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!)

Primary Care in the ER?

Original article at: http://tinyurl.com/washpost071309 See my points/comments in bold/blue

A Critical Situation For Area Hospitals
Primary-Care Needs Spill Over Into ERs

This title is inaccurate: it implies patients are seeking "primary care" in the ED. This is false. Primary care (pap smears/breast exams, colonoscopies, diabetes managment etc) is not done in the ED, rather it's people who no longer have a PCP coming to the ED for their acute problems that would otherwise have gone to their PCP's office.

By Yamiche Alcindor

Washington Post Staff Writer Monday, July 13, 2009

Hospital emergency departments across the region are overflowing with patients who have been battered by the recession and are increasingly using hospitals as their primary source of health care, according to local and national health officials.

What national officals? This article mentions none.

At the District's Providence Hospital, emergency room visits increased by 13 percent in the past year. In Montgomery County, the number of patients seeking free care at community clinics designed to divert people from emergency rooms rose by 43 percent, many of them referred by hospitals.

The community clinics are not focused on providing ACUTE care, they are there for chronic, preventative and primary care purposes. They provide a different service line than the ED. That 43% increase are the people that have no PCP and are going there for their ongoing, primary medical services.

... A national debate is underway about how to reduce health-care costs and provide medical coverage to everyone. Diverting people from emergency rooms -- which are an inefficient and expensive way of delivering basic health care -- is a central issue, said Larry Gage, president of the National Association of Public Hospitals and Health Systems.

Don't forget dwindling reimbursements for emergency care are also to blame. Trauma funding is often inadequate as well. Lack of on call specialists, lack of qualified attending MD's and Nurses as well. Also patient "boarding" and psychiatric/mental health patient "holds" ....ALL these things are contributing in addition to people merely lacking a primary MD.

"The absolute number of people using emergency rooms has gone up as much as 20 to 30 percent in the last six to eight months due to the recession and people losing their jobs," he said. "The only option in their minds is going to the hospital."

...also, it's the only thing they KNOW. In my personal experience, quite a few of the folks I've had to refer to community clinics or free clinics had no idea they even existed. (Now here's an opportunity for public education!)

Last year, Providence and the D.C. Primary Care Association launched the ED Diversion Project, which places community health workers in waiting areas to help patients obtain primary-care doctors and sign up for Medicaid and Medicare coverage.

Now this is a GREAT idea! However, don't the hospitals have social workers and medicare/medicaid workers already? Can't the ED care team give these people the information to make a phone call the next day or give them directions to these people's offices? Why do the taxpayers (again!) have to fund this "diversion project" when we already have health care workers who can make the referrals?

Zoila Alvarez, who arrived in the United States three years ago from El Salvador, has been a patient at Mary's Center for a year. Before she found the clinic, she sought prenatal care and treatment for depression at hospital emergency rooms, she said.

Interesting, here is a lady (I'll assume a legal immigrant) who comes to the US (no mention of husband or family) to have her baby who "becomes" a US citizen upon birth....

...Albertha Boone, 55, of Southeast Washington, can relate. Her last visit to a primary-care doctor was in 1989, she said, even though she has asthma and high blood pressure and needs to have major knee surgery.

She said she has a monthly income of $1,400: $1,000 from a disability check and $400 from a part-time job as a clerical assistant. After she pays rent -- $800 -- she uses the remaining $600 to pay for utilities and buy groceries. She said that she has Medicare coverage but that it won't pay for regular doctor visits or for the knee surgery a doctor has told her she should have. So when she needs care, she will continue to go to an emergency room for treatment.

WHAT????? Medicare not paying for doctor visits? I don't believe this statement. However, if you tell me that she can't find a PCP who will TAKE medicare, then I can swallow that a bit more. We need more information here because this doesn't make sense to me.

"Moving forward, we need to do more so that people are aware of clinics in their neighborhoods," said Pierre Vigilance, director of the D.C. Department of Health. "We have to make sure that these clinics are available to people when they need them."

I agree, get the word out, run a campaign or a public education incentive. However, I postulate that the root cause of a lot of this (economy aside) from the provider's standpoint is the whole EMTALA (http://tinyurl.com/emtala) issue. Those of you in the "biz" you know what I'm talking about...the whole legislated principle of ED's not "turning" people away as well as ED's doing WAY MORE than they were designed to do beyond providing the legally mandated "Emergency Medical Screening" assessment/exam.

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

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
SURE!!!

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

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!

CLICK HERE TO CHECK YOUR ANSWERS

Brian Regan - Emergency Room Comedy

Hey all, I just came across two OUTSTANDING comedy videos. Comedian Brian Regan does an excellent job of pointing out some of the funnier aspects of our jobs in the ER. Watch and ENJOY!

Embedded video is courtesey of YouTube.

---

Part 1 (approx 2.5 minutes)

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Part 2 (approx 5.5 minutes)

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-KMG-365, Clear...

The REAL reason for spinal precautions!

-KMG-365, Clear

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

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.!