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

"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..."

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

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