Alex Egan

I have some issues and questions here. Are you saying that the agency you were at was operating without a current license? That seems to be what you are implying. Was the agency in its application period? often agencies and branches that are in the process of application for Medicaid will need to take a few cases prior to the inspection. This is a requirement from the state. (in PA) An emergency downsize trach tube is absolutely appropriate if the ordered size will not pass. How exactly were the numbers for CPR "way off"? I look forward to your reply.

Ah see here we have a misunderstanding of common language. Tolerance: the ability or willingness to tolerate something, in particular the existence of opinions or behavior that one does not necessarily agree with. see being intolerant would be yelling at, belittling, or talking poorly about the OP if she wore the shirt. Or forcing my belief that the shirt is bad on her by banning it. Now OP asked for an opinion and got it. I’m not stopping her. I fact I said in my post I was not speaking about her specifically but rather sharing my general observations. No one is telling OP she can’t. No one is attacking Her religious beliefs. We are answering a question. I resent you’re implication of my intolerance simply because I disagree and demand an apology or retraction of you’re statements against me personally.

Glad to hear things are going a little better. Agency buyouts are always tough. I have never experienced a sale/takeover that went well for the office. If you’re lucky it’s better in about a year. Good luck on the move. Let us know how things turn out.

I think it’s both tacky and tactless. Tacky- the design is not great. It’s text heavy and unbalanced. That and a white background is going to be unflattering on most body types. Tactless- can I be honest generally the person wearing the nurse or emt T-shirt is not the nurse I want. They tend to be self important and over confident. Same goes for T-shirt’s that proclaim religious beliefs. I find that often the shirt is not a corresponding label. Not saying that about you, but that’s right where my mind goes.

"The application of a tourniquet is only ok if you are in a life or limb scenario, loose the limb to save the life". That was the extent of my training on tourniquets in my EMT training in the year 2004. The common knowledge at that time was that tourniquets caused damage, often irreparable damage to the limbs they were applied to, and that generally bleeding could be controlled with direct pressure only. While direct pressure remains the first step to treatment, there has been a rapid evolution in the control of severe hemorrhage, and arterial bleeding in the past several years. Advances that many nurses not involved in emergency care may be unaware of. Tourniquets are back in use, and if nurses in the camp setting are not prepared to apply tourniquets in cases of severe hemorrhage, they are not meeting the standards of care on this topic. Tourniquets have been a fixture in medicine since the late 1600s especially in battlefield injuries and surgery. By the 1900s problems with prolonged tourniquet use were well known, and the use of them in the field began to loose popularity.(1) Many Harsh criticisms of tourniquet use were voiced after both world wars, mostly due to the devices being applied improperly, or forgotten under blankets, or in the confusion of evacuation. In World War Two the army surgical division established the directive that tourniquets should be used only for active spurting hemorrhage from a major artery and established guidelines on care and time restrictions in tourniquet use. (2) Through the 19th century military use of the tourniquet continued, with the opinion of military surgeons becoming slightly more favorable by the end of the Vietnam War. Civilian use of tourniquets was minimal to nonexistent, being used primarily in vascular surgery, field use was strongly discouraged. Going into our most recent war the routine use of tourniquets was still generally frowned upon. The implementation of the Joint Theater Trauma System, allowed for real-time evidence-based practice evaluations of both causality treatments and outcomes. This clear and ample data demonstrated very clearly that hemorrhage was a leading cause of death, and that tourniquet application in the field made a huge difference in outcomes. It also demonstrated that the concern over limb loss and nerve damage was overstated, in the present medical system definitive surgical intervention is almost always achieved before any serious side effects of tourniquet application can set in. Over the past decade military training has focused on early hemorrhage control, and has seen a dramatic rise in causality survival. The US armed forced have made the Combat Application Tourniquet (CAT) standard issue to all ground forces, deploying over 400,000 CATs in the field. (3) As with many other advances in emergency care, the military medical community leads the civilian community in techniques and science. The tourniquet has returned to civilian EMS, and first aid, in a big way. Most recently with the Department of Homeland Security's "Stop The Bleed" Program. This program provides information to the lay person as well as professional rescuer on tourniquet use. (4) Tourniquet application in the camp setting is important for a few reasons. Most camps are in rural locations, prompt and complete control of severe arterial hemorrhage is very important, as EMS response and transport times may be prolonged. Camps should also be equipped and trained in tourniquet use due to the low, but present risk of active shooting scenarios. Many nurses are not especially familiar with tourniquet application and may fail to recognize when a tourniquet is necessary. Direct pressure over absorbent dressings remain the first step in control of most hemorrhage. In cases where bleeding from an extremity is severe, the victim presents with hypovolemic shock, or the injury's are from explosive devices, a tourniquet should be applied as close to the site of the would as possible. A second tourniquet may be applied even closer to the would if bleeding doesn't cease. (5). Having established that tourniquet use has been added back into the first aid skill set for hemorrhage control, and established the parameters and techniques for application. The next issue to confront is what type of tourniquet to use. There are many commercial options on the market today, however many nurses may be most familiar with basic improvised tourniquet, that uses a triangle bandage folded so the with is about 1-2 inches, and tied tightly around the limb with a square knot. An improvised windless, such as a stick, is slid under the bandage and twisted until arterial occlusion is achieved, the windless is secured and time noted. (6)This style of tourniquet is cheap and effective, the major drawback being that it requires a bit of skill to apply, and there never seems to be a good sturdy enough stick around when you need it. The most popular commercially available tourniquet is the Combat Application Tourniquet CAT. This easy to apply device has an attached durable windless, that tightens an internal band, that applies circumferential pressure. The windless is easily secured with a hook and Velcro fastener, and a label is prominent on the front to note the time of the application of the device. (6)The CAT has been extensively used by the armed forces, gaining more time in the filed and more real life applications than most other commercially available devices. It will be a familiar device for veterans and most EMS providers, for that reason if you decide to buy a tourniquet, I would recommend the CAT. However there are any number of options for commercial tourniquets, and any can be used with proper preparation and training. Whatever type of tourniquet your camp employs, all nurses regardless of experience and background should be able to demonstrate its use, and articulate the conditions where a tourniquet will be necessary. Training is important to insure that providers are able to correctly use tourniquets in a correct and timely fashion in an emergency. Severe hemorrhage and arterial bleeding, are low occurrence high acuity events in the camp setting. However preparation for such events is key to good outcomes and patient survival. Camps offer a wide verity of potential for injury's and as nurse we must be prepared to cope with any level of event that occurs at our camps. Tourniquets must be a readily available tool for camp nurses to use in the event of emergency, and modern science supports their use in the civilian realm when necessary. References 1.David R Welling MD, A brief history of the tourniquet, Journal of Vascular Surgery, 2012 2.G.A. Cosmas, A.E Cowdry, The Medical Department: Medical service In the European Theater of Operations, 1992, Center of Military History, United States Army 3.Alec C Beekley, Prehospital Tourniquet use in Opperation Iraqi Freedom: Effect on Hemorrhage Control and Outcome, Journal of Trauma, Injury, Infection, and Critical Care, 2/2008 4.Stop The Bleed, www.dhs.gov/stopthebleed, 11/20/2015 5.Bleeding Control Statewide BLS Protocol, PA BLS Protocol 601, 6/1/2015 6.Dan White EMT-P, Return of the Tourniquet, http://www.multibriefs.com/briefs/exclusive/return_of_the_tourniquet.html#.Vuue3_krLIU

Every year the boards here at allnurses are abundant with the same question, what do we do? In this article I'm going to identify your enemy, give objective and factual options for treatments, and attempt to address the special challenges about controlling and treating lice infestation in the camp setting. What are Lice? The head louse, Pediculus Humanis Capitis, is a wingless insect that spends its entire life cycle on the human scalp feeding on blood. Unlike body lice, head lice are not vectors for disease. They cannot fly, jump, or even walk on flat surfaces. They rely almost entirely on casual head-to-head contact, but can be transmitted on combs, hats, and clothing, (although these are much less commonly the source of infestation.) They show no preference for socioeconomic or hygiene status. Eighty percent of infestations occur in children ages three and twelve, with studies showing that approximately 8% of school aged children are infested with lice each year. Millions of dollars and countless hours are spent by families, institutions, and healthcare providers in attempts to control or eliminate lice infestations. Similar efforts are put into funding drug research or developing and marketing patented medicines to treat head lice. Despite all these efforts, the head louse has been, and continues to be, a formidable foe; evolving defenses against and eluding our best efforts at elimination. Summer camps join the ranks of other institutions such as schools, residential living, prisons, and the military in an endless struggle to control lice. Lice Control in Camp Environments Many camps have taken a proactive approach to louse control, some utilizing a head check process in attempt to keep lice out of camp. The theory being that if no lice come into the camp community, then by nature camp will remain lice-free as there is limited contact with the outside population. However, a study conducted in 2000 found that traditional scalp inspection produced 30% false positives, and failed to catch 10% of lice infestations, making the dry scalp inspection clinically ineffective. The study found wet combing to be much more effective in correctly identifying infestation. Wet combing is done using a standard comb followed by a lice comb on hair moistened with water, wiping the comb off on a paper towel in between each swipe, and looking for nits and live louse on the towel. Studies have also shown itching to be a late indication of infestation and as such a poor screening tool. The scalp will not develop a reaction to the lice saliva for 4-6 weeks after the infestation is established. Most persons complaining of head itching are stuffing form dandruff or even simply anxiety over having lice rather than a genuine infestation. Another attempt to keep camp lice free is the "no nit policy." Once a mainstay of policy in public schools and private institutions, it has fallen from favor in recent years. The presence of nits, especially more than 1/4 of an inch from the scalp, does not necessarily indicate infestation. A2001 study concluded that only 18% of children identified as having nits subsequently develop a lice infestation. It is now almost universally known at the presence of nits is not a sufficient basis for the exclusion of a child from education. How to Treat Lice? Treatment of lice infestation is divided into two types of methods: manual removal/physical impedance and chemical/pesticide. Below are brief descriptions and some available statistics for each method. Mechanical Means Mechanical removal/physical impedance techniques use combs to physically remove lice, or various materials to coat the hair to suffocate them. These methods are gaining in popularity as the concerns over the use of pesticides on children's scalps increase and as lice develop resistance to many over the counter chemical treatments. Wet combing (Bug Busting) - simply use a wet comb and conditioner, followed by a repeat combing. Once conditioner is rinsed out, it removes live lice every 3-4 days for a period of 14 days. Immature lice cannot reproduce until seven to ten days after hatching, and have a difficult time moving from host to host, so combing every 3-4 days removes the immature lice preventing them from mating and laying more nits. After 14 days all nits should have hatched, and if no live lice are present, the infestation is eradicated. A 2005 study of 133 children showed this method effective 57% of the time compared to 13% of the participants provided with a permethrin shampoo. While these success rates may seem low compared to other techniques discussed later, remember that the study was conducted with lay persons providing the treatment in the community setting so it reflects an actual use, rather than perfect use results. Household items - a common technique is to coat the hair in oil, mayonnaise, petroleum jelly, or other materials. These items generally attempt to suffocate the louse. The hair is coated in the material of choice before bed and rinsed in the morning. Often this treatment option is less effective as the material dries or shifts and exposes some hair leaving live lice after treatment. As with all mechanical treatments, household remedies are only effective against live louse, so treatments must be repeated every seven to ten days until clear. Studies have shown no home ready treatment is 100% effective. Petroleum jelly was found to be most effective, however no human trials have been conducted and the inconstancy in materials and technique means results will vary. Hot air (Louse Buster) - the application of hot air to control lice was studied in 2006. The results varied widely. Commercially available products, mainly the louse buster with hand attachment, boasted an impressive 80% louse mortality, and 98% nit mortality. However, more commonly available methods such as a hand or bonnet style dryer killed only 10% of lice and 89% of nits. Cetaphil (Nuvo Method) - uses the common skin lotion Cetaphil to coat the hair completely. The lotion is then dried with a hair drier, encasing the hair, effectively suffocating live lice. The treatment must be left on for 8 hours, generally overnight, and then is washed out. It is recommended the treatment be repeated every week for three weeks. The inventor of this method claims 96% effectiveness and is non toxic. Although it is time consuming as Cetaphil-covered hair takes two to three times as long to blow dry as untreated hair. Dimethicone (LiceMD) - used extensively in shampoos,other hair products, and also as an industrial lubricant,dimethicone works by suffocating live louse and makes combing out nits easier. A 2005 study showed it to be 70% effective. Product literature seems to indicate this is a onetime treatment, and that combing is required to complete treatment. Chemical Treatments Benzyl alcohol (Ulesfia) - this prescription treatment works by suffocation but is quicker, requiring only 30 minutes of application time and no combing. It is effective only against live lice and not against nits, so it requires reapplication 7 days after first use. It's non-toxic and has been shown to be 75% effective. Treatment with chemicals known as pediculicides has been the treatment of choice for decades. Many treatments are falling out of favor as they have become less effective as time progresses, and as concerns about chemical exposure increase. However, chemical treatments remain a common treatment option and are easily available over the counter. In the past few years,new products have appeared on the market that are highly effective but may be prohibitively expensive. These new treatment options are unfamiliar to many nurses and physicians and should be thoroughly reviewed before use. Permethrin/Phenothrin (rid/nix) - this first line pediculicide has been in heavy use for decades. It is the most common over the counter treatment. It is applied to dry hair, sets for 10 minutes, and must be rinsed out. This is followed by the hair being combed out. The treatment is repeated in 7-10 days. A 2005 study found 70% effectiveness. However a 2014 study found most lice in North America are resistant to permethrins, casting doubts on the effectiveness of this long standing treatment. Lindane (Kwell) - is still available as a shampoo or lotion by prescription. It is not generally used as a first-line treatment, only being used after treatment with Permethrin has failed. It's more commonly used for scabies and body lice. It has caused seizures; however generally only in cases of repeated treatment or misuse, and some accusations of permanent disability have been reported. It also has a long list of restrictions as to who may not use it, including woman who are pregnant and persons who are immune compromised. It is reported to be effective against louse and nit, and generally only requires one application. Malathion (Ovide) - a prescription topical treatment, again generally only used when first line treatments have failed. It has been associated with neurological side effects and overdoses have occurred even with careful use. It is also flammable and should not be used near any heat source. It is applied and left in for eight to twelve hours, and rinsed out. It is 97% effective, killing both louse and nit. Spinosad (Natroba) - a new prescription treatment derived from bacteria, giving it a unique mechanism of action. It has been tested on children as young as six months. A single application is placed on dry hair, left in for ten minutes, and rinsed. It is 86% effective at 14 days after treatment. Ivermectin (Sklice) - a newly approved prescription treatment that kills both lice and some nits. One treatment with 4oz of lotion applied to the scalp for 10 minutes and then rinsed out. No combing required or recommended. Effectiveness was 74% at 15 days. It is reported to be very safe with minimal side effects and is recommended for children as young as six months. At this time, treatment with oral ivermectin is off label although thought to be safe. Organic Treatments Presently many organic and natural products are marketed for lice treatment. They make a variety of claims. Some claim to repel lice, others will weaken the glue that binds the nits to the hair. At present all are untested, but have many users who will swear by them. They often work by mechanical means either by suffocation of live lice, or simply facilitating easy removal with combing. They are generally more pleasant to use than other methods, as they smell pleasant, and often put parents' minds at ease with their all natural ingredients. Many camps have found them to be successful; however as with many such products actual quality research is generally not available. After Treatment After treatment has been initiated the environment needs be cleaned to prevent live lice from re-infesting the scalp. Combs must be changed out, soaked in alcohol, or washed in hot water greater than 140 degrees. Bedding should be placed in a dryer on high for 15-30 minutes. It is generally not necessary to vacuum furniture or carpets. No treatment is required for stuffed animals or other objects that have incidental contact with the child, as lice cannot survive more than two days without a host. Treating lice in the camp setting comes with a unique set of challenges. The communal living situation and prevalence of activities create abundant opportunities for close casual contact and clothes sharing. It is practically assured that if one case of lice is found in a bunk, it is present in other members of the bunk. With bunk sizes between eight and thirty, and the labor intensive task of using almost any removal technique, the job of treating an outbreak quickly becomes daunting. Social concerns must also factor in to your considerations, children with lice may feel singled out or become the victim of teasing. The nurse must work quickly to coordinate with the counselors to try and keep the bunk moral positive. Camps using chemical methods of removal exclusively, especially over the counter premetherin, quickly encounter the concern that the lack luster success rate may result in re-infestation of the bunk. Also many parents wish to avoid chemical use on their children, which results in ma many parents refusing specific treatments or requesting their favored brand of OTC shampoo. This increases confusion, and may contribute to treatment mistakes. Concerns Regarding Chemical Treatments The concerns regarding chemical treatments have lead many camps to use exclusively manual removal techniques. These are more time consuming the course of treatment may span over several weeks. The longer treatment times will quickly overwhelm the health staff, and the perfect technique required to achieve best results becomes challenging as the length of treatment drags on. Although the success rate of many manual methods is often not significantly higher success rate than the chemical methods, parents are often more comfortable with them. Due to the unsatisfactory success rates of both chemical and manual methods, and the desire of many camps to treat entire bunks or living units as a preventative measure generally leads to the use of a combination of methods. Usually chemical methods are being reserved for confirmed infestations, and manual methods used on the exposed bunk mates. Alternatively, prescription treatments for confirmed cases and less effective methods for exposed bunk mates, is a common choice. However you choose to address your camps lice issue, you will quickly find it a labor intensive and often overwhelming process. Often the nursing department is the only one to handle this task. It's very important to stress to your camps management that if they want the issue dealt with correctly, and believe me they do, they will need to assign extra staff to assist. Simply expressing your needs in terms of man hours may be helpful. If we have 8 campers with lice and treatment will take an hour each, there is no way one department has eight additional man hours to dedicate to this task today. Reassignment of volunteers to assist, or hiring outside community assistance may be options to assist. Also letters and calls home will quickly raise alarms in the community of camp parents, who will undoubtedly call camp with vigorous concern and generally one resounding sentiment of "don't send them home with lice!" Working with your camp director to get ahead of the rumor mill is quite helpful; mass emails and a script for the office to read will help keep parental hysteria under control. Many camps realizing that their health department cannot address lice outbreaks to the satisfaction of the clientele have outsourced lice screening and treatment to outside companies. These companies can take the time to do through lice checks, and will arrive at camp with staff dedicated exclusively to addressing the lice infestation. These companies often offer lice-free guarantees and will retreat the child in their home if the lice infestation persists, much to the relief of the families. Key to Success ... Plan Ahead As with most camp crises, it is important to plan ahead. A quick conversation with your director about screening and treatment options is critical. Laying-in supplies to treat at least one bunk of campers is very helpful. If you're in an area that is heavy with summer camps, don't rely on Walmart to have an endless supply of combs and other essentials, another camp with the same problem may have beat you to all the supplies. Speaking to your local pharmacy to make sure they can acquire your prescription treatment of choice is an important step, especially if forms have been sent to parents authorizing a particular treatment. Get all the health staff on board with the plan, the last thing you need is a debate on what to do when the first cases start to roll in. Even if you're not a Boy Scout camp, "be prepared" is always good advice. References Below are the sources used for this article. Please pursue your own information, as new products and studies are always coming out. http://www.hse.ie/eng/services/publications/Children/Bug_Busting_An_Action_Research_Study_to_Treat_and_Prevent_Head_Lice.pdf Head lice - NHS Choices News - Heads Up Nitpickers 3 New Head Lice Drugs Could Change How Lice Are Treated - Forbes FAQs - Nontoxic Head Lice Treatment The clinical trials supporting benzyl alcohol lotion 5% (Ulesfia): a safe and effective topical treatment for head lice (pediculosis humanus capitis) - PubMed - NCBI http://www.childrensmercy.org/Content/uploadedFiles/Departments/Nursing/Link%20Head%20Lice_Repurposed.pdf

As always, I am not an expert. All information presented below is correct as I understand it, however I possess no degrees or certifications in infectious diseases. I recommend you do your own research using the links at the end of this article, or other peer reviewed materials. History First identified in 1975 in the towns of Lyme and Old Lyme Connecticut, the history of Lyme disease has been quite muddled. To quote Dr. Ed Masters, a noted researcher in tick borne illness, the "track record" of the "conventional wisdom" regarding Lyme disease is not very good: "First off, they said it was a new disease, which it wasn't. Then it was thought to be viral, but it isn't. Then it was thought that sero-negativity didn't exist, which it does. They thought it was easily treated by short courses of antibiotics, which sometimes it isn't. Then it was only the Ixodes dammini tick, which we now know is not even a separate valid tick species. If you look throughout the history, almost every time a major dogmatic statement has been made about what we 'know' about this disease, it was subsequently proven wrong or underwent major modification. This confusion and frequent changes in the nature of the disease has led to a lot of public confusion and mistrust. Over the last 40 years of research, a general consensus has been reached for the diagnosis and treatment of Lyme disease. However outlying opinions and treatment regimes continue to add controversy to the topic. Transmission It is known for sure that Lyme disease is transmitted to humans through the bite of ticks. Previously it was thought Lyme disease was only carried by the deer tick, however it is now believed that other types of ticks of the genus lxodes may be carriers based on the discovery of the bacteria B. burgdorferi in ticks in the Pacific Northwest, as well as Europe, Asia, and Australia. The disease remains most prevalent in the northeastern United States, but pockets of cases are found just about anyplace. Stages Lyme disease affects multiple body systems and presents with a host of symptoms. It has three stages, with symptoms generally becoming more severe and debilitating as the disease progresses. Stage I, known as early localized Lyme disease, occurs days or weeks after infection. It presents with the most common, and most recognizable symptom, erythema migrans. This distinctive bullseye rash is red and painless with raised borders and a firm indurated center. Erythema migrans is present in 80% of Lyme cases and occurs 3-30 days after the initial tick bite. It should be noted that erythema migrans may not present as a bullseye but as a patchy plaque-like rash that is painless. The indurated center and raised boarders remain the tell tail sign. Other symptoms include chills,fever, malaise, headache, joint pain, joint swelling, muscle pain, stiff neck. Obviously in the 20% of cases that do not present with a erythema migrans the diagnosis of Lyme disease can be hard to make, as the disease can easy be mistaken for many common aliments. If a routine illness is not following it's routine course, Lyme should always be considered, especially if you're in an at risk area. Stage 2, known as early disseminated Lyme disease, occurs weeks to months after infection. Symptoms include numbness or pain in the nerves around the infection. Paralysis or weakness of the face known as Bell's Palsy. Heart issues such as palpitations, or chest pain. It should be noted that the erythema migrans present in stage 1 may be faded or completely resolved. Stage 3, known as late disseminated Lyme disease, occurs months or years after the initial infection. It is characterized by abnormal muscle movement, joint swelling, muscle weakness, neuropathic pain or sensation, speech and cognitive problems have also been reported. Diagnostic Tests Blood tests for Lyme disease and their reliability remain controversial. There are two common serological tests. The ELISA test is recommended first to be followed by the western blot test if results are positive or questionable, in a two tiered protocol. However, this protocol is only 64% sensitive in the early stages of the disease, but nearly 100% in stage 2 or cases with arthritic symptoms. The general unreliability of blood testing in the early stages of infection and the urgency with which Lyme must be treated to prevent progression to a more advanced stage, has made the diagnosis of Lyme one based primarily on clinical exam. Treatment Treatment recommendations for Lyme disease focus on the the early application of antibiotic treatment to treat the causative organism B. burgdorferi before the disease progresses. Presently, the recommendation from the CDC for adults and children 8 and up is the Doxycycline 100 mg BID for 10 to 21 days, amoxicillin 500 mg TID for 14-21days, or cefuroxime axetil 500 mg BID or between 14 and 21 days. IV antibiotics and more intense regimes would be reserved for advanced cases, who's symptoms would certainly make them not candidates for camp. There are also therapies being practiced in the treatment of Lyme disease that are presently not recommended: first-generation cephalosporins, fluoroquinolones, carbapenems, vancomycin, metronidazole, tinidazole, amantadine, ketolides, isoniazid, trimethoprim-sulfamethoxazole, fluconazole, benzathine penicillin G, combinations of antimicrobials, pulsed-dosing, long-term antibiotic therapy, anti-Bartonella therapies, hyperbaric oxygen, ozone, fever therapy, intravenous immunoglobulin, cholestyramine, intravenous hydrogen peroxide, and specific nutritional supplements. The nurse would have to evaluate their comfort with administering therapies that are not presently recommended, especially in the practice environment of a summer camp where close medical supervision would be challenging. A discussion with your camps physician, possibly including your camp director may be required when dealing with off label or alternative medical treatment ordered by an outside physician of a camper. There are many "Lyme Literate" doctors who prescribe therapies not presently recommended, or supported by strong scientific study. In advanced Lyme disease the symptoms can persist even after treatment is concluded. This is often referred to at post Lyme disease syndrome. There is no well-accepted definition of post-Lyme disease syndrome, which has led to much confusion and controversy around it. Further study is underway at this time, and presently no treatment recommendations exist for post-Lyme disease syndrome. Prevention As always in camp nursing, prevention is just as, if not more important than early detection. A strong education, prevention, and monitoring program is critical to good outcomes for campers and staff alike. Some actions to take include: Educate staff about ticks and Lyme symptoms. Remember staff may be from areas where Lyme disease is rare or unheard of. Education keeps them alert for symptoms at camp but may also be useful if they develop the disease at home where physicians are not familiar with the diagnosis and treatment of Lyme. Encouraging the application of bug repellent containing 20% DEET, especially before activities that will involve walking through tall grass or brush. Encourage long pants and boots when taking part in high risk activities like hiking. Consider treating camping gear with permethrin. One application to gear at the start of the summer season may provide protection all summer. Treated tents and boots will help prevent stowaway ticks. Make sure grass around sports fields and other camp areas is trimmed low. Ticks live in tall grass, they do not fall from trees or blow in the wind. Keeping grass short makes the environment less hospitable and will lessen the tick population. Get staff and campers in the habit of tick checks. Visually inspect the skin every 24 hours. This can generally be done during established shower times. Get everyone in the habit of checking armpits, hair, behind the ears, behind the knees, between the legs, and around the waist for embedded ticks. Tick Removal Remove ticks as soon as possible after they are located. Use fine tipped tweezers to grasp the tick close to the skin's surface, avoid compressing the tick's body. Pull the tick upward, if the skin tents pause briefly and allow the tick to let go. Try and avoid twisting or jerking, as this is likely to leave the head of the tick in the skin. If the head remains in the skin after tick removal, remove it with tweezers if it is easy to do so. If not, simply leave it alone and let the skin heal. After removal wash the skin with soap and water. Consider having ticks removed only by nursing or other designated staff to ensure proper technique. Improperly removing a tick may increase the chance of infection by leaving, or forcing infected tick saliva into the victim. Note: infection is much less likely if the tick is identified and properly removed within 24 hours of attachment. Prophylactic Treatment Work with your physician to determine if prophylactic treatment for confirmed tick bites will be recommended. Current recommendations for prophylactic treatment is a single dose of doxycycline 200mg for adults and 4mg/kg up to 200mg for children greater than eight within 72 hours of the removal of the tick. Presently this treatment is only recommended in high risk situations such as the removal of an engorged tick, or in areas the have a high prevalence of Lyme disease in the community. Work with your camp director to plan for parental notification in cases of suspected Lyme disease. As with all disease contracted at camp, parents can overreact and create a panic among the community of camp parents. Work with management to make sure that they are educated about Lyme, aware of any suspected or treated cases, and have correct and easy to understand information to provide concerned parents of non infected children if they contact the office in a panic. While Lyme disease if not a challenge unique to camp nurse practice it is of special concern. Our population is constantly involved in high risk activities, more so than the average population. The camp setting makes the nurse the main observer for Lyme symptoms, and the leading advocate for prevention. Using the information above I hope you are more prepared to address Lyme disease diagnosis, treatment, and prevention in your practice. References Clinical Infectious Diseases | Oxford Academic http://www.idsociety.org/uploadedfiles/idsa/guidelines-patient_care/pdf_library/lyme%20disease.pdf Bicentennial: Close to Home: A History of Yale and Lyme Disease

Making sure your camp's emergency response plan is in place and well understood prior to an emergency is critical to success. No response plan can be comprehensive; you cannot produce a protocol for every situation. Also, realize at some camps, response plans are less a written procedure and more of a "this is how we did it last time" thing. In the absence of a written procedure, or the desire to create one, a clear understanding of the roles and responsibilities of all involved is vital. A written or verbal response plan should include the following components: Staff Requirements Who do you require to respond to your emergencies? These persons, and these persons ONLY, should respond to an emergency. For my camp; head staff, a nurse, and operations will automatically respond to any medical emergency. Any persons trained in first aid in the immediate area are encouraged to help, but cross camp freakout runs are discouraged. The camp director and the doctor are located and advised they may be needed to attend the incident. Make sure every member of the team is clear on their role, and discourage moonlighting or sightseeing by staff who do not really need to respond. Communication Once an emergency is recognized, how will you, or the required staff, be contacted? Can bystanders communicate the nature and location of the emergency to everyone from anyplace? My camp's communications are handled via radio. Emergency traffic is assigned to specific channels to keep the soccer roster change announcement from stepping on the emergency traffic. Whatever means of communication you use be sure all staff are familiar with the equipment itself and how to use it. Equipment What equipment is required in your emergency plan and who is responsible to bring it? At my camp the response bag and oxygen are the standard equipment brought by the nurse from the Health Center. Unless the emergency occurs at meal time, in which case operations will bring it to the incident. We have other equipment located around camp that we can access such as, backboards, stokes baskets, AEDs, and emergency drugs. The response bag easily handles 99% of our emergencies. In the rare case that we need the special equipment the operations person assigned to the incident will fetch it. You will need to assess what is required for your particular situation, however remember sometimes less is more. Escalation Who determines when an incident is beyond the scope of what the camp staff can handle? Who is responsible for notifying 911, and what procedures will be started when EMS is activated? At my camp any nurse can decide to activate the EMS system if they believe it is necessary. We prefer when possible to have the doctor decide, however in the absence of a physician, the nurse will be supported in their decision. Once 911 has been called operations is notified to open the secondary entrance to camp and wait there to guide the responding ambulance to the incident. The camp director responds to the incident location, as they generally escort the child to the hospital. The child's chart is located and brought to the incident location as it will accompany the child to the hospital. Resolution If escalation to an EMS response is not required, the child is transported to the health center for evaluation. The physician may still decide to have the child evaluated or treated in the ED. In that case, the child is generally transported via camp vehicle with report being called to the ED by the charge nurse. A nurse, or senior staff member, should accompany the child and handle all communications between the hospital and camp, and more importantly, the hospital and the family. Evaluation When an incident is over, have all parties involved think about how it could have been made easier or better. Generally, there is some way to tighten up the procedure. The goal should be quality improvement, not finger pointing. Revising or creating a written response plan, or more clearly establishing a verbal plan, should be the goal of a successful evaluation. In addition to establishing and understanding your plan, some specialized training may be in order to make the nurse more confident in their abilities and refresh basic but important skills. A basic first aid course through the Red Cross or Heart Association is a one day class that can refresh little used skills such as splinting, burn first aid, and envenomations. I highly recommend a more involved course such as first responder, or even EMT-B if your time allows. These offer vary basic assessments, specific to emergency situations. They also teach skills such as spinal immobilization, basic airway adjuncts, and management of trauma patient. If your camp has a robust excursion or trips program they may also run a Wilderness First Responder course through ASHI. I attended a WFR course,as an EMT, found it quite interesting. Even a few hours speaking with a more experienced provider about some of your questions, can be very beneficial. If you are part of a smaller camp, you may want to seek out trained staff that are functioning in other roles on camp. EMTs, athletic trainers, or even nurses licensed in other countries can be hiding in the ranks, and could useful to add to your emergency plan, or kept in a roster to be called on if needed. Another useful task is to interface with your local EMS squad and get a feel for the local resources and response plans. A quick chat with the local chief, or community resource officer can be enlightening. Be sure to ask how the time of day may effect EMS resources. What hospitals are commonly used, and what specialty hospitals will be used for situations such as burns, trauma, or stroke. Emergency response and management is only a small part of the camp nurses role, however it is often a part that causes a lot of anxiety. It is not a skill especially focused on in nursing education, or a role that many nurses may feel entirely comfortable in. I hope this article helps you in your practice at camp and gives you a starting point to establishing, or improving your camps emergency plans.

My first year as a camp nurse I spent hours learning everything I could about my new job. I read the book, looked at all the websites, and browsed every forum. I was disappointed to find so little information on camp nursing. I have come to realize there are several reasons behind the lack of information. First, there are no experts! The truth is that very few camps have full-time nurses and a lot of camps don't have many returning staff. Even those who do generally only continue camping until their life circumstances prevent them from returning. The result is that most nurses don't log enough time to really consider themselves experts. Second, the differences in camps make complete expertise impossible; each camp is different. The practice of nursing at each particular camp has evolved to suit the particular needs of that camp. There are some similarities in practice however, an expert can really only be an expert on their particular camp, or camps with similar design and culture. I won't claim to be an expert, because I don't think anyone can claim to be an expert on the totality of camp nursing. I am starting my third year of camp nursing. I work at a large summer camp, we keep our kids for the entire summer, and have no special needs considerations besides some ADD. These are 10 lessons I have learnt along the way. I hope they can help you. Preparation is key Every minute of preparation you do before the campers arrive is worth an hour of headache later. Some things can't be accomplished until the kids arrive, but make sure everything that can be done is done. Make sure the health histories are filled out, insurance cards are copied, medication records and inventory are as complete can possibly be, and files are actually in alphabetical order. Make sure your camp first aid kits are stocked and emergency response plans are made and understood. You're stuck with these people, better make the best of it I spent half of my first summer being angry at one of my coworkers. They weren't the best employee, liked to stay out late drinking, return at all hours of the night, waking me up in the process. They couldn't do laundry or dishes. The nurse was profoundly unhappy at camp, and for about a month made me unhappy too. At about the half way mark I realized, it's actually pretty hard to get fired. No camp is going to discard an able body, and my boss was right, a poor coworker was better than a missing one. So I got some ear plugs, put on my big boy pants and just put up with it when I had to. I did my best to enjoy my job, and not focus on what I couldn't change. I wish I had done this from the start. You're going to think about leaving My first year, when I was miserable, I seriously contemplated just getting in my car and driving off. I was in a strange place, with people I didn't like, at a job I wasn't familiar with, and all this for less pay than I could make just three hours away at home. Camp is hard, and your going to want to leave. In my opinion, that's normal. Just don't leave, that's cruel to your coworkers. Make low friends in high places My second year I became friends with the kitchen, and my life changed. Suddenly I got fed, not just leftovers but real food. The health center meals got delivered on time. I also had friends for times that I was off shift. The kitchen and the nurses should, in my opinion, be fast friends. We are both in a support role at camp, we both have odd hours, and we both don't room with children. I also inherited a friend in the office, and I never couldn't find a pen again, my copies actually got done, and I got my license renewal paid for (I work in the state year round, not like the other nurses who had to travel, but he submitted it, and they paid it). I was nice to the shopper and didn't have to make the 30 minute drive into town to buy a new tooth brush when I dropped mine in the toilet. I gave her money and asked her to get it on her daily travels. I thought that I would be playing games and doing camp stuff all summer, and to an extent I did, but my friends in the other support departments make my job easier, and are all around cool people. Don't make enemies! My first year the new doctor, who was only there for a week, made a big stink to the camp directors that the health center was not being cleaned enough. In her opinion all floors and common surfaces should be cleaned daily. This led to a meeting with the maintenance/cleaning team. That meeting was the last time we saw the cleaning team that year. Camp is only 8 weeks, which is plenty of time to hold a grudge. Don't make people mad when you don't have to, especially if you rely on them to make your job easier. We mopped our own floors for the rest of the summer, for which the doctor who caused the ruckus was not present anyway. Know your strength and your weakness I have a pretty strong dislike of talking on the phone. I have a blunt personality, that only about 30% of the world finds charming, and I would rather clean vomit off the floor than sit in a chair at a desk. All these things are reasons I make a bad charge nurse. All of these things are why I have only charged when there is a gun to my head. I'm not that good at it, I will help you with it, but it is not my strength. I like big projects with goals. Want all the first aid kits restocked, medications inventoried, a room reorganized? I'm your guy! You have a difficult staff member that all the other nurses don't want to deal with? IM ALL OVER IT! Camp only lasts eight weeks for me, I would rather spend it using what I am good at rather than, dragging the team down by insisting on doing things that I'm not talented at. The job will take everything you give it If you spend twenty hours a day in the health center you will find twenty hours of things to do. Know when you need to put in some extra effort to get things done, and know when it's time to call it a day. Camp is a 24-hour operation, make sure you sleep, eat, and get a day off every so often. This really isn't a big deal Maybe two or three times a year something in camp will rise to the level of emergency. Everything else is, at worst, a crisis and mostly just inconvenient . Don't panic, flip out, or spend excess worry over thing that in the big picture are small stuff. Don't fall into the trap of letting your level of concern be dictated by those around you. A camper twisting their ankle, missing a seasonal allergy med this morning, or having a fever is in fact not a five alarm emergency. They may be emergencies to the staff, camper, or parent ;but no one is going to die, so don't freak out about it. Follow the campsite rule Try to leave things in better condition than you found them. Take one thing that was a problem for you, or you had a hard time learning and make it easier for the next nurse. For me it was an actual inventory to how many first aid kits we had on camp and what was supposed to be in them. My second year it was tweaking a form so that it could be one page instead of two, and would collect data better. Those aren't big changes, but they help. For three years running, the nurse I have helped has turned out to be me, which is a win-win situation. The kids are here to have fun, you're here to work I think the most common misconception about camp is that it is fun. It will have fun parts. When you sit down and think back on it will average out to fun, but there are times when working at camp is equal to a root canal, just like every job. You will have fun, and you will enjoy yourself, especially if you can get into the mindset of camp, but if you are expecting a vacation your going to be in for a surprise. Please add your lesson, what have you learnt that you wish you would have known on your first camp nurse job.

Like a septic system a little maintenance and prevention goes a long way. I like to be proactive in avoiding injures, making sure your camp has a culture of safety will go a long way to reducing business in the health center. Accidents happen, however every accident should involve the question of how can we keep this from happening again. Making sure that counselors have basic knowledge of first aid, and things parents know that college kids don't, goes a long way to preventing and identifying problems when they are small and manageable. Some of my favorite topics to work into conversation are things like checking for ticks every four hours or so; making sure the kids change out of wet swim suits; changing socks every day; applying sunscreen frequently; and my favorite WASHING YOUR HANDS. We also make clear that some things must come to clinic immediately; crusty eyes, wounds with drainage, and confirmed fevers should be reported as soon as possible. This seems like common sense, however I have cringed more then once when a child with an obvious case of conjunctivitis reports at noon saying that he woke up with his eye glued to the pillow this morning. The happiest camper is the one who avoids the health center with simple prevention, the second happiest is one who makes a speedy trip through do to staff education. Maintaining contact with counselors and leaders about concerns is also critical. I have caught several a case of impetigo or strep throat by simply walking the bunk line and checking in. Often some of the worst cases will just say something in passing about a bad rash or a persistent sore throat, then a simple on the spot exam reveals a raging communicable disease. I also regularly find staff who are neglecting themselves health wise. They would never come up to clinic call, but are more than happy to show me their athletes foot on the bunk line. Support staff are of special concern, the kitchen, operations, and excursion staff should be checked in with regularly, as their schedule may not allow them to present to clinic at clinic call times. (also a cared for kitchen staff will make sure you get fed) Camp nursing differs from other settings because healthcare and nursing are not the primary focus of the staff around us. Some nurses have trouble understanding this. In a hospital or other health care facility all support services revolve around the patents health and well being. However the primary goal of camp is fun, and we often have to adapt our practice around that rather then camp bending to our needs. Camp nursing is a rewarding and unique specialty, one with many challenges both personally and professionally. Often the most successful camp nurses are masters of not just nursing skills, but of the many interpersonal interactions and relationships with staff, campers, and families. Nurses should try to integrate into camp culture as much as possible. We as camp nurses should try and view the health center as a vital support component, we exist to make sure medical needs are met, and people are safe. If we are doing our job correctly most of camp will never have to put much thought into our existence, however our jobs, like so many at camp are vital to operations but mostly unseen by the campers and consumers.