Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.

Saturday, June 24, 2017

What are you doing for the rest of your Life?


            This is the time of year that is usually inter-term or long vacation for educational institutions. You could be out enjoying the weather and friends, working extra for that special holiday, or making the most of family time.

            ─It's a good time to take stock of your 'Life Plans.' If you decide to make changes, it's a great time to investigate data, brochures, institutions, obtain financing, get transcripts and make applications, … Oh, no, I don't want to go back to school just yet! I've had so much of it!

            What do you want your future to be? Do you want improved opportunities? Control over what you do: Respect from your colleagues? Freedom to schedule work life as you wish? Do you want to make more money? Even, some fame? Do you wish your opinion to be sought at high, even highest, levels?

            Look at those people who are doing some of what you want to do. Unless they're independently wealthy (and probably not a nurse), I'll bet that they have higher degrees and more certifications or additional studies, than you do. So, this might just be the time to decide what you want to do, and how to get there. While these achievements won't guarantee your wildest dreams, they make it a lot easier to show that you have the knowledge and abilities to show you'll be able to do the work at the level you want.

            If not now, when? Though there may be some "adventures" in meshing your new plans with the realities of your life, when will it ever be better? Will you be as young and resilient? Will you have as much energy to match your motivation? Will you be better able to flex your work and earnings as needed? With delay comes only more difficulty with less flexibility.

            If you aspire to succeed in academia, writing and publishing, higher levels of advanced practice, administration, or leading an enterprise, you may need to increase and diversify the letters after your name. Good Luck! May your dreams become plans that succeed!


                                     Tom Trimble, RN
                                      All opinions are solely those of the author.
                                      Readers must verify validity to their own practice.




Wednesday, May 31, 2017

It's EMERGENCY Nurse to you!


     In hospitals, the work role or function of nurses and other staff is usually (and traditionally) defined by place, e.g.: O.R.; Post-Anesthesia Care Unit; Delivery Room; Medical-Surgical Ward Nurse. Seldom is the work of such specialties ever performed outside of that place. Job ads will ask for 'O.R. Nurses'; L&D Nurses, Pediatric Nurses.

     When those ads ask for 'E.R. or E.D. Nurses', I gnash my teeth. To me, in whatever aspect of our specialty I work, I am an Emergency Nurse. I am not a generalist worker temporarily assigned to a place to perform some duties.

Our specialty requires enhanced education, training. a mindset capable of excellence in both team and independent thought and action, most often (at least initially) in a medical model rather than in Nursing Diagnosis structure. Our specialty incorporates the most dreaded moments and aspects of every medical and surgical discipline, focused in time and criticality in patients arriving suddenly and without a diagnosis.

     My workplace is where the patient is in his time of need and the condition in which he is found. It might be in a resuscitation room, the waiting room or rest room, the hospital lobby, or even the parking structure, perhaps even on the way home.

     If I chose not to work primarily in an E.D., work is available in flight nursing, either helicopter EMS or long-distance repatriation flights; remote worksites, critical-care transports. Those who are also trained in forensic work can work with sexual-assault cases, law enforcement, or death scene investigation and survivor counselling. I've known one nurse with advanced degrees who was preparing for a goal of nursing in a space colony; therefore, even the sky is not the limit.

     In short, Emergency is a mission not a place.

     Few remember that the Founders of ENA, Judy Kelleher and Anita Dorr, combining their fledgling separate West Coast and East Coast groups in 1968 called it the Emergency Department Nurses Association. However,

"In 1985, the Association name was changed to Emergency Nurses Association (ENA), recognizing the practice of emergency nursing as role-specific rather than site-specific."

(Bold added) About ENA.


                                                  Tom Trimble, RN; Emergency Nurse
                                                  All opinions are solely those of the author.
                                                  Readers must verify validity to their own practice.

Monday, May 15, 2017

Breaking the Sound Barrier (to Action)


All experienced emergency workers upon opening the door to the department, can 'read' or sense the activity within seconds just by application of the senses. One that seems obvious is the hearing of sounds, yet there are unusual aspects to the interpretation of those sounds, and some less common. 

The healthy cry of a newborn baby is considered a happy sound. 

Semi-obstructed airways and wet or wheezy lungs are famed for characteristic sounds unto the "death rattle" and "last gasp." 

Some epileptic seizures will be heralded by a loud inspiratory "cri du epilepsie" as the diaphragm contracts in spasm and by the strong negative pressure against a partially closed larynx (in the form of a Müller maneuver or "reverse Valsalva maneuver") similar to that made by a partially-obstructing laryngospasm. 

Fractures and dislocations that are being reduced can produce a snap or click as the parts mesh again.

Even the electrocautery pen can induce a little sizzle as it cauterizes or as it perforates a nail with a subungual hematoma.

Everyone listens for the hissing sound of a tension pneumothorax as the pressure is relieved by thoracotomy.

Surgical emphysema (air trapped under the skin) can produce a "Rice Krispies®” sound of "Snap, Crackle, & Pop®” when palpated.

There are sounds that we don't want to hear: the plangent wailing of a family in anguish and grief at a death; the wild cries and threats of a violent agitated patient, or worse, a hostage situation; the dead quiet despondency when a child has succumbed. 

The sound of crashing stainless steel or enamel bedpans and urinals is generally obsolete, having been replaced by plastic. There goes the chance to test for a startle reflex! 

We would rather hear the happy and efficient hum of a department that is running well, for the moment, and patients are doing OK, and are satisfied. Better yet, is the relaxed and happy laughter of a staff "food night" that things are under control and everyone is gleefully under-utilized. 

Some sounds will 'galvanize' (in the original electro-galvanic sense, not the weatherproofed hardware) experienced staff into instant activity. —The large heavy thump on the floor. It has a peculiar 'deadfall hammer' aspect to it: that is say it is like the mechanic's tool designed to provide a heavy impact without rebounding. A thud that doesn't bounce. This is the fall of a body to the floor, either from falling from bed or someone with sudden unconsciousness or death, unable to mitigate the impact. Sometimes, it is accompanied by a crunching and crepitant sound of facial or cranial bones shattering. Staff will respond faster than a Superhero. A slightly hesitant response to the sound discerns those who have not heard it or imagined it. No good can come of this sound, and it will surely mean extra reporting. A surviving victim would likely call out or express their pain or attempt to rise.

Perhaps the oddest sound is when a patient has died and is being removed from the department, and the bed hits a bump at a doorsill or a join between buildings. The concussion causes residual air in the lungs to be expelled with an audible grunt or moan 'from the dead.' This can greatly surprise someone who is not aware of the phenomenon.


                                        Tom Trimble, RN
                                        All opinions are solely those of the author.
                                        Readers must verify validity to their own practice. 


Tuesday, May 2, 2017

In the northern hemisphere, Spring is becoming Summer, and in the southern hemisphere, Autumn will become Winter. This seasonal change is a fine opportunity to plan for staff in-service training and drills for the challenges brought by the coming weather. Likewise, if you contribute to the departments public education efforts or institution’s newsletters and public service announcements, bring up a slate of potential topics.

Consider the traumas and medical emergencies that have a seasonal prominence in your locality, then prepare topical presentations in formats that work well with your group. Devise brief drills or simulations that can be covered in an impromptu manner for those ‘slack’ times that you may have for teachable moments. Consider preparing, or recording them, in a digital format that can be used and shared when personally convenient, that can be a supplement or alternative to traditional staff meetings. Useful combinations can be made such as near-drowning & hypothermia & intoxication. (Not an impossible likelihood, eh?)

The main points should be brief, lucid, and memorable. Detailed slides (grr) should be relegated to references and additional matter. Whenever possible, the sessions should coincide with activities that reflect actual activities in real-time. As with a well-run ‘mega-code’, these are rehearsals for future events that may present suddenly. The memory-tracks and physical enactments can improve actual responses and performance.

                Tom Trimble, RN
                All opinions are solely those of the author.
                Readers must verify validity to their own practice.


Monday, March 27, 2017

​Clinical Tips # 200 {'Double-Century' Edition} – Helping Those with Hearing Loss, appearing Monday, March 27th, 2017 to April 3rd, 2017, brings back the "Ten Commandments the Hearing Impaired Wish You Knew" previously listed in this blog in "Ten Commandments for Emergency Professionals; a compendium."

This has particular significance and importance for us as emergency professional for several reasons:

  1. Our business is helping patients who are unselected and undifferentiated. We take all comers. Some have hearing problems also. We must be able to communicate effectively.

  2. Hearing problems may develop insidiously; the patient, perhaps with some denial, may not yet have realized how hard of hearing he has become. We may notice behaviors that indicate difficulty in hearing. In fact, we may not have admitted as much to ourselves that our hearing 'isn't what it was.'

  3. Office practices may be open forty hours weekly. We're open 168/168. Patients may come to us with a sudden decrement in hearing, or in caring for a work-related condition, we can counsel them as to the potential worsening of their present hearing.

  4. We are bombarded with noise in our own work environment. Alarms; tools; falling objects; screams and shouts; PA systems; radios; doors; computers; on it goes. Rarely is there a calm and noiseless time. (There, I wrote it without saying the dreaded "Q word.") This contributes to the totality of risk factors in our lives from genetic or familial causes to percussive sounds with high intensity.

  5. We may be able to suggest less ototoxic drug choices to lower the risk of impaired hearing or tinnitus.

  6. If we are able to counsel and intervene effectively with the patient who hasn't yet admitted to hearing loss, we can restore a sense of joy to their world and their social interactions that can ease the progression to stress, depression, learning and memory difficulties, social isolation/withdrawal, and dementia.

In my family, my brother and I had so many elders who had severe hearing loss that we took for granted that this lot would befall us also. We learned early to speak slowly, clearly, with sharpened articulation, in a normal or slightly louder voice, in good light while facing the person with whom we were talking. The dictum "Children should be seen and not heard" and other maxims of old-fashioned "polite conversation" helped ensure that only one person spoke at a time.

My brother had many ear infections, including an emergency meryngotomy while papoosed in a sheet on his own bed. His hearing deficiency was such that, as a contributory factor, he deliberately chose for his life's work, an industry known for its noise levels and the number of deaf men who worked in it so that he would not be disadvantaged. It was probably a decade in the future before sound safety muffs would be provided to the men.

Hearing loss is not always inevitable. The earlier diagnosis and assessment by otologists and audiologists can lead to better protective measures, treatments, or hearing instruments that minimize disability. (Yes, I know that 'disability' is a word that is charged with much baggage of political correctness.)

In my case, increasing tinnitus was not something that might go away {it didn't}, but a sign of increased hearing loss. As my hearing worsened, I worried that I might miss an essential clue at Triage, or that I would not be able to hear a patient's last words; such worry is a burden. It became a factor as I chose how best to carry on. If you, or someone else, is having hearing difficulty, take an audiometry test to determine how things stand. It's quick, easy, and can start one on  the road to improved hearing and participation in life.

Hearing loss is common and usually noticed by others first, be the advocate who encourages testing and treatment.


Tom Trimble, RN
All opinions are solely those of the author.
Readers must verify validity to their own practice.