flyer for their CEN classes.

I found this passing rate pretty high and had some questions as to how they calculated it so on 9/12 I called them. I called their office in Charlotte and spoke with the lady who answered the phone. She was nice and pleasant. I introduced myself and stated that I was wondering about their quoted passing rate. I asked her how they knew who did and did not pass the exam. (I do not have her permission to use her name publicly, so I will honor that).

She politely told me that they know the pass rate based on the number of people who have requested a refund based on not passing their exam.

Okay, I can buy that, I guess. But, what if someone doesn't even take the exam? I asked her this, and she said, "well, why wouldn't they take it?".

So I clarified by saying to her that she was telling me that they calculate their pass rate based on how many attendees request a refund for not passing; she said "Yes"....

Seems to me this isn't very scientific at all.
Just because someone doesn't pass the exam, does NOT mean they will contact Med-Ed for a refund.

I can think of several scenarios where someone would NOT be contacting them for a refund....

1) If the attendee is taking the class merely for CEU (continuing education) purposes and they are already certified as a CEN - they have NO NEED to take the exam! (I've had a few of these people in my own classes)

2) If the attendee does not take their exam within the 60 day window, then they do not qualify for a refund; there is the potential for many delays in this 60 day time frame. It takes at LEAST 3-4 weeks to get the "permission to test" letter from the BCEN, then you still have to make an appointment to take the exam. Some exam centers have very limited openings.

3) Another person who would not qualify for a refund is an attendee who has had their registration paid for by the hosting institution in a "flat fee" pricing structure.

There are other permutations of similar scenarios here but I believe the point is clear, there is ABSOLUTELY no sure way to know who has not passed their CEN exam.

The opposite is true however, you can find out who HAS passed their exam by checking the BCEN website and looking at the names of those who have passed their CEN. However, that still would not account for those who have NOT taken it yet.

I'll be doing my own research and study from an upcoming Med-Ed CEN review class and seeing just who is and who isn't passing their exam and running my own numbers.

In the meantime, feel free to check out MY CEN revivew book which is 10% off through the end of September!

10% OFF Thru September 30, 2009

Use code "LULUBOOK" at checkout.

(Click on the Book to Preview or Purchase!)

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

GOOD LUCK!

CLICK HERE TO CHECK YOUR ANSWERS

CEN Review Questions 3-30-09

(ANSWERS POSTED 4/3/09 - Scroll to bottom of this article for link)

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.....

Category: Orthopedic/Trauma
(1) Your patient is complaining of a painful right hand. She states it got hit one day ago, and now the hand is painful and swollen. On exam, the hand and fingers are swollen and there is a wound with dried blood over the third knuckle. You anticipate an order to:

A) Perform an iodine scrub to the finger
B) Administer oral antibiotics
C) Obtain an x-ray
D) Soak in cool saline

Category: Environmental
(2) A geriatric man arrives by EMS with reports of marked lethargy. The pt has been having a steady decline for approx 4 months. The pt appears lethargic but responsive with slow speech. Skin is pale, cool and dry. Rectal temperature is 94°F, pulse 52, resp 16, BP = 82/40. IV access is accomplished. Which is the most appropriate method for gradual re-warming of this patient?

A) Heated bladder irrigation via urinary catheter
B) Passive rewarming with warm blankets
C) Warmed IV fluids
D) Peritoneal lavage with warmed fluids

Category: Psychological
(3) A female is brought by her spouse for evaluation after she made several self-inflicted lacerations on her forearm which appear to be superficial. The spouse states that the pt has been very depressed and withdrawn for over a month since the death of their only child. The spouse also indicates the patient has taken to drinking heavily and not sleeping. What is the priority intervention for this patient:

A) Ask her if she has a plan to harm herself.
B) Bandage her wrists
C) Ask her what her usual coping mechanisms have been in the past
D) Take her to the registrar so you can get a chart started

Category: Professional/Legal Issues
(4) A 52-year-old man with a subarachnoid hemorrhage is identified as a potential organ donor. The patient’s family consists of his estranged wife, geriatric parents, a 20-year-old daughter, and 40-year-old sister. Who is the legal next of kin that can give permission?

A) His daughter
B) His sister
C) His parents
D) His wife

Category: Special Populations/Pediatrics

(5) A 4-month-old female comes in with: low-grade fever, rhinorrhea, tachypnea, and poor feeding. You suspect which of the following?

A) Epiglottitis
B) Bronchiolitis
C) Croup
D) Pneumonia

GOOD LUCK!

CLICK HERE TO CHECK YOUR ANSWERS

I Got My EM training during 'Prime Time'....

In the article "Young Doctors Learn Bad Habits From TV Medical Dramas", in the NATIONAL POST, (Mar 23, 2009) author Tom Blackwell talks about how more and more young physicians are becoming a product of the entertainment industry rather than the medical education establishment.The original article published in the "Journal of Resuscitation" looked at data gathered by a survey in which evaluation of young MDs (YMD) ability to perform endotracheal intubation (ETI) was influenced by television medical dramas.

When YMDs were asked where they "learned" their skills (when they were noted to have performed them incorrectly) some responded by indicating that they saw it "on TV". Further information showed that the most often cited TV medical drama for this was NBC TV's "ER".

Researchers then backtracked to investigate this more and find out just how mis-leading some TV medical dramas are.


The researchers (Dr Brindley and Needham) looked at an entire season of ER episodes. They specifically looked at scenes depicting ETI; and more specifically, ones where they could clearly see the entire procedure to critique it.

Their research showed that 22 observed ETIs that met criteria, had at least one step done incorrectly.

INTERESTING SIDE NOTE:
There were 22 ETIs that met criteria, I can only assume that some did not; but they do not say how many were excluded. A typical North American TV "season" averages from 22-26 episodes. This means that on the average, nearly one person received ETI each episode! Unfortunately, without data from the other seasons of ER, it's hard to compare if this particular season had more or less ETIs than their "season-average" (???)

The researchers went on to explain that "traditionally" topics such as ETI are taught in a lecture-classroom setting first, and then reinforced in the clinical (IE: hands on) setting. So when those YMDs attributed their performance failures, it is interesting to note that they recalled their more influential experience watching ETI to have come from the TV medical dramas.

So why the disparity? Why did some of the YMDs remember their ETI "training" more from the TV rather than their didactic and practical instruction? Is there something different the establishment needs to do to drive home the education and experience? Is there something to be learned from TV medical dramas?

When we look at what is "entertainment" things like: story line, special effects, continuity, contemporary issues, hi-profile actors/actresses and plot intrigue factor into play. If you look at NBC TV's successful ER drama, it is no wonder that it was successful. This was an adrenaline pumping, fast paced, on the seat of your pants show. ER was one of the innovators in using the first-person-continuous-scene filming style. This greatly enhanced the "realism" of the show. As well ER frequently dealt with issues of such impact and significance as: resuscitation, trauma, life-death -- it lends itself easily to a hi-powered drama.

All these factors that go into making ER a great show (as well as a much recognized and rewarded show), make it also form more of an impression on the viewer. You remember, more...You contemplate it more... You analyze and think about it more.

Now back to our traditional model of education; that dry, stuffy, formal lecture hall or classroom. Do you really think the classroom can lend itself to as much as an entertaining-learning experience as prime time TV?

Probably not.

Even if we step forward out of the lecture hall and into the clinical arena, it still fails to compare. The "real world" business of treating patients and learning by hands-on, does not compare to the pulse-pounding world of shows like ER. Although one would argue that once you apply learning to the psycho motor (IE: hands on) phase in the clinical setting, you should get higher reinforcement and retention - but apparently not.

I'm guessing that prime time medical dramas like ER, are just hard acts to follow when it comes to teaching and learning.

In the end, I think the lesson we can learn here is to look at what we (as educators) can do to make our teaching and our student's respective learning experiences more "high powered", engaging and compelling.

With our currently expanding use of life-like simulators, skills labs and technical advances - eventually we will reach a cross-roads where life meets technology. At that point we can start to see how a new "technical-altered-reality" would evolve.

I think there is something that we can take from all this, and see the future of education and how we can apply it to the learner's skill sets.


NEXT UP: Now I'm going to pick a season of ER and do my OWN study - I want to look at of all the ACLS scenarios, how they adhered to the AHA guidelines of the day!!!

"KMG-365, Clear..."

CCC Class Wake Med - Day 1 Report

What a day!
Just finished day 1 of a 2 day CFRN/FP-C course here in Raleigh NC at Wake Med. This was a 2-day certification review course produced by Critical Care Concepts and Rick Patterson. I was assisting Rick in teaching for his company during this class.

Their conference facility was THE BOMB. Rick even compared it to some conference hall. He said "man this is like JEMS" the EMS today national conference. Wake Med (WM) has this AWESOME conference center across from the main hospital. It's got several multi-size rooms with sweet A/V setups in each. Nice central lobby, reception areas and a juice/soda/coffe bar (self serve)....it's freakin sweet! Just being in such a nice place, made us feel like some special guest speakers and such!

Class went pretty well on day 1. We ran long and didn't cover as much as we wanted. We hit most of the big topics, but probably ran a little long winded for most of the audience.

After course introductions and "settng the stage". We kicked it off with me doing the cardio lecture. This cardio lecture is always a tiring one. The one we do for Rick's classes is a bit longer (about 80-90 minutes) than the stand alone one I do for my "CEN-only" classes. I think it's a good starting point however, and it DOES lend itself to some minor alterations depending on class prior expeience and knowledge level. Today's version we cut a bit short due to time and we dropped off the 15 or so, ACLS review slides. Instead of slides we closed out the ACLS with a 20 minute "core" ACLS review and Rick went impromptu as he finished the cardiovascular by hitting on the main ACLS bullet points. And, as always, reminded the students that if they hadn't attended an ACLS provider class within the last 6-8 months, that it's probably a good idea to hit that before taking the cert exams (CEN, CFRN, FP-C).

Then we jumped over to the flight portion of the class. Rick jumped right in and ran through the flight principles and concepts (gas laws, stressors of flight etc)..and as always, while I was sitting back watching/listening - I once again was quite engaged when Rick "does his thing"! Shortly later, we went to aircrew safety, survival and regulation to complete most of the dedicated flight content. And once again, Rick gets right into his "zone" and runs through this, lecturing effectively while inserting his anecdotes and war-stories as appropriate. Pretty cool this time working through the survival/shelter part using the big graphics on the LARGE screen; cool to see the "big picture".

Due to time concerns we carried the neuro lecture on into and through lunch this time. I was giving this one and probably where we started to see the early signs of the diverse audience starting to loose their learning thread. You start to see it when we start talking about some more "general" neuro stuff like Multiple Sclerosis or Lyme disease -- the people there for flight certifications are probably starting to think like "why do I need to know this"... So it's always a challenge to try to deliver it and at least make some relevancy to the entire audience. Interesting, at the beginning of the neuro lecture we review the cranial nerves (Nursing 101 right?)....well when I threw up the "Old Olympus Towering Tops" slide, I got so many blank stares...? Kind of made me stop and think. However as this was not a "teaching class" but rather a "review class" - I just referenced it and pointed out that some people may want to spend some time reviewing this on their own before sitting for their exams. So I knocked out the neuro lecture and then we took a break for fresh air and a leg stretch.

We proceeded to head across the parking lot to the helipad. We all posed around the Wake Med hel0; a beautiful machine -- the EC 135 with their appealing crimson and white paint scheme. It really is an appealing piece of equipment - I hope the class photos came out okay!

Afterwards we headed back in for another lecture. This time it was back to Rick for his ABG lecture. Now since I've known Rick, and since the first time I've seen him do this lecture; I am continually amazed and blown away how he does this. The first 15 min or so arethe groundwork for the topic; looking at some basic ABG concepts, pulmonary function/gas laws etc. Once that's done, the "show" begins. Rick starts to run through these ABG "problems" on the board. He starts off like a kindergarten teacher, holding the student's hand through the first few examples, prompting them along the way. Then he backs off a bit and starts letting the class work through the problems more independently.

Towards the end, the students are engaged and interacting. There were a few people however that just "didn't get it" completly and a few who were aking the time honored "calculus question: but what will I do with this in the real world?"... We had to try to explain to them that it's not so much that you'll be doing calculations like this bedside or stretcher side, rather it was a learning curve to start to drive home the relationships between the components and the principles there which lent themselves to overally pt management.

There wasn't a person who told us they had looked at the whole ABG/respiratory function like we just did here - I'm sure there were SEVERAL seasoned people who left that room feeling like they actually LEARNED something!

That pretty much wound it up for the day, it was close to 5pm and people were tired.

We'll be back hitting it early Sunday morning...bright and early at 0800!
Gonna have to step it up and get in our "zone" to keep this puppy on track.

Full day tomorrow, topics include...
1)Airway/respiratory/vents
2)Toxicology
3)Burns
4)Thoracic/abdominal trauma
5)OB/Neonatal
6)Peds
7)General medical

Gonna sign off for now, it's late and I gotta review some notes!
http://www.bemetweb.com
"...KMG-365, Clear..."

Getting Blood Out of a "turnip"...

So... the coroner comes in with a body. Tells us he needs an order and a requisition for a carboxyhemoglobin level. Apparently there was concern on scene that this deceased had quite a few kerosene heaters running in the house and the concern is for carbon monoxide poisoning.

Well we wrote up the blood gas lab slip and gave it to him (the coroner) with the appropriate specimen labels. I was standing right there, with a little free time on my hands (imagine that- free time in an ER! yikes~!)...and I told my attending MD, "I'll go do it if you're busy" (cool!).

So I went with the coroner and set about to draw this "arterial" sample...!!!
Then I got to thinking....
1) Does it have to be arterial? Isn't the COhb level the same arterial vs. venous?
2) If it has to be arterial, how do you palpate the artery on a corpse?????
...hmmmm

Anyways, after consulting with the respiratory therapist on duty (who I trust) they explain that it really won't matter at all but to try for arterial if possible.

So I set about to do a radial artery stick. First I thought about doing Allen's Test (yeah right), then I proceeded to do it just by "feel" in the same place I've always done it into the radial artery.

Got a good flash in the ABG syringe, but it was a S-L-O-W draw. Usually I'm quite used to this brisk, bright red flow from the artery; you could definitely tell this was different. It took a few seconds, but we got it done and sent it off.

Something you don't get to do every day that's for sure!
http://www.bemetweb.com
"...KMG-365, Clear..."

CEN Practice Questions 2-25-09

(ANSWERS POSTED 3/12/09 - Scroll to bottom of this article for link)
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.....

Category: Special Populations
(1) You are discharging your 79 year old female pt who sustained a large skin tear. Which of the following is the best answer regarding patient education for this client?

A) Use pre-printed instruction sheets.
B) Prepare handwritten instruction sheets.
C) Instruct the patient to call their private physician if they
have any questions.
D) Conduct a one-on-one discussion with the patient.

Category: Gastro-intestinal Emergencies
(2) A 36-year-old male is in severe distress due to upper gastrointestinal bleeding. He has been vomiting bright red blood at home for 4 hours. Which of the following interventions is the highest priority?

A) Apply 100% non-rebreather oxygen mask.
B) Initiates IV access and starts a Normal Saline bolus.
C) Inserts nasogastric (NG) tube.
D) Draws blood for a type and cross.

Category: Respiratory Emergencies
(3) The SPO2 of an ED patient suddently drops to 88%. Of the following, what should the RN do first?

A) Put the pulse ox sensor on another finger.
B) Check to see if the auto-blood pressure cuff is inflated.
C) Assess for changes in the patient's mental status.
D) Obtain an arterial blood gas.

Category: Environmental Emergencies
(4) Your patient sustained a near-drowning incident. Which of the following plays the most significant role in their condition?

A) Hypothermia
B) Pneumonia
C) Dysrhythmia
D) Hypoxemia

Category: Professional-Legal Topics
(5) Which of the following legal principles applies to the RN working in the Emergency Department?

A) Duty of care
B) Breach of duty
C) Proximate causation
D) Injury

GOOD LUCK!

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CEN Practice Questions 2-12-09

(ANSWERS POSTED 2/15/09 - Scroll to bottom of this article for link)
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 with rationales will be posted here in 1-2 days.....


Category: Professional-Legal
(1) Local EMS brings you, into your trauma bay, a 17-year-old female, who was involved in a pedestrian versus motor vehicle crash. A CT of the head shows that she has an epidural bleed and the neurosurgeon is summoned for emergent, life saving surgery. However, the neurosurgeon refuses to come in for this pt. Which of the following best explains the possible liability for the neurosurgeon in this case?

A) Federal laws that require all patients who present to an emergency department receive stabilizing treatment and state laws concerning professional negligence.
B) Case law requiring a specialist on call to respond and federal law requiring all patients who present to an emergency department receive stabilizing treatment.
C) State laws relevant to professional negligence and case law requiring a specialist on call to respond.
D) There are state laws covering professional negligence and case law requiring a specialist on call to respond.

Category: Special Populations
(2) An elderly trauma patient "might" be considered for early, invasive hemodynamic monitoring because the geriatric population has:

A) Decreased peripheral vascular resistance and cardiac workload.
B) Increased pulmonary compensatory mechanisms.
C) Increased physiological reserves
D) Decreased cardiac output

Category: OB/GYN
(3)A patient with an ovarian cyst may present with signs/symptoms similar to which of the following?:

A) Pyelonephritis
B) Pelvic inflammatory disease (PID)
C) Intrauterine pregnancy
D) Ectopic Pregnancy

Category: General Medical
(4) What is the treatment for acute sinusitis?

A) Over-the-counter nasal decongestant sprays for 1 week
B) Hypertonic saline nose drops
C) Use of a humidifier
D) Application of ice or cool compresses to the sinus area

Category: Cardiovascular
(5) The MD has ordered a heparin drip to be started at 1000 units/hour. Your pt weighs 220 lbs. You have on hand a heparin IV bag with 20,000 units of heparin in 500 cc of D5W. How fast (ml/hour) would you run the drip at?

A)20 ml/hour
B)25 ml/ hour
C)40 ml/hour
D)100 ml/hour

GOOD LUCK!
CLICK HERE TO CHECK YOUR ANSWERS

-KMG-365, Clear

The Economy and Specialty (CEN) Certification...?

So I was sitting down tonight watching President Obama's first press conference (8:00 pm EST ????)....Anyways, as he was explaining his take on the pulse of our current economy and how he has seen "first hand" the effects of it on places like Elkhart IN that saw it's jobless rate nearly triple in the last 3 months, and how people are out of work and loosing jobs; I was considering what relevance this state of affairs has to achieving specialty board certification for nurses.

Mr. Obama was explaining his take on principles of economy that decreased consumer credit causes people to spend less, companies to produce less and companies to have to reduce their costs on such things as payrolls and numbers of employees. He went on to talk some about the hardships faced by "Main st" while on the unemployment dole and I got to thinking about nurses...Specifically my brethren Emergency Nurses.

Through many online and in person conversations, one of the recurring themes as to why more ER nurses don't pursue specialty certification (CEN) is their "lack of interest or motivation". Some people I've talked to have even said the extraordinary lengths their employers will go through to support and encourage certifications. At some facilities, the nurses actually risk NOTHING at all due to employer compensations - and they (the nurses) still aren't motivated to pursue certification.

Although we hear about a nursing shortage (and I'm not here to tell you there isn't one) we know that in hospitals, the payroll is THE SINGLE LARGEST line item and it is a direct reflection of the current numbers on the employee payroll. So if a company is going to start "downsizing" to control it's costs, don't you think the choice of who stays and who goes will factor in things like credentials or qualifications.

Like myself, ALL RN's came on board with only a generic entry-level license (AKA right to practice) in a general setting. No RN comes out of nursing school with a competency or credential to practice ER nursing. It is through the on-the-job-training, experience, mentoring and good 'ole 'elbow grease' that many RNs working in an ER setting claim the title "Emergency Nurse".

Until those same nurses acquire a professionally recognized and verifiable credential as the CEN (Certified Emergency Nurse), they technically remain just a generalist in nature.

Now, don't get me wrong, there are THOUSANDS of RNs working in our nation's ERs who probably have the experience and knowledge commensurate with that of the CEN credential, however, they have not been recognized in that manner...yet.

Once the ER RN decides to prepare for and sit for the CEN exam, and then PASS it - then they can truly call themselves an "Emergency Nurse".

In today's health care arena we are already seeing a shift in our Emergency Medicine Doctors in that more and more hospitals and practice groups are mandating Board Certification in Emergency Medicine. The days are slipping by where once a Family Practice trained MD could take a job in an ER and practice as an "Emergency Physician". The credentialing, accrediting and regulatory groups are more and more looking to set the bar "higher" for the attainment of an elevated, verified skill, knowledge and practice level. And like the RN's -this does NOT mean that there aren't some FP's out there that are not EM boarded, practicing at an equivalent high level as their boarded peers; on the contrary, there are assuredly MANY who are.

But as we see this push and shift from non EM boarded MD's to EM boarded one's, undoubtedly natural progression will dictate at some point that it is desirable for the RNs as well as it denotes a verified specialty locus of practice.

So as we see our nation's economy stumbling, the workforce dwindling and health care crumbling, it becomes more concerning for the Emergency RN who wants to secure their place in teh workforce to attain certification in their speciality.

Some call it pride,
Others call it professionalism,
Others still call it accountability,
I say it is more and more likely that someday not too far off, it will be mandatory....

LINKS for more information:
-The BCEN (who adminsters the CEN)
-The Emergency Nurses Association (ENA)
-CEN exam preparation continuing education

ABG Basics

ABG's can be one of the more difficult concepts to grasp when reviewing Emergency Nursing or Critical Care. The whole ABG interpretation process has caused many people lost/sleepless nights trying to decipher and understand the concepts. I can relate. Every time I prep for a lecture that includes ABG's I have to review myself the night before. Over time I've come up with a couple of rules for working with ABG's:

1) Don't do "ranges" (IE: 7.34-7.45), use a mid-point cut off.
For EXAMPLE: I don't consider if my pH is "towards" the low end or "towards" the high end, rather I pick 7.40 as my cut point. If it's above 7.40 even just a 0.01 above, then it's alkalotic and vice versa. Do this for your PaCO2 and HCO3 also - use mid points.

2) I like to draw a 4x3 box and fill in the values starting with the ones I KNOW FOR SURE
For EXAMPLE: My prototype Resp. Alkalosis pt is that hyperventilating-anxiety-stricken-20-something-female that comes into triage. I can easily remember that she has "blown off too much CO2" thus her PaCO2 is LOW. I know it's a respiratory problem because she's hyperventilating. I know that CO2 is a weak ACID so if she's blown off too much of it her pH is HIGH - given that information I can fill in those boxes.

3) Now I look for OPPOSITES. If the above patient is Resp. Alkalosis, then by default, the Resp. Acidosis pt MUST have a LOW pH. Now the prototype pt I use for this is my CARDIAC ARREST pt. We know that they have STOPPED breathing, so too much CO2 is built up (it's a weak acid remember, so that pH MUST be down). So I can now fill in the boxes for that one.

4) Now I move to the Metabolic syndromes. The rules for acidosis and alkalosis pertaining to the pH being HIGH or LOW still hold true - so plug those in under pH.

5) Now look at the HCO3. I KNOW that HCO3 buffers CO2 so if CO2 is an acid, then HCO3 is a base. If my pt is in an acidotic state, then the HCO3 is NOT ENOUGH to compensate and therefore HCO3 is LOW, and thus vice versa. If my pt is alkalotic then the HCO3 is TOO HIGH.

So basically it's a process of elimination and fill in the blanks. When you're done your little table should look a little something like this....

Good Luck!
-KMG-365, Clear...

CEN Practice Questions 2-5-09

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.....

Answers with rationales will be posted here in 1-2 days.....

Category: Professional-Legal
(1) A 49-year-old woman with a subarachnoid hemorrhage is identified as a potential organ donor. The patient’s family consists of her husband, from whom she is separated, elderly parents, her 18-year-old son, and 44-year-old sister. Who is the legal next of kin that can give permission?

A) Her son
B) Her sister
C) Her parents
D) Her husband

Category: Neuro
(2) The normal range for intracranial pressure (ICP) in an adult is:

A) 0 to 15 mm hg
B) 5 to 30 mm Hg
C) 30 to 45 mm Hg
D) 45 to 60 mm Hg


Category: Pediatrics
(3) A 3-year-old presents with N/V/D for 36 hours. The assesment shows: pale skin, sunken eyes, and is tachycardic. The child is unresponsive to pain. The priority intervention for this patient is to administer:

A) Intravenous fluids (IVF) immediately
B) Oral replacement fluids in small sips
C) Prochlorperazine (Chlorpazine®) 12.5 mg IM
D) Ciprofloxacin (Cipro®) 500 mg PO

Category: Respiratory
(4) An obese 33-year-old female presents with sudden onset of left-sided chest pain and shortness of breath. She is diaphoretic, pale, and in acute respiratory distress. There is no history of trauma, fever, nausea or vomiting. Medical Hx is unremarkable. Current Meds: Birth Control Pills. VS: BP = 100/60, HR = 118, RR = 36.

ABG's are done which show:
pH 7.27,
PaCO2 53,
PaO2 61 and
HC03 26.

These results suggest which of the following?

A) Uncompensated respiratory acidosis
B) Compensated metabolic acidosis
C) Uncompensated metabolic acidosis
D) Compensated respiratory acidosis

Category: Wounds
(5) An 78-year-old is being discharged after having a laceration of his left leg sutured. Which of the following methods of patient education is most appropriate for this patient?

A) Use preprinted instruction sheets.
B) Prepare handwritten instruction sheets.
C) Instruct the patient to call his physician if he has any questions.
D) Conduct a one-on-one discussion with the patient.

GOOD LUCK!

CLICK HERE TO CHECK YOUR ANSWERS

CEN Study Pointers...EXAMS vs TESTS

Recently I have been receiving more frequent emails
asking how I would specifically recommend someone studying for their CEN exam. The answer is as individual as it is long and really no one methodology would be appropriate for everyone. Instead of laboriously typing the same email response to everyone with the similar background information and advice,
I figured I'd put this on a blog and have people refer here instead.

So when someone asks me the best way to begin prep for the CEN exam I like to find out their background and where they're coming from first. Also I try to get a feel for their previous experiences and knowledge level.

One of the first things I recommend to most everyone, is to take an ASSESSMENT EXAM.

Ideally this would be a 150-175 question exam that is identical to the actual CEN exam with regards to breadth of content as well as the same representative percentage of different content areas. This practice EXAM should be done just like the actual testing environment: 150-175 questions, a quiet desk w/o noise or distractions and a 3 hour stop watch.

The prospective examinee would take the practice exam (at one setting), then self grade it and correlate the right answers to the different content areas so they can see which areas they are strong in and weak in.

This information would then be used to do FOCUSED studying. Spending the most time on the weaker areas. I wouldn't recommend neglecting the areas they scored high in, I would still recommend some brief, rapid review of those too - but the point is to spend the MOST time on the WEAKEST areas.

ASSESSMENT EXAMS
As of right now there are a couple of options for this. The more economical (but probably not as quick as you have to order the book) way is to order the "CEN Review Manual" Third Ed. 2004. (The "white" book). In this book there are 5 full sample exams. Each contains the same content and subject distribution as the official exam. The answer key in the back allows you to self-grade your exam and then identify which questions relate to which of the specific content areas. This allows the student to see which areas they were strongest in and weakest. This book is currently available at the following:




ENA Website: $65 Non-ENA members, $50 for ENA members. S/H extra.
Amazon.com: New and Used from $87-$115.

The other option to take an assessment exam is to do it ONLINE. This is probably the quickest way because you can register for the online exam, take it right away, and get it graded for you right away.

The ENA is hosting a 150 "CEN-Like" online exam for $75. You get one "entry" to take the exam online, at home (timed) and experience the same exam like content in a realistic manner (computer/keyboard). The online exam can be found HERE: ENA Online Exam Info.

Pro's & Cons.
"The Book" method:
PROS: Each question complete with rationale, overall cost is very economical (if you don't get scalped), 5 different exams so you can go back and re-test to check your improvement.
CONS: You have to pay and wait for it to get shipped to you.

Online Exam:
PROS: Quick, immediate, nearly like the actual exam (computer/keyboard)
CONS: You get less "exam" for your money

Whichever route you take, the goal is the same; to identify the areas you are weak in so you can hit those hardest.

FOCUSED STUDYING
So now that you've taken at least one sample exam and you know your strengths and weaknesses, now you're ready to start your true test preparation.

Look back at your score results/printout and look at the percent achieved in each content area and rank them from 1 (highest score you got) to 13 (lowest score you got).
What you'll want to do is try to proportion your study time more on the areas you got the lowest score on, but not to completely ignore the other content areas.

You can use many different ways to divide up your focused review time to the necessary topics.

At this time, now the student should invest in a review book that breaks down into systems; preferably one that matches up with the official CEN blueprint and systems. Find a book/guide that also has specific questions at the end of that system content.

A good book for this is:
"Lippincott's Q&A Certification Review: Emergency Nursing".
I call this one the "Red book". Here is the description from Amazon.com:

Product Description

This comprehensive workbook is an indispensable aid for emergency room
nurses preparing for the CEN exam. The book contains over 1,400 questions and answers in an easy-to-use two-column format--questions in the left column, correct answers and rationales in the right. A bound-in CD-ROM contains over 300 additional questions. Coverage encompasses all subject areas in the CEN exam blueprint, and includes 5-tier triage, ECG strips, long-term complications of ED care, disaster management, and recognition and emergency management of chemical and biological weapons of mass destruction. The book includes sample tests with 175 questions, weighted according to the CEN exam blueprint.

You can go through here and work through the sample questions/answers or just test/quiz yourself over and over using that specific content area.

After you've spent at least 1/3 of your total pre-CEN exam study time, consider doing another sample exam to see how your scores compare.
You can get this book from:

Amazon.com : New and Used; $34-$30






Check back often as I'm going to be posting some "pointers" every week or so.!