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  1. Founded in 1970, ENA has proven to be an indispensable resource to the global emergency nursing community. With more than 42,000 members worldwide, ENA advocates for patient safety, develops industry-leading practice standards and guidelines, and guides emergency healthcare public policy. Dates: Sep 13-16, 2017 Registration: Online Form Attendance:3,500 Highlights: CNE contact hours. CERPS, Up to 150 Sessions, Hands-On Learning, 200+ Sponsors and Exhibitors, Advocacy, Networking, Music & Dancing, Welcome Party at Ballpark Village. Emergency Nursing Conference 2017 Be part of the most exciting hands-on emergency nursing education: Emergency Nursing 2017. Held in St. Louis, Missouri, this four-day conference is an opportunity to expand your knowledge, learn new skills through hands-on opportunities, and return to your ED reinvigorated to share new ideas and best practices. The largest conference dedicated to emergency nursing includes: More than 150 sessions ranging from pediatrics and geriatrics, to leadership, trauma, and more Interactive demonstrations, hands-on learning labs, and Mass Casualty Incident (MCI) Training ADVANC-ED - a 6-bed area with interactive manikin simulation exercises, and a SIM Wars friendly competition against your peers The NEW TECH-ED area, a close-up look at the newest and most advanced high-tech emergency care products Electronic Posters (ePosters), featuring the latest emergency nursing research and evidence-based practice Cadaver and Ultrasound hands-on labs Networking, networking, and more networking Some of the sessions include: Strategies for Implementing the Geriatric ED Guidelines: Education, Best Practices, Quality Improvement Ultrasound Assessment and Guided Procedures in the Emergency Department Bridging the Academic-Practice Abyss: Nurse Residency and ED Professional Development The Colorado Cannabis Experience - Lessons Learned for Other States Trauma Nurse Fellowship: Developing the Novice Trauma Nurse Human Trafficking in the Emergency Department: Navigating Medical Forensic Protocols Emergency Management of Chronic Pain Body Modification: The What, How, and Pitfalls ED, ICU, Critical Care in the Emergency Department Opioid Addiction and Death Spiraling Out of Control Download Emergency Nursing 2017 Registration Brochure WELCOME PARTY AT BALLPARK VILLAGE Thursday, Sept. 14 - 7:00-11:00 pm Enjoy an evening of fun at Ballpark Village, the newest dining and entertainment district in the St. Louis area. This first sports anchored entertainment district located next to Busch Stadium, home of the St. Louis Cardinals, offers a wide variety of restaurants, bars, lounges, and entertainment venues. Come join us for great food, and a whole lot of fun! Exhibit Hall The Exhibit Hall offers hands-on training, product specific training, and access to more than 200 leading suppliers of products and services for every type of emergency care environment. Take new product ideas back to your institution. DisastER From natural disasters, to major accidents, DisastER requires emergency preparedness for catastrophes in the field. Located in the Exhibit Hall, this hands-on DisastER area offers techniques in S.T.A.R.T. Triage, self-aid, buddy-aid, tourniquet application and lessons from the field. Featuring hands-on work with MCI, military SMRT tents, and medical helicopter, these exercises prepare nurses for emergencies outside of the ED. Short ED Talks will also be held here. All hands-on training and ED Talks in the DisastER area start at the top of the hour during Exhibit Hall hours. ENA Way Follow the arrows on the Exhibit Hall floor and head towards the music. ENA Way is where you will find: ENA Marketplace, filled with ENA educational products and merchandise ENA Foundation, where you can donate to help nurses further their education, or learn about how to apply for a scholarship. ENA LEARN kiosks, where you can learn about and purchase ENA digital educational products ENA Career Fair and Wellness, hosting a professional headshot photo lounge and job center ENA Education Booth #426 Journal of Emergency Nursing Booth #429 Academy of Emergency Nursing Booth #427
  2. The nurses took report on both patients and prepared the trauma bays for a couple in their 80's who had been T-boned when the husband pulled into an intersection. No current life threatening emergencies were reported. Each patient was assessed and stabilized. A recurring theme was each spouse asking about the other spouse. After the hustle and bustled settled down we reassured each patient that their spouse was fine. We opened the curtain separating their rooms and informed them that they were right beside each other and they could talk to one another. They could not see one another because they were secured to backboards and unable to turn their heads to the side but they could hear one another. The wife wanted me to know her husband had a blood pressure problem......oh dear she couldn't remember the name of the medicine he was on. The husband told me how they had been married for 60 years and I could see the sparkle of love in his eyes. As time went on and test results returned it was decided that the wife had an injury that required her to be shipped to a Level 1 trauma center. The doctor informed the couple of the care decisions he felt were necessary. I began to see fear and worry in the husband's eyes. That is when I jumped into gear of getting the portable heart monitor. I connected the husband to the monitor and moved his IV pole and bed right beside his wife's bed. I put his left bed rail down and her right bed rail down. I told them that if they just reached out they would be able to feel each other's hands. They reached out and found each other's hands and held on tight. They talked and reassured each other it would all be okay. They told each other they loved them. The husband told her as soon as he could find someone to drive him to the other hospital he would be there. The doctor told the wife it would be best if her husband stayed all night for just one night to be observed and make sure he was okay. The husband didn't want to but the wife encouraged him that he could see her tomorrow. The helicopter crew came and the beds had to be separated after a final hand squeeze and I love you. The Mrs. was loaded and transported to the other hospital while the husband was admitted for overnight observation. The next day I came to work I found out the wife had died that night from her injuries. I was heartbroken for this lovely couple. As I reflected, I was so thankful that I had taken the time to connect the portable equipment and rearrange the beds and allow them to hold hands. Many times we are too rushed in the ER to make time for the important things in life. And what was more important at this point in time? To hold hands for the very last time...
  3. A new practice improvement initiative and study indicates active shooter training and simulations are vital to ensuring staff is equipped to respond effectively should their emergency department ever become a target for such an act of violence. The goal was to develop and successfully implement a safety strategy that increased the ability of a large pediatric emergency department staff to effectively respond to an active shooter in their hospital. The corresponding survey results, set to be published online in the Journal of Emergency Nursing, show that out of 202 emergency nurses and ancillary staff members who participated in active shooter training, 92 percent felt better prepared to respond if a shooting occurred at their facility. Additionally, 70 percent of participants reported an increase in knowledge and readiness. "We are in the infancy stage of this conversation," study co-author and Emergency Nurses Association member Mary Baker, BSN, RN, said of active shooter training in hospitals. "As emergency nurses, we practice our ACLS and PALS a lot. We've gotten very proficient at it because it's always top of mind. But when it comes to preparing for a catastrophe such as an active shooter in our own emergency department, most nurses have no idea how we'd react because we aren't preparing for it." Active shooter situations and mass casualty incidents have become an unfortunate and increasing reality in society today. That has put emergency nurses on the front line of caring for victims of mass casualty incidents, but also on alert for the possibility their facility could become part of a large-scale disaster or tragedy. Due to the complexity and potential devastation of such an incident, it is critical for emergency nurses to be prepared. ENA knows it is vital for emergency nurses to regularly engage in active shooter training and mass casualty preparedness. To further prepare emergency nurses for their role in those scenarios, ENA is offering multiple opportunities for emergency nurses to participate in readiness courses and activities at Emergency Nursing 2018 - ENA's annual national conference dedicated to the emergency nursing profession occurring Sept. 26-29 in Pittsburgh, Pennsylvania. Mass casualty readiness educational sessions and activities at ENA18 include: MCI Escape Room Participants work as emergency nurses in a small community hospital emergency department with limited resources. After a brief description of the disaster, attendees will be broken into groups of five to quickly go through stations, solve clues and demonstrate skills needed for a variety of patient scenarios in a mass casualty incident or other disasters. "Game of Thrones" Attendees can compare make-believe traumatic injuries from the hit HBO series "Game of Thrones" to real-life traumatic injuries caused by modern threats to provide today's emergency nurse an opportunity to correctly identify these injuries and learn the proper course of treatment. DisastER Check out the 35-foot helicopter at the center of the exhibit hall and listen to ongoing presentations from Air and Surface Transport Nurses Association on topics such as transport after a mass casualty. State of Emergency - How We Prepared for Richard Spencer: Wendy A. Swan, director of emergency services at the University of Florida Health, describes how a Level I Trauma Center and emergency department prepared for a radical speaker, and the potential influx of thousands of associated supporters and counter-protesters. For more information on these mass casualty readiness activities, register for Emergency Nursing 2018.
  4. This is Part 2 of a two-part series of articles on caring for the elderly in the ED setting. Sanders (1996) developed 11 principles of geriatric emergency care that should be used when assessing older adults. These precepts are as follows: Complex Presentation Older adults, those at least 65 years of age, often present as complex patients for a number of reasons that extend beyond physical disease. It may be difficult to distinguish which symptoms are the patient's chief complaint, as well as which symptoms are the most important, as the elder may have multiple complaints. In fact, the clinician may feel overwhelmed by the deluge of complaints. The nurse needs to take the time to listen carefully, record each complaint, and ask insightful questions. For instance, late one evening, an infirm older adult came to the ED with complaints of back pain, indigestion, and headache. Upon further questioning, the patient mentioned that he was also experiencing chest discomfort, tightness, and pressure. It was interesting that "chest pain" was not even mentioned in his initial litany of complaints. Teasing out this vital information took quite a bit of time and effort. Atypical Symptomology The elderly patient often presents atypically. Because illness in older adults is complicated by the normal changes of aging and multiple chronic conditions, many older adults do not display the usual signs and symptoms of illness. Atypical presentation of illness in older adults includes absence of fever and cough, anorexia, confusion, dizziness, falls, fatigue, new-onset incontinence, lethargy, level of consciousness changes, malaise, self-neglect, and unexplained weight loss. For instance, the typical symptoms of pneumonia include chills, fever, cough, chest pain, labored breathing, fatigue, and bloody sputum. In the older adult patient, many of these signs and symptoms may be absent. The elder with pneumonia may simply present with level of consciousness changes and anorexia. Depression may be masked by nonspecific somatic complaints, such as multiple "aches and pains." Falls may signify serious illness in the frail patient. Confusion, lethargy, new-onset incontinence, and/or anorexia may signal a urinary tract infection or urosepsis. Atypical presentation often delays the diagnosis of acute illness with a resultant higher rate of mortality. It is essential for nurses to conduct careful and thorough assessments of older adults to consistently recognize vague presentations of illness and ensure appropriate and early treatment. Multiple Pathology (Comorbidities) The majority of the elderly contend with two or more chronic medical conditions, or comorbidity. Chronic diseases are more common than acute illnesses in the older age group. The chronic disorders most prevalent in the older population are ones that can have a significant impact on independence and the quality of daily life. Examples of comorbid conditions are cardiovascular disease, cancer, chronic obstructive pulmonary disease (COPD), diabetes, arthritis, hypertension, and Alzheimer's disease. Elderly patients with multiple chronic conditions often have worse outcomes and increased mortality. Indeed, chronic conditions account for 70 percent of all deaths in the U.S. Older adults usually visit the ED for an acute exacerbation of chronic disease such as heart failure or COPD. Polypharmacy The elderly are more likely to take multiple medicines. People aged 65 and over comprise 13 percent of the population but account for 34 percent of all prescriptions. On any given day, the average senior takes four or five prescription drugs and two over-the-counter (OTC) medications. Because they take more medications than younger people, the elderly have a higher risk of adverse reactions. As a matter of fact, 5 percent of all elder hospital admissions are related to an adverse drug event. It is vital to have an effective method of medication reconciliation in the ED. This includes accounting for all prescription medications, OTC products, herbals, and supplements. Cognitive Impairment An estimated 40 percent of all elderly ED patients have some form of cognitive impairment (i.e., dementia or delirium). Older patients with cognitive impairment are vulnerable, since they may be unable to make decisions for themselves or function independently when they visit the ED. This can pose many challenges for ED clinicians during admission, assessment, and treatment. Delirium is the most common cognitive impairment, and it is often under recognized and overlooked. Also known as an acute state of confusion, delirium is a medical emergency, with a fatality rate as high as acute MI or sepsis. It can present as lethargy, agitation, or a fluctuation between these two transient states. Correctly identifying cognitive impairment is critical for medical testing, effective treatment, and to facilitate safe and realistic discharge planning. Physiological Efficiency Aging results in a diminished ability to maintain homeostasis and regulate body systems. Organ function becomes less efficient with age, correlating with laboratory values. For instance, the glomerular filtration rate (GFR) of a ninety-year old is normally half that of a twenty-year-old. Other alterations include alkaline phosphatase, cholesterol, PSA levels, and sed rate values, which increase somewhat in seniors. To provide safe and effective care in the geriatric population, clinically significant changes in lab values need to be recognized and accurately interpreted. Decreased Functional Reserve As a result of the effects of aging on the physiological processes, the elderly have less functional reserve. While performing normal activities, the elderly may function well. When stressed by illness or injury, however, their functional reserve may be depleted quickly. As people age, functional reserve diminishes so that a stressful event can have much more severe consequences. Older people who develop acute illness or suffer a trauma usually require longer periods of recovery and have more complications from these conditions. Importance of Family or Community Support Does the older adult require assistance with performing daily activities? Are caregivers available to help him or her? Correctly assessing an elder's support system is critical to discharge planning. Baseline Premorbid Health Status It is important to know the older person's baseline health status to discern cognitive and functional decline and assist diagnosis and treatment. A simple strategy is to compare the presenting signs and symptoms with the elder's normal baseline that preceded this occurrence. Medical history provided by the family can provide important clues as to what is normal and abnormal for the patient and what may be the underlying cause of the presenting signs and symptoms. Psychosocial Impact of Illness and Trauma Social and personal concerns of the elderly are frequently not addressed in ED encounters. Emotional problems, such as depression, often influence somatic complaints and can disguise underlying health problems. The Need for Comprehensive Assessment Some specific areas that ED nurses can focus on include a more comprehensive approach to assessment and discharge planning, improved communication with the patient and their informal caregivers, substance abuse, and elder abuse and neglect. Failure to consider the possibility of abuse and neglect will mean that the appropriate diagnosis is not made and the older adult is returned to an unsafe environment. Danger signals are sudden weight loss, dehydration, medication over dosing or under dosing, injury marks, personal neglect, car accidents, forgetfulness, extreme suspiciousness, fires in the house, bizarre behavior, or disorientation. Emergency department nurses are challenged to meet the needs of older patients, who have complex presentations and require comprehensive assessment and referral. Problems such as atypical presentation, chronic health conditions, altered cognitive state, and polypharmacy can complicate diagnosis and management. These 11 principles can assist clinicians in meeting these challenges and help ensure that older adult patients receive appropriate care in the ED setting. References Aging Effect on Laboratory Values The Unlikely Geriatricians
  5. Emmalee Miller, age 82, is brought into the Emergency Department by a concerned neighbor. The patient is a widow with mild Alzheimer's dementia, who used to live alone in her own house until about three months ago, when her unemployed son came to live with her. The frail elderly woman has a disheveled appearance with tattered soiled clothing. She acts frightened and withdrawn. A physical examination reveals that Mrs. Miller is dehydrated, malnourished, and mentally confused. The nurse notes a 10 cm purple hematoma on the left side of her face, numerous bruises in various stages of healing on her lateral right arm and on her posterior torso, and three dime sized burned areas on her upper inner thigh. The nurse strongly suspects elder abuse. Frail, dependent elders are highly vulnerable to anyone who might take advantage of them. Elder abuse is any action or inaction that results in harm/ loss or endangers the welfare of people age 65 and above. Elder mistreatment is a general term for abuse, neglect, and exploitation. It can include physical abuse or neglect, psychological abuse, financial or fiduciary abuse, self-neglect, or the inappropriate use of medications, restraints, or confinement. Like Emmalee, the 'typical' abused elder is a female over the age of 75, who is socially isolated, suffers from chronic health conditions, is in the lower socioeconomic strata, and lives with her abuser(s). Common characteristics of abusers are as follows: family member (majority of cases); male; impairments such as mental illness and substance abuse; poor social network; history of family violence; legal/ financial issues; and, dependent on the older adult. The most frequently identified perpetrators are adult children, followed by a spouse, long term care facility staff, or other relatives. Elder abuse/ mistreatment is the least reported form of domestic violence. The prevalence of elder mistreatment is difficult to accurately gauge since many cases go unreported. It is estimated that for every one case of elder abuse reported to authorities, about five more go unreported. One reason may be that normal and common age-related changes mask or mimic markers of abuse. The best available data indicate that each year between 1 and 2 million older Americans are injured, neglected, exploited, or otherwise mistreated by someone on whom they depended for care or protection. The number of cases of elder mistreatment will undoubtedly increase over the next four decades, as the population ages. Laws vary from state to state, but elder abuse may be broadly categorized as: Physical Abuse Any action that results in physical pain, injury, or impairment is considered physical abuse. An estimated 0.5 to 4.3 percent of older adults are physically abused annually. This includes, but is not limited to: striking, beating, handling with unnecessary roughness, purposeful injury, unreasonable physical restraint, sexual assault, and deprivation of food or water. Neglect The most common form of elder mistreatment is neglect. Neglect is the failure to take care of the needs of an elderly person. This includes, but is not limited to: failure to provide nourishment, hydration, hygiene, clothing, shelter, medical care, and protection from injury. Self-neglect is common among frail elders who live alone. Indicators of self-neglect are malnourishment, dehydration, falls, poor hygiene, and inadequate clothing. Psychological (Emotional) Abuse This can be difficult to identify and prevent. In psychological abuse, an elderly person is treated in a way that causes emotional pain or distress. This can range from extremes of verbal abuse, coercion, and accusation to more subtle tactics such as manipulation, intimidation, withholding attention, and a general lack of patience and respect. Emotional abuse is damaging in that it wears away the elderly individual's self-confidence, self-worth, and self-esteem. Frail, dependent elders often have little means to defend themselves from the constant humiliation and verbal assaults. Sexual Abuse Sexual elder abuse is non-consensual sexual contact with an elderly person without the elder's consent. Such contact can involve unwelcome sexual touching, physical sex acts, forcing an older person to view pornography or watch sex acts, and making an elder undress against her will. Financial (Fiduciary) Abuse In these tough economic times, crimes and financial exploitation against vulnerable older adults are among the fastest growing in the country. Many seniors across the U.S. suffer financial abuse at the hands of friends, family members, telemarketers, unscrupulous TV evangelists, people they meet on the Internet, and financial services employees. Financial abuse or exploitation is misappropriation of an elder's property or identity by means of trickery, manipulation, or exploitation. This includes, but is not limited to: making unauthorized withdrawals from an elderly person's account, cashing an elderly person's Social Security check and keeping part or all of it, forcing an elderly person to suddenly change her will, falsifying claims, or diverting funds and assets. Financial exploitation by a family member is reported annually by 5 to 6 percent of older people. Healthcare Abuse This is harsh treatment of elderly patients by healthcare personnel. Most of the time, this type abuse is not intentional, but results from frustration and lack of self-control on behalf of harried healthcare workers. Caring for the needs of frail dependent older adults can be unrelentingly stressful. When staffing is inadequate, the frustration can grow to a boiling point, manifesting in many harmful ways. This includes, but is not limited to: excessive force in treatment, intimidation by yelling or humiliation, ignoring a patient's needs, rushing a patient through a meal, inappropriate use of medications, restraints, or confinement, and depriving an elderly patient of food, water, and medications. Part 2 of this two-part series will discuss ways to identify elder abuse, common presentations, and mandatory reporting requirements. Please stay tuned. References Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America What Is Elder Abuse?
  6. allnurses

    Addressing Bullying in the ED

    allnurses.com staff recently had the opportunity to interview Lisa Wolf, PhD, RN, CEN, FAEN, Director of ENA's Institute for Emergency Nursing Research. She has published research about bullying and how it affects nurses patient care. How does bullying in the ED manifest itself? Bullying can manifest as the dynamics of aggression, which includes overt hostility, denigrating comments, giving inappropriate assignments for the nurses' experience and expertise, and selective reporting. More difficult to identify and call out, however, are the dynamics of exclusion, which is marked by a withdrawal of help, support, and information. These types of behaviors often result in a nurse being "set up to fail", which has consequences for patient care. How does this differ from bullying in other departments? I don't know that it is very different in other departments, but the constant flow of patients, the short turnaround times, and the initial lack of knowledge about patient conditions make the emergency department a particularly high-risk area for this dynamic to manifest. What kind of collateral damage results from bullying in the ED? Workplace bullying is a significant factor in the dynamics of patient care, nursing work culture, and nursing retention. The impact on patient care cannot be overestimated, both in terms of errors, substandard care, and the negative effects of high turnover of experienced RNs who leave, compounded by the inexperience of newly hired RNs What methods did you find to be the most effective in addressing/decreasing bullying? Our respondents report that a "calling it out" strategy by both staff and management is the most effective way to reduce bullying and its consequences. An assessment of hospital work environments should include nurse perceptions of workplace bullying, and interventions should focus on effective managerial processes for handling workplace bullying As a result of your research, what type of training do you recommend? Given that management is the key role in mitigating bullying behaviors, education in the identification of bullying behaviors (especially those marked by the dynamic of exclusion) and in addressing them with staff is probably the most effective way to reduce workplace bullying. Bullying is becoming more pervasive in our culture as a whole. However, as nurses on the forefront of life and death decisions, it is imperative that nurses have a toolkit to deal with bullying at work. The American Nurses Association published a position paper on this in 2015 with a goal; "to create and sustain a culture of respect, free of incivility, bullying and workplace violence." ENA has also published guidelines to deal with and curb lateral violence which is defined as; "violence, or bullying, between colleagues (e.g. nurse/nurse, doctor/nurse, etc.)." "According to a 2011 study by the Emergency Nurses Association (ENA), 54.5 percent out of 6,504 emergency nurses experienced physical violence and/or verbal abuse from a patient and/or visitor during the past week. The actual rate of incidences of violence is much higher as many incidents go unreported, due in part to the perception that assaults are "part of the job"." ENA offers a toolkit with six distinct steps to address workplace violence. The first step is acknowledging that it exists and that nurses have the capability to decrease the incidence. There are many shareholders in this initiative including the front line staff but managers and administrators also have a key role in this. JCAHO, OSHA and other governmental agencies require documentation of a safe workplace and offer recommendations as well. Violence should never be tolerated. Do you feel safe from lateral violence in your emergency department? What has your ED done to combat lateral violence?
  7. I have been a nurse for 8 years now and had worked in a nursing home. I recently decided to transition to a hospital as everything in my life is undergoing change. I do believe in God and with every decision that i make, I always ask his guidance. Thus, when i uploaded my resume, this hospital called me with a job interview for Med-Surg. During the interview, the hospital recruiter asks me if I would be open to be interviewed for telemetry, rehab and ER. I said yes and fortunately, 2 offers came my way. Tele and ER. Of course, I chose ER just because I can see myself working in that kind of setting. I am currently 3 months in the ER and I can say that I am learning a lot. For a long time nurse like me who is new to the ER setting, I am obviously struggling. A colleague of mine told me that it would take me a year to get at least a bit comfortable with the transition. It is a fact that nursing home nurses are being looked down upon by hospital ones. But i don't let that get to me. I am lucky to have a "good bedside skills" preceptor but she has a tendency to become a sucker for her colleagues. Sucker in a sense when her colleagues has 4 patients, she has 8. The charge knows she will not complain to him/her. Nonetheless, I am not expecting anybody to hold my hand. I am currently reading/reinforcing further on things that I've learned for the day. Now my question is, how do I become a better ER Nurse? What are the things I should read/take/undergo? Certifications? (I did not acquire my BSN Degree nor my schooling in this country and I am originally not from here) I am also looking to get a masters degree.. What career path do you think I should take? is it better to get it online or in a classroom? How does one get a higher pay grade? Also, have you ever experienced workplace politics? The reason why I asked is because i realized, the hospital is no different. I hate racism and although I shrug it off, i can't help but feel it. The hospital is trying to promote cultural diversity but apparently majority of the nurses there are not open to this idea. They can be very ****** and gang up on you as what happened to the other orientee in our batch. As a nurse, do I have to be a member of certain organizations? If yes, which one? ANA? What else? Anyways, thank you Nurse Beth. I'm Looking forward to reading your advice for me. Dear New to the ED, Good for you for in having the courage to make such a huge change! Time and experience will make you a better ED nurse like your colleague said. Give yourself time. Emergency (ED) nurses typically are required to have Pediatric Advanced Life Support (PALS) and Advanced Cardiac Life Support (ACLS). I would start with those and then later ask your manager or colleagues if they recommend Trauma Nurse Core Course (TNCC) for your particular ED. Becoming board certified (CEN) requires two years of ED experience. Put off your MSN decision until you are more comfortable in your new job. Before embarking on your MSN, spend time considering what role you ultimately want in what setting. MSN programs offer educational tracks, administrative tracks and more. You may even decide that you want your FNP. Check with your manager and/or HR for information on pay grades, as they vary from facility to facility. Some hospitals reward advanced degrees, some do not. Start working on your Clinical Ladder advancement if your facility offers one. Workplace politics exist everywhere, and ED settings are no exception by any means. In some specialized ED circles, you have to "earn your stripes", which is often a function of time and learning how to fit in. Racism in the workplace should never be tolerated but unfortunately, stereotyping and hostility do exist. Blatant discrimination may not be apparent, but subtle social messaging is. The challenge is knowing when behaviors cross the line and become reportable - which isn't really what you asked but bears mentioning whenever this topic is brought up. We still have a long way to go, and nurses all need to be part of the solution, not the problem. Consider joining the Emergency Nurses Association (ENA) and getting involved in your local chapter as well as joining the American Nurses Association (ANA). Nurses can only bring about change when we work together and the benefits of professional membership are enormous. Best wishes, Nurse Beth
  8. OIFSapper

    ED Shocker

    So I am an ED RN at a large hospital in St Louis,MO. I started my career later in life in my early 30s. I am a 15 year Disabled Army Veteran with 2 tours in Iraq. I am currently 37 years old. I am a loving husband and have two beautiful daughters that I love dearly. I have great faith in God and try my best to impact the lives of those around me. I was part of a Unit that did Roadside Bomb removal and due to a shortage of medics were cross trained to be a combat life saver placing IV lines, needle-chest decompression, tourniquet and dealing with amputations and sacking chest wounds. I ended up being fairly good at all of those and it inspired me after a long road of recovery to use my GI bill and go to school to become a RN. I faced a lot of adversity dealing with residuals of traumatic brain injury and a processing delay and through a lot of therapy and treatment passed an accelerated program with a respectable GPA. I started my career in a Trauma/Neuro ICU fellowship and had to step back after a while as it was a little too close to home with my combat experience and also having some cognitive delay from a TBI I felt concerned that in 12 hours of non-stop chaos I couldn't keep up mentally and didn't want to hurt anyone. After a long search through multiple different areas in nursing I have found my love. The emergency department at night has just enough chaos to feed the adrenaline junkie in me but has such a variety that it isn't just 12 hours of titration to keep people from death. To be honest in all my time in the unit I never had my own patient crash and only assisted with codes of others. Two weeks ago in the ED I had my first code since the military and it was a patient I never expected to go that route. I'll spare the details to keep privacy but long story short after reviving and getting up to the ICU they coded again and ultimately died. Once I got back downstairs I took a moment and went outside of the ambulance Bay in the wee hours of the morning to take 5 and decompress. I felt weird. I was uncomfortable in that post CPR moment. I remember the absolute shock of the patients wife's blank expression as she just didn't even process that I was breaking ribs and crushing her frail husbands chest trying to save him as the DR tried to intubate. After I wanted to go give her a hug and console her as she was waiting in The ICU waiting room for an update but I just couldn't do it. I had to go back downstairs and try to process what had just happened. I wouldn't know what you say anyway. I have never had an adrenaline dump like that and soon found myself puking in the bushes and choking back tears. I was shocked! This isn't like me. Is it always like this? I felt like it was hard to let go of it. I am OK now but the impact was much more than I expected. Any tips to help process these moments? I have always counted myself good in chaos and am seldom at a loss for words. I would be encouraged to hear your stories and suggestions so I can grow and learn to deal better in these situations. Much love ... Matt, RN
  9. I really had no idea what to expect from working in an Army ER, but I suspected it wouldn't be much different than any other ER. I knew just from my experience with various ERs in the northern and northwestern Virginia area that most ERs had similar patient demographics and similar ... patient "challenges," shall we say? One thing that is markedly different from my old ER: the average age of my patients in the Army ER has dropped dramatically. One would also assume that because of the younger age range, these are healthy people, but that is not always the case. I have stopped in the middle of several shifts and thought to myself, "Wow, we see some really sick people here!" Though I am thankful for the younger demographic, because I can recall shifts during which the average age of my patients was about 95, and they were all very sick or trying to climb out of bed. We also see some extraordinary numbers in our small Army ER. When I was first in contact with the head nurse and started asking typical questions about the ER (number of beds, nurse to patient ratio, number of daily visits, etc.), I thought her answer for the number of patients seen daily was a typographical error. We average more than 100 visits daily in our few beds -- we have 11 beds in the main ER, then 4 beds/rooms in our urgent care/fast track area that are only open for about 12 hours a day, so for the most part, we're pushing big numbers through the main 11 beds. I am still scratching my head over this, after coming from an ER of 15 beds where seeing 75 patients in a day felt like the seventh level of hell. The only thing I can figure is that maybe it's because we don't really slow down at night, and we are usually running the entire shift. But I adore my night shift people! My RN coworkers and medics rock, and I am grateful to work with such a team. When I left my ER in Virginia, my biggest regret was leaving my fabulous team -- these were the people that raised me as a nurse over the years, as it were; they even gave me an beer stein as a farewell gift that has "Raised By [Facility Name]" engraved in the glass. I thought I'd never find such a great group of coworkers again, and I'm happy to say that I was wrong. Not to say I don't miss my Virginia peeps, but the sadness is lessened by the awesomeness of my new peeps. And Army healthcare in the ER ... well, it's free. Really. No money exchanges hands anywhere in our ER, no copay, nada. People who are eligible for care (active duty and their family members, eligible retirees and family members, reservists or national guard on orders, etc.) don't pay a dime to come to the ER. It's like a frequent flyer's dream! It also leads to abuse of the ER, for sure, but often these patients aren't able to get in to see their primary care managers (PCMs), or it's the middle of the night and they're having acute symptoms. I get it. And you know what? I'm fine with it. I joined the Army Nurse Corps to care for soldiers and their family members, and I am getting what I asked for, and then some! We see a lot of pediatric patients, and with the post-deployment baby boom, a ton of OB patients as well. Greater than 20 weeks and they go right upstairs to L&D if they have a pregnancy-related complaint, but we keep the less than 20-weekers, and there are a lot of them. Military people seem to like making large families! And this is interesting -- we can turn away civilian patients who are not eligible for care, as long as they aren't presenting with a life threat. That was weird for me one night in triage to tell a patient that we weren't going to see him for his minor complaint. He was on post with a group of contractors for some kind of conference, and his coworkers told him he needed to go to the ER for this minor issue. He was prior service, but was not eligible for care in a military treatment facility. I learned that even though he has insurance, he would still get an enormous bill that his insurance would not likely cover. Once he heard that, he thanked me for my time and beat feet out the door. Granted, if that same guy showed up with chest pain, we wouldn't even have had the conversation; we'd see him, no question. The military system has its flaws, but overall I have to say my experience as both a nurse and a patient has been good. No, I have not been a patient in my own ER, but I was able to get in to see my PCM for my periodic health assessment in a timely manner. Also, the pharmacy is great -- a patient can pick up prescriptions almost as soon as the doctor enters the order in the computer, and guess how much prescriptions cost? That's right -- nothing! Medications are free. The first time my husband and I went to pick up a 90-day supply of one of his regular medications, I kept waiting for someone to ask us for money. Pretty strange! Am I still glad I joined the Army Nurse Corps? Absolutely. I am loving it! At the tail end of a shift spent in the "penalty box," AKA triage, I am not quite as cheerful, but no regrets ... proud to wear the uniform! I just kinda wish I could wear scrubs in the ER, though.
  10. spotangel

    Mary's Gift

    It was Christmas Eve and I was in the ER working a 11am-11.30pm shift. I eyeballed her across the ER. She walked in with her son, an old frail lady. I looked at her pallor and shaky steps and knew in my gut that she was deathly ill. "She's not going to make it out of here alive," an unbidden thought sprang to my mind as I walked towards her. Cindy was the charge nurse and as she looked to see who was on next to take a patient, I reached her. "I'll take her Cindy," I said smiling easily at mother and son and taking the paper chart from Cindy. "Hi, I'm Annie. I will be your nurse today," I said as I deftly got her on a stretcher and closed the curtains of cubicle #4. I helped her change into a hospital gown, hooked up to the cardiac monitor and got my first set of vitals. Her name was Mary. She had been feeling more tired, fatigued and had lost her appetite for over a week. She was a little short of breath. Her vitals were normal. Her BP was border-line. I listened to her lungs and abdomen while my mind raced. I suspected that she was septic and so drew 2 sets of blood culture along with other labs and got a urine sample that was a tad cloudy. Probably a UTI that turned into sepsis, I thought. By the time the doctor came in to see her 15 minutes later, and EKG and CXR was done and I had normal saline running. The doctor agreed that she could be septic and I monitored her vitals carefully. The lab called back half an hour later with her blood count. Her WBC was 37. Bingo! I thought. Right on the money! I had antibiotics running and we kept pushing fluids. Her pressure began to drop and she started becoming tachycardic. I knew that she would crash pretty soon and wanted to make sure I was prepared. So I gently broached the subject with her son James who had no clue how sick his mother was or what her wishes were in case of an emergency. I talked to Mary in her son's presence and asked her. She looked at me, with wise knowing eyes and told me, "If you can save me, go ahead and do what you need to do, but at any point if you see it not going to help me, then let me go. I do not want to be hooked up to machine and it is futile." I told her, we would follow her wishes. I took James aside and talked to him. I asked him if he had any other family. He said he was the sole caretaker of this 87-year-old mother. His dad had died many years ago. He had a sister, who he had not talked to or seen for 20 years. She lived in the same city but they had a fight and stopped talking. I told him gently that it would be a good idea to call her as his mom was very sick. It would only be a matter of time before her systems collapsed due to the overwhelming infection in her blood. He was bewildered and said, "But she walked in! She can't be that sick". I told him that UTI and sepsis signs in the elderly were very subtle and that she might take a rapid turn for the worse very suddenly. I encouraged him to call his sister Ella. "After all, wouldn't you want to know if your mom was very sick and you were not with her?" I asked. He readily agreed to that and dialed her number (I got it from the patient) as I held my breath. They talked and Ella asked to speak to me. She told me that she was an RN and so I was able to give her an update on her mom's clinical status. She had just picked up her husband from another hospital after discharge and promised to be there in half an hour. "Try and keep her alive for me, Annie" she begged. I stayed by Mary's bedside but she was rapidly going downhill. I looked at her and marveled at how her dying was bringing her two children together one last time. I now had her on multi drips. She crashed. We intubated her. Five minutes later her daughter rushed through the ED doors. I took her and her brother to our tiny family room where they talked for the first time in 20 years and hugged each other. Tears and laughter rang as they reconnected. Later Ella came to me and told me that her sick husband was sitting in the car and she had to take him home. She gave me her number and left. James came to me and told me that he could not watch his mother die. By now she was made a DNR after they talked to the doctor. He gave me his number and left. Another nurse relieved me for break but I stayed at the nurse's station drinking my coffee and writing my notes playing catch up. A few minutes later I heard a voice in my ear, "It is time". Probably my guardian angel Providence, I thought to myself. I quietly got up and went to her cubicle. I sat down near her and held her hand. I spoke to her softly, "Mary, you did it. You got them back together one last time. Now it is up to them. Go in peace." As I recited the Lord's Prayer, she flat lined and was gone peacefully. I sat at the nurse's station and made the calls to her children. Mary had gone leaving her final gift behind; the gift of peace to her two children. I walked out of the ER at 12 midnight on Christmas day marveling at a mother's final act of love where she used her dying to bring her children together. Merry Christmas and God bless us all!
  11. EMSnut45

    Little Anna - Child Abuse

    We had just backed into the station and set the airbrake after running our fourth "sick person" to the hospital since our shift started five hours ago. The pager went off again. My partner, Kevin, and I looked at each other, rolled our eyes, and said, "here we go again!" The dispatcher came over the radio-"Medic 2 respond for the four year old burn patient at 3626 Peachtree Avenue." My heart sank as Kevin threw the ambulance into drive. We looked at each other again, only this time we weren't joking. We knew what we were in for. The fire engine had arrived first. Kevin and I grabbed our bags and head inside. Upstairs in a dimly lit bedroom was Anna lying on the bed on her stomach-no clothes on, and a room full of strangers-the firefighters from the engine. I looked down. Huge blisters. The skin on her buttocks and feet peeling off in sheets. Purple welts across her back, and bruises of every color in the rainbow. I bent down to Anna's face, stroked her hair, and told her "My name is Mandy. I'm here to take care of you." Her big, distant brown eyes stared up at me. Not a tear had been shed from them. The lady in the corner stepped forward. She introduced herself as the child's foster mother. She calmly ran through the events stating that she had been running the water in the tub so that Anna could take a bath. She had stepped out of the bathroom, and Anna climbed in. When she reentered the bathroom, Anna was sitting in the bathtub and said she had a "boo-boo." The boo-boos were the burns. We wrapped Anna up in our burn sheets, and carried her out to the ambulance. She laid on the stretcher on her stomach and facing the cabinets. I asked her what happened today, not sure I could stomach her answer. A little voice-almost a whisper, said, "Mommy beat me. Then she put me in the bathtub." I said the only thing that came to my mind-"I will keep you safe until we get to the hospital, and then all the doctors and nurses will keep you safe there." Anna stared at the cabinets, and shook her little head "no" when I asked her if she had any pain. Kevin and I estimated 12-15% total body surface area of second and third degree burns. Anna's foster mother got into the back of the ambulance, and we began our trek across the city to the regional pediatric burn center. Neither one made eye contact or even acknowledged each other's presence. When we arrived at the hospital, Anna's foster mother was escorted to another room while Anna "was settled in." Anna was met by doctors and nurses who specialize in burns as well as the city's child abuse team. The police were already en route to the scene to take custody of Anna's brother and sister who were also in foster care with her. Kevin and I watched as Anna was sedated and debrieded. We watched in horror as more and more of her beautiful skin was sloughed off, and burnt tissue exposed. The extreme sadness that I felt for Anna was quickly getting overrun by anger towards her foster mother. It was time to leave. I had fulfilled my responsibilities to Anna. She was safe now. My hope is that one day little Anna's big brown eyes will be full of life, and not hollow like they were when I met her. Let her feel peace knowing that many people shared in her pain that day. She probably won't remember me, but I will never forget her. **All identifying information (names, medic number, address, etc.) have been changed to protect privacy.
  12. Irish339

    The Weeping Turkey Diaries

    As dinner time grew close, the family members of several of the staff brought in wrapped plates from the family dinner table. My family would have never heard of doing such a thing. According to my mother, my current holiday lot was my own doing. "You're the one that wanted to be a nurse". Several codes and a food bolus dislodgement later left me wondering if I did, in fact, want to be a nurse. As often would happen in this facility, someone ate my lunch. I moped and sulked through the first 4 hours of my shift. Admissions were winning 3 to 1 over discharges. It was truly getting hectic, and my mood was deteriorating beyond morose. I was wrapping a relatively large hand wound, and giving instructions to a fine gentleman who just happened to have been minding his own business and was attacked viciously just a few blocks from the hospital. As most of you know who have worked ER, minding your own business can tragically result in anything from gunshot wounds to beatings with a baseball bat. "I'll bet you've had your Thanksgiving dinner," I said...with just a touch of bitterness in my voice. "Well yup," my quiet little patient replied, "I did." "Really?" I said. "And what did you have exactly?" I wasn't wallowing in enough self-pity already. I needed to know. "Oh, well, I had a great turkey sandwich at the shelter." Oh, cripes I thought. A great turkey sandwich at the shelter. No cranberries. No mashed potatoes. No Norman Rockwell scene with happy, clean people chatting around the dinner table. Not even close to anything I was missing in my tiny cube of a brain. All the things I hadn't noticed. He was wearing 3 layers of clothes. Layer number one was a newspaper. He had duct tape holding his shoes together. There likely may have been small things living under his hat. And he was happy. He had a sandwich at the shelter. I wanted to crawl under a rock. I was so wrapped up in my own misery that I failed to see another's misfortune. And I was the one being ungrateful. Being ungrateful for a job, my health, and family...even though they hadn't come through with the stuffing and mashed potatoes that others had received. I felt humiliated and ashamed. What kind of a selfish, spoiled human being was I? I still remember this patient, 22 years later. Every time I do, I am astounded at my total lack of ability to step outside myself. I have such gratitude for this simple man that opened my eyes to my own self-absorption. Never again will I take for granted anything in my life. I silently thank him for the gift of appreciation for even the tiniest and most basic things we are given every day. In such a dirty place, with such horrible weather just outside the door, my eyes were truly opened to the beauty around me.
  13. nurse2033

    The Schemas of Emergency Nursing

    As an ED Educator I am frequently tasked with training nurses who are new to the Emergency Room. It is true that every nursing unit has their own culture, practices, and sometimes jargon. But, it seems that the ER is just special in how we approach patient care (I'm admittedly biased). But a concept called "schemas" is one way to approach the sometimes demanding and rapid-fire workflow. Conditions in the ER can change minute by minute so nurses (and techs and providers) must be flexible in their thinking. They must also be quick to change direction when needed. This is where schemas come into play. I first utilized schemas as a paramedic early in my career, but didn't realize what they were until I learned the concept later in educational theory. So what is a schema? Schemas have many definitions but a good one is, "A schema is a cognitive framework or concept that helps organize and interpret information" (Cherry, 2015). Piaget, a well-known psychologist, coined the term and popularized the concept (Cherry, 2015). Piaget recognized that we group information into mental packages, which are schemas. We all do this without thinking all the time. By describing schemas in this way, we can make it easier to develop them. A nursing example of a schema would be starting an IV. This is one of the most common procedures in the ED. An experienced nurse will instantly be able to visualize all the steps and equipment needed. This is the schema. This includes (but not limited to): The indications Informing the patient Gathering the supplies Performing the procedure Adapting to irregularities Assessment/ reassessment Documentation Removal A new nurse will have to think about each step (in a process is called conscious competence). Over time and repetition, this schema will be strengthened and become unconscious. The key is to develop these schemas in a way that makes sense to you. You would start to build this schema by observing the procedure, studying the policy, and practicing. There are obviously many, many, schemas in play in the course of a routine shift. The challenge for the new ED nurse, is to start to organize what you are learning as you gain experience. Since the schema is about organizing information, you clearly must have the information to start with. I recommend an excellent text, Sheehy's Manual of Emergency Care published by the Emergency Nurses Association (I am a member of ENA but have no other ties to the organization). The information is organized by problems and gives step-by-step advice on what you need to know for the pathologies you will see in the ER. You also have many resources at your disposal such as policies and procedures published by your organization. You can study TNCC or other sources. What do you see your coworkers do? But ultimately you should be prepared to answer the question in your mind, "what do I do if my patient has X"? This will prepare you for when you have to do it. Think of the schema as a package you will open that contains everything you need to know. All nurses know how the body works, and what wellness is. But the approach of the ED nurse is to drill down into what can go wrong. Injury and illness produce somewhat predicable patterns within the body. So based on a complaint, an experienced nurse will start their assessment and test, reject, and eventually arrive at the correct interventions using their schemas. This includes ruling out injury or illness based on the situation. So as an example, a patient is coming in via EMS with a leg fracture. Just based on that information, the nurse can probably predict what assessment and interventions will be needed. The schema on fractures would include: mechanism of injury, physical assessment, x-ray, pain control, infection control, splinting, and education (among others). Obviously the nurse must be flexible because the information could be incorrect to start with. If the patient takes a blood thinner, for example, that would add another schema for that issue. Or if the injury was the result of domestic violence, that would add yet another schema. Schemas can be described as a tool kit. Visualize a huge backpack with all your ER nursing knowledge. For each patient, you will take out smaller packages that contain each schema, customized for what they need. I made reference earlier to testing and rejecting schemas (you might call this ruling-out). If a patient is short of breath for example, you should "test" each schema within that problem. If during your assessment you find their lungs are clear, you could put your asthma schema back in your tool kit, but you would continue to test other schemas. Cherry (2015) writes that there can be problems with schemas. You must be flexible and be able to incorporate new information into your schemas. You can't accept the schema as an "end product" that is perfect and needs no revision. If you do, you will have trouble in adapting to changes that will inevitably occur. Hopefully, you recognize the schemas that you know and use. By understanding how they work, they can be used to help you develop and improve your practice. Take a problem, investigate all the possible actions and solutions, and this is your schema. For the new nurse, develop your schemas as you gain experience. For each patient problem, think about the care that was given and the outcomes. As I wrote earlier, use the reference materials at your disposal to war-game all the possibilities. References: Cherry, K (2015). What is a Schema? Retrieved from What Is a Schema in Psychology?
  14. spotangel

    HELP ELLA! THEN ME!

    She sat quietly as I drew her bloods after inserting a heplock. The ED was packed and as evening Manager, I had noticed that two of my nurses were struggling to play catch up with the volume of patients needing lab and line. So I had pulled a few in to get them started and decongest the backlog. "Ms. Williams, I have noticed that you have come 11 times in the last 3 months for the same complaint. Can you tell me what is going on?" She looked around fearfully and started taking about her GI and Gyn symptoms. As she talked, I sensed there was another story under that layer that she was not telling. I casually started asking her about her family and support systems. Her eyes lighted up when she talked about her 4 year old Ella and a stoic expression came over her when she talked about her boyfriend Brent. "Ms. Williams many times when we have GI symptoms, it is a response to stress in our lives. Is anything happening that is causing stress to you and Ella?" The tears started falling hard and her shoulders shook although her head nodded no. I pulled her into a room that had just been vacated and had her sit on a chair as I quickly prepped the stretcher. Once she sat on the stretcher, I closed the door, pulled up the chair next to her and held her hand. "Ms. Williams, please tell me what is going on so that I can help you." Her eyes red and puffy she started talking slowly first, then in a torrent. I learned that she was being physically, emotionally and sexually abused by her boyfriend Brent. Ella was not his child and recently he had begun to sexually abuse her as well. He beat her up severely when she tried to protect her child. The only time he allowed her outside the house by herself was when she had a Gyn problem and had to be seen in an ED. She had no primary care doctor and no insurance. He threatened to kill Ella "Piece by piece" if she reported him. "Ms. Williams please allow me to help you. Where is Ella now?" "She is with him in the house." "I am going to get the social worker Pamela come in to help you. Thank you for telling me. Is this really why you came to the ED?" "Yes. I was hoping someone would ask. Help Ella, then me!" I stood up, gave her a hug and turned to go. "Nurse Annie, take this with you. I don't need this anymore." "What is that?" I eyed the package. "It's two bottles of pills. I was going to kill Ella and myself tonight." I took the packet from her shaken. "Have you tried before?" "No." "I am glad you are not going to anymore. Let me get Pam here for you." I walked out with the packet and found Pam and updated her. Pam helped her. Got the cops, state and child protective service involved. He was arrested without incident. Ella was transported to the hospital for an initial examination. Since we had an advocacy center for pediatric sexual abuse, the detailed exam along with the psychosocial interview of child and mother were done there. It's a one stop shop. The survivor(s)/families have a team that conducts medical evaluation, forensic interviews, behavioral health and treatment services in a safe environment. The child's forensic interview is conducted by a specially trained interviewer who asks open ended questions to the child while the rest of the team observes behind a one way mirror. The family is gets connected to help they need. The last I heard they were doing good and Brent was in jail. I eyed the bottles on my desk. There were enough pills to kill an elephant. She had been gathering them and hiding them over the last year as she planned the murder /suicide. I marveled at how God used me to save her. This was payback for a time when I was 18 and sat at a table with 50 pills in front of me and 2 glasses of water getting ready to kill myself. I thanked him for sending a friend into the place I was and stop me from committing suicide. As I went to the bathroom and flushed Ms. Williams's pills down the toilet, I remember how my friend talked me out of it and how we flushed the pills down the toilet so many years ago. The good lord saved my life by sending my friend to help me. I remember asking her how she knew I was in danger and where to find me. She insisted that there was a persistent voice in her head that kept telling her to find me and would not stop till she found and helped me. I in turn, have had countless opportunities to make a difference in other lives and save many as a nurse. I feel that beyond the stresses of working as a nurse, we have a calling to be of help. Sometimes all you need is to help a coworker who is drowning in work to save a life!
  15. First, your ER should have a standardized length of orientation and it should definitely be more for the new grad RN. An orientation of 6-16 weeks is the norm, depending on your particular ER, number of visits and trauma level. Some things you want to accomplish while on orientation: 1. Notice the climate of the ER? Is this a fast-paced, 75,000 visits/year level one trauma center with 30 nurses on duty at all times or is it a community based ER with 23,000 visits/year and all traumas, AMIs, sick kids are turfed out or is it a rural Critical Access Hospital where there is just one RN on duty in the ER and your help comes in the form of the nursing supervisor? 2. Learn the basics first, then proceed to the more complex tasks. Basic tasks include learning how to operate the computer or learning the charting system, where are supplies kept, do you have the passwords needed to access supplies and meds if an automated system is used. Familiarize yourself with the lay of the land: where is the charge nurse, do you reach her by cell phone, pager or yelling across the room? What type of system is used for room assignments? Team or individual approach? 3. Next, every ER has protocols on which to base your care. These are pre-approved treatment modalities for different symptoms. For instance, you have a middle-aged male who presents with CP, you would automatically place the pt on a monitor, provide oxygen at 2L/NC, give ASA 324mg and of course obtain an EKG. There is often a time limit for these interventions. You won't need to memorize these protocols but as you go thru your orientation, you will start to learn them and they will become second nature. 4. As you get further into your orientation, start to scope out your fellow nurses: who do you admire, get along with exceptionally well or want to emulate? Approach them to help with mentoring. Your orientation will zoom by and soon you will be on your own and it is imporant to always have someone in your corner. 5. And...finally, relax and enjoy the ride!
  16. Ugh...could your night get any worse? Here are some tips for dealing with the patients who are demented: 1. Enlist family support if at all possible. Make sure the nursing home or facility has sent a current next of kin notification and try to get the NH to call the family as they already have a working relationship with them. 2. Provide the patient with their hearing aid and/or glasses or dentures. It is difficult enough to deal with someone who is confused and even more so to try and understand them when they can't hear or see you or answer back because they don't have their dentures in place. 3. Try to keep the interruptions and interactions to as few people as possible. Ensure consistency of caregivers in the ER if at all possible. 4. The ER is a loud and bright place. When you are done with your assessment, try turning off the overhead lights but ensure that a directional light remains on just not directed at the pts face. 5. Confused people have pain. Treat their pain and yes, with narcotics. 6. Keep them close to the nurses station if possible to ensure adequate eyes on them. Some pts will not be aware that they are seriously ill or injured and might try to climb over the bedrails. Keep them in sight. Reference: Cohen-Mansfield, 2000
  17. traumaRUs

    How to Be Organized during Chaos

    You work in the level one ED in a big city - its a fairly normal evening, the usual variety of patients, some that are truly emergency, others not so much and the majority somewhere in the middle. Suddenly the EMS radio starts blaring with the news that there has been a mass shooting incident at a population dense venue. The voice on the radio rings with excited distress and you can hear background noises of screams. The paramedic tells you that many people have been shot and its still happening - they can't tell you how many patients to expect but you can expect a lot. What to do? Your mass casualty training kicks in: Notify your supervisor, and initiate the mass casualty plan Incident commander needs to the decided upon Designate all staff as to their roles and responsibilities Have non-clinical staff start calling personnel in from the recall roster Clear out the ED of non-emergent patients, get already admitted patients to the floor Start collecting trauma equipment Assemble beds, cots, monitoring equipment Set up and staff triage area Be ready for the media and set up administrative staff to deal with them Preserve the patients privacy Continue to move patients along a recognized triage protocol We are all aware of the recent Las Vegas tragedy. As of this writing over 60 people are confirmed dead and over 500 required ED care. Could your hospital handle an MCI? Have you trained to be on point if this ever happens? Training and simulations are invaluable. This must be practiced though over and over before it becomes routine. ED personnel are used to controlled chaos - however, no one can prepare for hundreds of patients inundating your ED within minutes - many with penetrating trauma. In Las Vegas because the shooter was using an automatic weapon, the destruction of human tissue was unheard of except in wartime. This resulted in many patients requiring urgent surgical intervention. Triage was of the utmost importance. Those patients who had injuries incompatible with life or unsurvivable injuries were not taken to the OR. Resources had to be used for those patients who had the highest odds of survival. There are many resources to assist in training for an MCI: FEMA offers a comprehensive toolkit. Staff from AN recently attended the Emergency Nurses Conference in St Louis. One of the interesting presentations was from Dan Nadworny, MSN who was the point person for the 2013 Boston Marathon Bombing in the level one ED where many of the victims were taken. We also had an earlier interview with Dan. Also very important is the aftercare of the staff. This can't be stressed enough. To experience an MCI is to go thru a trauma similar to your patients. Some thoughts from the US Department of Health and Human Services comes these suggestions: It may take some time to return to normal operating procedures Supplies will be low or perhaps nonexistent Staff will need to be rotated in and out to allow for rest, eating, hygiene needs Equipment will need to be cleaned Personal belongings of patients will need to be sorted and returned Debriefing of staff will be necessary This video gives a realistic simulation of a mass casualty incident. This scenario involved a tornado. However, the protocols are the same for any mass casualty incident. Your response to a MCI will only be as successful as your MCI training is.... allnurses staff join in our nation mourning this senseless loss of human life. We offer positive thoughts and gentle hugs to our Las Vegas EMS, police, fire and ED personnel.
  18. vadushkas_nurse

    The Case of the Missing Dentures

    I attentively and carefully searched everywhere in his room, through his belongings and of course in the bedding for the missing dentures and couldn't find them anywhere. I assured the patient that his dentures must be back at the nursing home as I couldn't find them anywhere. With noted mild dementia, the patient continued to be preoccupied with his teeth for the next couple of hours. I was at a loss for what to do. I vaguely remember calling his nursing home and with little assistance on their behalf, was still unable to track down the dentures. All night the patient continued to call out about how his dentures were missing and if someone could just look for them. I became more and more frustrated about the so-called missing teeth. I was being pulled in many directions that night and felt terrible that I couldn't settle this man. His preoccupation wouldn't allow him to sleep or for others to have a quiet environment. Out of frustration, I went to check on him again and as I approached his room one more last time a flash of white caught my eye. I took a closer look and sure enough, it was the MISSING dentures... sticking out from between the bed frame and the MATTRESS... like a smile staring at me. I started laughing and couldn't stop... all that time I was convinced there were NO DENTURES and sure enough, they were in front of my eyes!!!! What made me recall this funny moment was a similar episode I had during my most recent shift in the same ER department last week. I had an older lady that was formed for her safety, a case of? delirium vs.? dementia. With my initial introduction and assessment, this lady asked me to find her glasses. Aware that her belongings had been locked up for safe keeping, I asked security to go through her belongings and find the MISSING glasses. Sure enough, there were no glasses to be found and PREOCCUPATION began again. For the first five hours of my shift, the patient would call out for us, knock on the wall to get our attention, and begged everyone to find her glasses. I assured her that security had looked, with no avail. After countless explanations to my patient, I frantically called medical units for a magnifying glass or spare pharmacy Rx glasses so that this lady could have some piece of mind. I received a laugh from all the nursing units I called, thinking it was such an odd request. I sadly went to the patient again after 7 hours in my shift and told her the same thing I had told her numerous times earlier "security looked through your belongings and no glasses were found". With red-rimmed tearful eyes, the patient begged me to look again- as the glasses might be in her sweater or her pants. I couldn't take the distraught that this women was feeling and decided to look for her and myself. I went to security and asked them if I could please look through the patient's belongings. I mentioned this is purely for peace of mind and promised not to bother them again. I slowly went through the pockets of the patients pants, jacket, and shirt.... with no glasses to be found. I then rechecked the purse and SURE ENOUGH, there were HER GLASSES. I excitedly went to my patient and said I have a surprise for you... and showed her the GLASSES... she started crying and kissing my hand, then laughing. It was such a heartwarming and happy moment. I and other staff had quite the chuckle about this experience. These examples remind us that despite impaired cognitive function, we really should try to LISTEN to our patients. They deserve the benefit of the doubt. Moments like these are funny and definitely remind us of the importance to look more carefully and take some patient preoccupations seriously!! It's worth going that little extra.
  19. It is a typical shift in the emergency department (ed). Lydia smith, a 79-year-old woman, has fallen at home, hitting her face on the concrete slab on her front porch. Her medical history includes mild parkinson's disease, congestive heart failure, and osteoarthritis. She arrives via ambulance stretcher, strapped to a spine board, her tiny face dwarfed by the cervical collar and head immobilizer. She presents with an open gash to her right forehead, another laceration between her eyebrows, and a third laceration just over her left eye. She is sobbing softly, with a frightened look in her eyes. Blood is still seeping from the wounds. The nurse notices multiple bruises, in various hues of red, purple and yellow, on her forearms and lower legs bilaterally. When asked if she falls a lot, she weakly mouths the word "yes." she appears emaciated, pale, and frail. Her clothing is threadbare and smells of urine and feces. Upon further questioning, the nurse discovers that the elderly woman lives alone, with no family in the area. Like Lydia, the elderly often present with complex medical and sociological needs and this may pose unique challenges to clinicians in the ed setting. Older adults, those 65 years of age and above, are more likely to suffer from chronic medical issues and impairments in function, be unable to clearly advocate for their needs, take multiple medications with harmful drug interactions, and have inadequate social support systems. The care they need may extend far beyond the ed, requiring careful discharge planning and utilization of community resources. As a result, the elderly patient typically requires extensive coordination of services for diagnosis, acute intervention, emotional and spiritual support, medication reconciliation, education, follow-up, and possible home or nursing facility care. This can be difficult and time-consuming in the rapid-paced, high-volume ed setting. The population of older Americans is exploding, increasing more rapidly than any other age group. Accordingly, ed visits by the elderly have increased more than 34 percent during the last decade. People over 65 account for 40 percent of emergency-medical-service responses and 20 percent of emergency room visits, and that number will only grow with the rapidly aging population. Senior patients are more likely to suffer adverse health outcomes following discharge from the ed. The hospital admission rates for the elderly following a visit to the ed are three times that of the younger population. The elderly are also more likely to have repeat ed visits and to suffer functional decline. Within three months of the ed visit, nearly a third of the seniors have another emergency, are admitted to the hospital, or die. Clearly, there is an urgent need for nurses with expert knowledge and skill in the care of older adults. To provide safe and effective care for older patients, nurses must have keen geriatric assessment skills, be able to differentiate the normal changes of aging from pathology, have a thorough knowledge of symptom management, be able to manage patients with complex care needs, possess effective communication skills, be able to sensitively address psychological and spiritual concerns, be aware of cultural variations, be able to collaborate with other disciplines to resolve problems and potential complications, be familiar with available community resources to support the elderly individual and caregiver, and be able to use evidence-based clinical research in practice to improve geriatric emergency care. In part 2 in this two-part article series, we will discuss the 11 principles of geriatric emergency care to facilitate care of patients such as Lydia. Please stay tuned. References Geriatric emergency units
  20. jadelpn

    EMT and Nursing

    I am both an EMT and a nurse. I like the variety it brings to the table. Many other nurses (both LPN and RN) get involved in both hospital and pre-hospital care for the same types of reasons. I have just completed a course of study that allows me to keep my EMT license. To say that I was a bit shocked is a huge understatement. It was eye opening, and got me thinking. As an LPN, I am "used" to the "little pretend nurse" snarky comments that are often made. In my role on an ambulance, this is not the case. I have not found emt's higher on the food chain to be snarky in "you are but a basic emt". Perhaps it is the closed quarters of an ambulance where everyone has to work together toward the same goal. One would think on a unit, that would be the same type of thing, but I don't often see it. The scopes and responsibilities are totally different, however, each has its place in patient care. I was shocked at the general eye rolling, "oh look, the nurse thinks she knows everything now" attitude present at the presentations. (Uhm, no I don't know everything, however, lets get this show on the road so that we can leave on time, perhaps?!) Then, it was a lively debate on refering to EMT's as "clinicians", "practioners" and "medical practioners". In nursing, this means something entirely different. To EMT's that is how most of the teachers refer to themselves, and encourage EMT's at any level to refer to themselves. Which sets up for some incredibly skewed communication. MD's are "medical direction". It is a strange concept to grasp. Generally, I am treated completely different as a fellow EMT than I am as a nurse. I had a patient who had boggy heels. I attempted to put heel protectors on for transport. Was told that the EMT's "didn't get 'into' this M/S stuff" and they quickly left with the patient. Fast forward to the next day, when I was on ambulance to transport patient to an alternate level of care as an EMT. Heels even more boggy, I say "I need some heel protectors". EMT with me says "nice assessment and nice catch, document it, please". SERIOUSLY. There should be in every level of patient care a general respect for those who do what they do. If we all have the same goal, is it really necessary that egos get in the way? We all seek the level of training that will get us to where we want to be. What we enjoy. Where we can make a difference and get paid to do it. So know that an EMT at any level is being taught that they are practioners. Know that as nurses, that sometimes can come off as someone being something they are not. It is a word association thing, not an ego thing (or it could be, the jury is out for me). Know that as an nurse, we are taught entirely differently and are seeking to assess on the long term. EMT's assess on the short term. Nurses want to go home with everyone still alive who should be. EMT's want someone alive when they hit the ER door. What seems "basic" to a nurse, is not something that could be even in the realm of thought for an EMT. And they are taught that they are to report to MD's, or NP's and not "the nurse". EMT is not a nursing function. What seemed to be a common thread is that we all have patient populations that we don't necessarily enjoy. That we all have a part of us that asks "why is this patient here" or "why are we transporting this patient". It doesn't have to be all kumbya moments, however, general respect of differences can only benefit the patient.
  21. traumaRUs

    ENA Mass Casualty Incident

    AN staffers TNButterfly and TraumaRUS are at ENA 2017 in St Louis. The opening address was enthusiastic and got the crowd dancing in the aisles. Then, Dan Nadworny presented a mass casualty incident that has real world repercussions. MCIs come in many shapes and sizes from hurricanes, to tornadoes to fires in multi-dwelling structures. We must always be at the ready to handle MCIs and training in real time is invaluable. Dan Nadworny was the point person for the 2013 Boston Bombing. Stay tuned for more coverage of ENA 2017. AN is at ENA 22017 in St. Louis
  22. I got the call on the EMS radio around 5 am. This is the usual time we get calls from EMS responding to nursing homes- The nurses are rounding on their patients to give am meds, and they find their residents dead or in distress. An 87 yo female, febrile, and in severe respiratory distress coming in. Pt is a DNR, but family is very involved, is aware, and will meet them in the ER. I'm alerted that family is in the waiting room before the patient even gets there. I go out and introduce myself, tell them I will be her nurse, and that I will bring them back as soon as I get her settled in the room. EMS arrives, and carefully transfers their frail burden onto one of my stretchers. You can see the relief on their faces, that they got her here and are able to hand her off before she dies on their watch. I'm now the proud owner of one very ill person. Temp 102+, Respiratory rate 14 and irregular. HR 50's, sat 84% on NRB, I don't need my Littmann to hear the rhonchi- Other hx is advanced dementia, DM, CHF. Has been in the nursing home for about 6 months- her husband had taken care of her at home as long as he could, but it finally got too much for him to manage, as he was also dealing with his own health problems at the age of 92. I got her settled, and the Doc comes in- I give him the pertinent info- Not a whole lot we can do at this point other than make her comfortable and treat the infection. Chances are poor that she will make it, and we both know it. Doc moves on to deal with people he can help, leaving me in control of this mess. I bring her visitors in, including her only daughter in her 60's, and several close friends of the family. I get them settled in and TRY explain to them what is going on. They don't get how bad off she is- I try to explain it to them in soft terms- They share with me who she is- a wife, a mother, a friend.I learn her husband is frail and elderly. I strongly suggest that if he is able, that he come. The daughter tells me she is going to leave to go get Dad. I explain that mom could go at any moment, each gasp she takes could be her last. I don't want them to have to deal with the idea that she died without ANY of her family around. But I REALLY wanted her husband there. The daughter calls her husband, who is dispatched to go get him dressed and here. In this age of technology, we can keep up with a lot of things. I'm updated that son in law is at dad's house, he's getting him dressed, getting him loaded in the car with the wheelchair. I'm watching my patient brady down, 50's, 40's 30's....The monitor is alarming, and my pt.'s daughter sees it. Husband lands in the parking lot, and the son in law is getting him loaded in his wheelchair. Then she died, no resps, asystole on the monitor. The daughter asks me- "Is she gone?" "Not yet" I told her her- I gave her some silly answer- the monitor isn't picking up anything because she is so sick. I mute the alarms, turning the monitor away so she can't see the flat line.. I send 2 of my male coworkers to go out and GRAB the husband, RUN him in. He arrives, looking a bit baffled at the whirlwind of men running out to snatch him out of his van and deliver him to trauma room 3. I kneel down and introduce myself. I told him. "I'm sorry, but your girl is dying." He looks at me without comprehension. I took his hand, and joined it with his dead wife's. I told him "Your wife is dying right now- tell her you are here, tell her you love her- these are the last things you will be able to tell her....Tell her it's OK to go-" He grasped her hand and brought it to his temple. "I love you baby....it's OK to go, I'm here." I waited a minute and placed my stethoscope to her chest, made a big deal pronouncing her time of death as just then. I lied- she died without her husband.... but that is something they will never know, but I will live with forever. I know I helped the living, but damn, holding this stuff inside hurts. I tried to explain it to my husband when I got home. He didn't get it. This is something I carry inside. I know my fellow nurses will understand. Thanks for letting me vent and get this out.
  23. "Please, help my son! He is dying!" - a middle aged man screamed as he entered the emergency room. I looked up and saw one little boy age of nine in his arm with so much blood on his body. The blood is whooshing from the boy's body ... at this point, I'm not sure where it's coming from. Oh, God! I guided the father to the resuscitation room or red zone. Alerted the doctor and got help from ward's staff. Gave patient oxygen and set up all the cardiac monitor and blood pressure cuff. While doing everything I realize that there was a huge, deep, and open trauma on his back at the scapula region. I can see through it. I instructed the hospital assistant to help me press the wound to stop the bleeding. As I helped the doctor in assisting him in intubation. At this point, I thought only a miracle can stop the bleeding. A few minutes felt like hours - "Where is the other staff?" "Please I need help! I need someone to set the IV cannula! This boy is losing so much blood!" After successful intubation, I gave chest compression while the father was helping in giving manual ventilation through bag ventilation mask - with a lot of tears in his eyes while the doctor is trying to get a vein for IV. An RN arrived, she stepped back after seeing so much blood. "Sorry, I can't stand to see all the blood." I was shocked when the words came out from her mouth. "Oh, My God! Help me please. Get me someone else!" Being a new RN grad and working in this small center makes me have to work on myself really hard with a little experience. On that day, I'm working afternoon shift with two hospital assistant and one medical officer and it's on a holiday! I'm putting all my knowledge and what I learn through the three years of nursing school and clinical. The center that hired me is small but have a BIG sign of EMERGENCY 24 HOURS outside of the building with a bright light and you can saw it from 1000 meter far but the facilities and staffing is poor. That condition put my career and other patient's life in danger. I just graduated 8 months ago from nursing school and have only 6 months of working experience and they put me as in charge RN all by my own with one doctor and a hospital assistant who doesn't even know how to take blood pressure. This boy could have been saved if proper management, fluid resuscitation, and controlling the bleeding by binding and compressing the wound. When the doctor gave instructions to stop the resuscitation I couldn't hold my tears. Now, after four years in nursing, I never forget what happened on that day. I still think about the RN who chose not to enter the resuscitation room cause of the bloody body. I remember blaming hospital management for their poor management and staffing. I even blamed myself for the lack of knowledge and experience I had. I learned from his father that his son was hit by a car while cycling in their resident area and that day was the boy's birthday. Being a nurse and by choosing this career, we must be aware that we will be responsible for saving people. We need to accept that seeing blood is routine. Please don't sacrifice another person's life by choosing this career if you do not have the stomach for it. For those newly graduated RN, you will be facing 1001 kind of cases and incident through your career. Some will make you feel inadequate. Never give up. It's just another way for you to learn - to become a great nurse. Go on and never stop learning! I quit from the hospital and looking for a new job at well organized center. Now, I'm in the middle of taking my Advance Emergency Medical Trauma Care certification and I never forget the incident that happens on that day. From that day, I promised myself to become the best nurse that I can be. A nurse who can handle any emergency conditions and save lives.
  24. LatteGuzzler

    The Hair Not There

    As she speaks, I study the child, who looks simply pitiful. Yes, his eyes are a little hollow looking and complexion a wee pallid. Vital signs not outside of a panic margin. He is alert and interactive with decent capillary refill. But the vision that prompts me to exert an effort to not look at her with sad eyes is his head. Patchy spots of scalp present everywhere, soft hair looking like it was coming out in handfuls. The patternless, random, and shocking loss of hair makes his appearance very dramatic. I see a trace of ink on his scalp. He looks at me, sighs, and lays his head on his mother's chest. She appears to me to be holding up well, considering what is no doubt a deep pothole on a very rough road with this child. After vitals and chief complaint, I steel myself and ask about past medical history. I do this with all the sensitivity I can muster, knowing that the answer will be difficult for her to give. I tilt my head in an expression of sympathy and see no trace of grief or fatigue in her face. Still, I am ready to hear the words. Chemotherapy. Cancer. Radiation. Name of oncologist. Dates of treatment, surgeries. "Tell me," I think, "I am ready to hear you now." "Oh, he's very healthy, generally," Mom tells me. "Denial?" I think. I press on, "Any history of serious illnesses, surgeries? Is he currently under any therapy?" "No," states Mom, pleasantly. "Anything at all?" I let the question hang in the air and lean forward slightly. "No, except for what's going on today, he's really healthy." I am completely baffled. Finally, I cannot think past this illogical presentation. I try not to stammer when I ask, "...but his hair? What is the reason..?" I get no farther than this when his brother, calm and quiet to this point buries his head in his arms. "Uh oh, I thought, he understands how ill his brother is". Mom, now aware of my repeated questioning motives suddenly laughs. She gestures to the patient's brother and says, "His brother here...he sort of cut his hair today". Guess a little magic marker action was all part of it, perhaps trying to hide the glare of the scalp, or just adding a creative touch. Mom and I have a chuckle. Patient gets taken back, treated, and released doing much better. I, of course, initially accompanied the child to the ER room to make sure the primary nurse understood the alopecia etiology. I wonder if she would have jumped to the same conclusion I did, but of course will never know. What I do know, is that despite the boy's illness, he was able to spread some good humor that day.
  25. traumaRUs

    Opioid Epidemic - EDs Fight Back!

    This is a topic that has gotten a lot of press lately. We have all seen/heard about the opioid epidemic that is occurring in the US. I was very fortunate recently to discuss this issue with Patricia Kunz Howard, PhD, RN, CEN, CPEN, TCRN, NE-BC, FAEN, FAAN. She's a member of the ENA Board of Directors and practices in Lexington, KY. In Illinois, we have the Prescription Monitoring Program - do you foresee this becoming a federal mandate? Kentucky has the "KASPER" Law which is similar to the IL Prescription Monitoring Program. I believe it is highly likely we will see a federal mandate related to monitoring of prescription drug use with related restrictions. Opioid use especially carfentanil is a huge safety issue for EMS and ED personnel - what type of precautions do you recommend? It is essential that EMS, law enforcement and ED personnel use extreme caution when encountering any substance, especially carfentanil as it can be absorbed through skin or mucous membranes. Appropriate use of personal protective equipment is essential to avoid exposure, as is avoiding confined spaces where the powder could be inhaled. Police are now carrying narcan and using it frequently - do you see any implications if this is given in a non-OD incident? For instance, hypoglycemia? We have not seen any adverse effects from Narcan administration by law enforcement officials. To the contrary, we are having to use such high doses of Narcan for carfentanil that the single dose administration carried by law enforcement may be insufficient to reverse clinical effects of this drug. Is the pendulum swinging the opposite way? Are we NOT appropriately treating pain? It has been my experience that we are being more cautious in our use of opioids, trying non-opioid agents as first line treatments before moving to opioids, and in those instances where opioids are needed, those doses are used much more short-term than in the past. As providers, what advice should we give to patients that do require narcotics? ie...keeping them in a safe place, reporting, using them only for the amount of time absolutely needed, etc. We should let patients know that it is important to minimize knowledge of opioids in your home, store them away from children or those who may be pose a danger to themselves. Limiting use of prescription drugs to severe pain for a very short duration will help decrease the likelihood of physical dependence. The epidemic will be addressed in four different sessions at Emergency Nursing 2017: Opioid Addiction and Deaths Spiraling Out of Control ALTO I - Alternatives to Opioids - Intro to ALTO ALTO II - Alternatives to Opioids - ALTO Program Implementation Opioid Crisis and Information System Technology in the Emergency Department The Opioid Addiction and Deaths Spiraling Out of Control session will educate nurses on the dangers of emerging drugs sold on the street like carfentanil, a synthetic drug often disguised as heroin. "Carfentanil is traditionally used as an elephant tranquilizer, so the amount needed to kill a human is frighteningly small," said Cathy Fox, RN, CEN, CPEN, FAEN, who will lead the session. "EMS, police and emergency department personnel can easily come in contact with a fatal dose without even knowing it, so it's imperative that they are able to recognize patients that are on this particular drug and take extreme measures to reduce their risk of exposure." Carfentanil can be sold as powder, in pill form or on blotter paper and is five thousand times more potent than heroin. Healthcare workers who come into contact with an overdose victim of carfentanil can become lethally poisoned themselves, merely by touching the patient without the proper protective gear, or even by breathing in trace amounts of the substance. "Our goal is to educate emergency nurses about what's out there and the risks they could face any time an overdose patient arrives at their facility for care," said Fox. The ALTO I - Alternatives to Opioids - Intro to ALTO and ALTO II - Alternatives to Opioids - ALTO Program Implementation sessions will focus on breaking the grip of opioid addiction by cutting down on the number of prescriptions that are written in the first place. The sessions will be led by Dr. Alexis LaPietra, DO, and Kimberly Russo, BSN, RN, CEN, FN-CSA, of St. Joseph's Regional Medical Center in Paterson, NJ. St. Joseph's was the first in the nation to implement the Alternatives to Opioids program (ALTO), which focuses on treating patients for pain without exposing them to opioids and the dangers of addiction. The Opioid Crisis and Information System Technology in the Emergency Department session will highlight technology that can be employed in emergency departments to better identify and track patients who frequently seek opioid prescriptions. "Unfortunately, some patients are very opportunistic in getting providers to write opioid prescriptions to them," said Eric Ringle, MS, RN, who will lead the session. "The good news is, there is emerging technology that allows us to track prescriptions much more closely, so it's less likely that patients can go from one place to the next to get these drugs." Electronic Prescription Drug Monitoring Programs allow caregivers to share patient-specific information instantaneously. Whenever a patient is prescribed an opioid, their information is uploaded into a database that allows caregivers to more effectively track where a patient has been treated and how often he or she was prescribed opioids. We all want our patients to have adequate pain control. However, we also have an obligation to provide this care in a responsible manner. By using alternatives to opioids and/or opioids for the least amount of time necessary, we are being safe providers. Emergency Nursing 2017 is September 13 - 16 in St. Louis and registration is currently open. Here is some more info: Human Trafficking Recognition in the ED Interview with Dan Nadworny, MSN, RN Point Person for the 2013 Boston Marathon Bombing