Skip Navigation LinksHome > Blogs > The Procedural Pause
The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, CEN, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Tuesday, November 24, 2015
This new bonus feature from James R. Roberts, MD, & Martha Roberts, CEN, ACNP, brings you tips, tricks, and pearls to make your emergency medicine practice easier.
This month, their first Clinical Pearl features the JR Knot, invented by its namesake James Roberts. This easy pearl will show you how to secure a central line.

Monday, November 02, 2015

Part One in a Three-Part Series


How many times have you wasted at least 30 minutes (if not more) digging around in a patient’s foot to remove a sewing needle or piece of metal or glass? Or maybe the question is, how many of you have immediately referred the patient to podiatry because foreign body removal isn’t an ED procedure?


Foreign body removal may not be emergent, but it can be urgent. Items left in the skin can cause complications and should be removed whenever possible to decrease risk of infection or other future issues.


Foreign body of the left foot in a 56-year-old woman.


The ED is the right place to do any and all procedures under the constraints of your medical license and hospital policies. Often times, specialists can complete procedures in-house or with a prompt follow-up appointment. Other times they are unavailable, in surgery, or too expensive, so you need an alternative plan. Patients only want to make one stop, especially if they are without health insurance, fiscal means, or a home. Then again, you could do this procedure for just about anyone and feel confident about it.


First, we must pause and discuss one extremely important recommendation that comes directly from the American College of Radiology (ACR). The 2013 technical standards for using fluoroscopy are specific and detailed for a reason. Radiation exposure is a big deal, and it can have lasting, catastrophic, and stochastic effects on patients, especially children. Your department must have a conversation and protocol in place about fluoroscopy procedures, and you need to be familiar with fluoroscopy limitations, expectations, and other requirements.


The ACR guidelines state, “Each facility should have a policy for granting fluoroscopic privileges to all physicians who perform or supervise fluoroscopy. Local credentialing and privileging processes should include review of training records and of procedures that use fluoroscopy to determine that the physician is both properly trained and qualified in fluoroscopy. Physicians must comply with all applicable state and federal laws and regulations, and with institutional policies and procedures for fluoroscopy licensure or certification.” ( You should be able to rely on your radiology team, including bedside technicians and chiefs of staff to be up to speed when it comes to these rules.


Large C-arm in radiology treatment area.


ED providers can use fluoroscopy as long as they work with radiologic technologists or radiation therapists who have received formal training in radiation management. The 2013 guidelines also suggest that “those assisting with fluoroscopy for fluoroscopically guided interventional procedures should undergo a formal authorization process, administered by the facility.” ( The only way the radiology technician can assist you, however, is if there is direct supervision, but it does not mean “the physician must be present in the room where the procedure is being performed.” (


Finally, as far as direct supervision is concerned, the only exceptions are “for registered and licensed radiologic technologists or radiation therapists who perform fluoroscopy only as a positioning or localizing procedure,” which is exactly the procedure you are going to complete. Fluoroscopy must be performed under the direct supervision of a physician who meets specific qualifications. These procedures also must have “prior written approval by the medical director of the appropriate department or service, and there must be written authority, policies, and procedures for designating technologists who perform such procedures.” (


Evidence-Based Practice Pearl

Many studies elaborate on radiologic beams and fluoroscopy, and it’s important to know your risk, the patient’s risk, and what to do during your procedure. The radiology technician and the radiologist are excellent resources and should be well trained to know how much exposure is too much and help to keep you in check in the work area. They should be the main person in charge while you do this procedure. Don’t spend more than five minutes doing continuous fluoroscopy, and don’t use fluoro if you do not feel comfortable with your radiology team. Keep in mind that continuous fluoro uses far less radiation at lower levels than radiographs. The dose makes the poison, and radiation dose depends on many factors, including the type of examination, patient size, equipment, and technique.


The bottom line: The ACR recommends receiving only 6,000 mrem/year from occupational exposure. International standards suggest 5,000 mrem/year for those who work around radioactive material. A jet plane exposes you to 0.5 mrem/hour. A chest x-ray gives you 10 mrem, a plain lumbar spine plain radiograph 600 mrem (lumbar series). A CT of the abdomen pelvis gives you about 1,000 mrem. Finally, a single x-ray of the lower extremity is 0.5 mrem. This means, if you use continuous fluoro (at the lowest level used by the radiology team) for five minutes (with one shot/second), your total exposure would be approximately 150 mrem.


Also take into account the direct exposure your hands receive during this procedure (if they remain under fluoro), which is dependent on the operator and extremity placement. Consider using intermittent or “pulse” fluoroscopy instead of continuous. The lower the exposure time, the lower the exposure dose and the radiation side effects, of course. (J Clin Diagn Res 2015;9[3]; Radiation safety precautions should be taken and “exposures regularly monitored with at least one dosimeter for monitoring the whole-body dose.” Radiation safety programs should also be routinely conducted. (J Clin Diagn Res 2015;9(3); The American Nuclear Society offers more about your estimated annual radiation dose. (


Radiation should not be taken lightly, so be prepared when performing this valuable procedure. Fluoroscopy and understanding its use is essential to your practice. After reading this series, create a stronger relationship with your radiology team and try it.


Facebook Twitter

Thursday, October 01, 2015

Part 2 of a Series


Our series on joint care has given you a basic overview on knee arthrocentesis. Typically, it is not necessary to have an orthopedic consultant come to the bedside in the emergency department to do this procedure. Arthrocentesis is a procedure you can do well and feel confident about your technique.


Take a moment to review our last blog post on knee pain before reading this post and watching the accompanying video. ( As always, review the anatomy; it plays a key part in successful bedside technique. Ultrasound-guided arthrocentesis is always a favored approach.


Although emergency physicians and advanced practitioners can complete this procedure at the bedside, we suggest contacting the  surgeon involved for post-op patients before starting arthrocentesis. Most surgeons (if in-house at the time) will want to see a hot post-op knee. The surgeon may want to complete the procedure herself or omit a procedure if she does not feel it is necessary. Surgeons also may have concerns about antibiotics use (or misuse) and follow-up care for their patients.


The Approach

n Identification of knee effusion on physical exam

n Identification of knee effusion on plain radiograph

n Localized anesthesia prior to arthrocentesis of the knee

n Arthrocentesis of the knee

n Send laboratory testing including (but not limited to) cell count with differential, crystal analysis, Gram staining, bacterial culture(s), and sensitivity analysis.



n Suspected or definitive infection overlying the joint


The Procedure

n Obtain the following materials:

o 27 g needle x1 (for local anesthetic)

o 10 mL syringe x1 (for local anesthetic)

o 20 mL syringes x3 (for aspiration)

o 18-20 g needle x1 (for aspiration)

o Sterile gloves

o Hemostat

o Antiseptic of choice

o Sterile perforated drape

o Three-way stopcock

o Sterile testing tubes and/or containers

o Bandages and/or dressings of choice

n Identify all landmarks.

o Landmarks include the medial edge of the surface of the patella or at the middle or superior aspect. Note: The medial approach is typically the first-line approach, although a lateral approach is also an option.

n Position the patient lying supine and extend the knee as far as possible, keeping in mind that flexing the knee to a 20- to30-degree angle may assist with quadriceps relaxation.

n Cleanse the patient’s skin with antiseptic. Recommendations include clorhexidine or Betadine. Remember, if you use Betadine, you should remove the excess using an alcohol swab prior to injection to prevent Betadine from going into the joint itself. Entrance of Betadine into the joint can cause inflammation and should be avoided.

n Apply a sterile fenestrated drape.

n Use a 27 g needle to create a small wheal of anesthetic to the appropriate area. You may use 1% or 2% lidocaine in combination with sodium bicarbonate, approximately a total of 10-15 mLs. The solution is 1:10 mL of bicarb and lidocaine.

n Hold the patella firmly with your non-dominant hand.

n After a wheal is created, position your dominant hand so that it is parallel to the stretcher. Inject the anesthetic slowly into the skin and along the entire track of the aspiration of the needle. Infiltrate the skin down to the area of the joint capsule. The injection track should be dispensed between the posterior portion of the patella and the intercondylar femoral notch.

n Use your non-dominant hand to milk the effusion from the suprapatellar pouch above the patella. This will force fluid into the joint. This will aid in fluid removal as you aspirate.

n Do not forget to aspirate as the needle is advanced.

n Use a large syringe (20 mL is suggested) because there may be a larger-than-expected effusion present. The knee can hold up to about 50-70 mL of fluid.

n Place all fluid into appropriate tubes, and send to the laboratory.

(Adapted from Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)



n If this is your first time completing the procedure, consider using an ultrasound-guided technique to be certain you have the correct landmarks.

n If your first syringe is filled to its entirety, remove it and place a new empty syringe onto the needle. To do this, hold the needle that is in the joint with a hemostat to maintain the correct position. This also stabilizes the needle so you can remove the syringe.

n Another technique is to use a three-way stopcock applied to the needle to allow you to change the syringes without having to remove the needle.

n The procedure can be almost painless to the patient and you can limit his distress if anesthesia is appropriately used. Tense patients with tense muscles do not allow for solid technique, so be sure to aid in patient comfort. As always, we feel patient comfort is half the battle!

n Sedation is rarely required, but may be prudent in some patients. This is not routine practice.

n Always try to remove as much blood or fluid as possible. Large amounts of pus may clog the needle, and the joint may not be totally drained. If this occurs, inject a small portion of the aspirated fluid into the space from the syringe and attempt minor position changes. Do not forget to push down on the suprapatellar pouch.

n Do not completely withdraw and reinsert the needle. If positioning of the needle tip needs to be altered, advance or retract the needle a few millimeters, rotate the bevel or lessen the force of aspiration or injection.

n Avoid side-to-side movements of the needle. Keep the barrel of the syringe parallel to the stretcher.

n It is easier than you think to confuse your sharps after the procedure is completed. Do not accidently toss your sample into the sharps bin.

n Apply a clean, sterile dressing with an ACE bandage to the knee post arthrocentesis.


Tip of the Week

The string test is a bedside technique to determine if the synovial fluid is inflammatory or noninflammatory fluid. Noninflammatory fluid may result from a meniscal tear. To complete this test, place a generous amount of synovial fluid onto your gloved thumb. Touch the drop with your index finger and slowly separate your fingers. A string will be formed as the fluid is stretched and manipulated. A string of approximately 1-2 cm will be evident in a noninflammatory condition. No appreciable string will be formed in an inflammatory synovial fluid such as rheumatoid arthritis. (Clinical Procedures in Emergency Medicine.)



Watch the video here.


Evidence-Based Practice Pearl

The Scandinavians seem to be doing it right. The study reported “significantly less procedural pain, improved arthrocentesis success, greater synovial fluid yield, more complete joint decompression, and improved clinical outcomes.” (Scand J Rheumatol 2012;41[1]:66.) We also recommend reading our friend Dr. Todd Thomsen’s article, Arthrocentesis of the Knee. (New Engl J Med 2006;354e19;


Final Thoughts

Jim weighs in: “Once you learn the technique, the knee joint is quite easy to tap. Using suprapatellar pressure maximizes fluid in the knee joint itself.”


Martha weighs in: “I always provide a rolled towel under the patient’s knee to help with relaxation and comfort to aid in proper positioning.”


Next Month

Complications of knee arthrocentesis and other clinical pearls related to joints.


Facebook Twitter

Tuesday, September 01, 2015
Part 1 of a Series

How often do you come in contact with a patient whose chief complaint is knee pain? How often can you actually to do something about it? Collectively as emergency providers, we do not typically fix these types of injuries in the ED, and at times, it is not even certain if we actually diagnose knee pain properly. The truth of the matter is simply that we can diagnose it correctly, help our patients feel better, and give them some answers.


Frequently, traumatic knee pain can be diagnosed as a contusion, generalized strain, or sprain. Rest, ice, compression, elevation, and NSAIDS are often prescribed. If you are lucky, you may encounter the uncommon patellar tendon dislocation, and obtaining a radiograph for traumatic knee injuries may actually yield positive results. At least you can pop it back into place. (Read our previous blog post and watch our video on patellar dislocation at The differential diagnosis for knee pain, however, is endless. Here are a few for you to peruse.


Common Causes of Knee Pain 



Older Adults

Patellar subluxation

Patellofemoral pain syndrome (chondromalacia patella)


Tibial apophysitis (Osgood-Schlatter lesion)

Medial plica syndrome

Crystal-induced inflammatory arthropathy: gout, pseudogout

Jumper’s knee (patellar tendonitis)

Pes anserine bursitis

Popliteal cyst (Baker’s cyst)

Referred pain: slipped capital femoral epiphysis, hip fracture

Trauma: ligamentous sprains (anterior cruciate, medial collateral, lateral collateral), meniscal tear, fractures, muscle strains

Metastatic cancer

Osteochondritis dissecans

Inflammatory arthropathy: rheumatoid arthritis, Reiter’s syndrome, pigmented villonodular synovitis


Juvenile rheumatoid arthritis

Tendonitis (quadriceps, patellar tendon, etc.)


Trauma: ligamentous sprains (anterior cruciate, medial collateral, lateral collateral), meniscal tear, fractures including epiphyseal fracture, muscle strains

Septic arthritis




Stress fracture/stress reaction



Referred pain: neurogenic, hip and leg pathology



In the end, it seems as if we habitually slap a knee immobilizer or ACE bandage on knees, have the patients follow up with an orthopedic specialist, and hope for the best. Knee pain is such a frequent guest in our emergency department that we need to be prepared for its daily arrival. It is time to put an end to the pass off to orthopedics because the buck stops here and now in your ED. We are going to make you all experts by the end of this series on joint injuries and aspiration.


First, let’s discuss the statistics. Many different providers treat knee injuries, but the National Institutes of Health reported 6.6 million people visited the emergency department in the United States from 1999 to 2008 with the chief complaint of knee pain. This is an average rate of 2.29 knee injuries per 1,000 people. Although 42 percent of the knee injuries were diagnosed as a strain or sprain, contusion and abrasions (27%) followed behind. Knee lacerations and punctures (10%) proved to be a solid offender as well, while arthritis, tibial plateau fractures, and other various knee ailments brought up the rear. (Acad Emerg Med 2012;19[4]:378.)


Further statistics reveal knee pain also accounts for approximately “one third of musculoskeletal problems seen in primary care settings.” (Am Fam Physician 2003;68[5]:907.) That means many of these cases of knee pain are first seen by their primary care provider, then possibly by the emergency department, and finally by the orthopedist. That is three providers and an exorbitant amount of time, resources, and money.


Knee pain can also be a source of significant “disability, restricting the ability to work or perform activities of daily living,” according to that same article. This means we need to really start paying closer attention to these patients.


The rate and pattern of knee injuries can vary by sex and age, so it’s important to know what to be concerned about depending on the chief complaint. Adolescent boys will often present with knee pain related to sports injuries. Those over 65 may present with arthritis. It’s very important to know the subtle differences between osteoarthritis and rheumatoid arthritis, which are two completely different ailments. The key is to understand knee pain. This enables clinicians to “better anticipate caseloads, allocate resources, and determine best practices for diagnosis and treatment of knee injuries in different age groups” in the emergency department, according to the Academic Emergency Medicine article.


This month, we are going to ease into our series on joint aspiration mindfully. Later, we will show you the proper procedure via video. This technique needs to be reserved for the correct patient because you do not want to tap every joint that looks irritated or is painful. Our initial portion of this series will begin by discussing traumatic knee injuries and related procedures.



Click here to watch the video.


You definitely need to keep the Ottawa Knee Rules in mind. (JAMA 1996;275[8]:611.) The question is, x-ray or don’t x-ray? These rules describe the criteria for knee trauma patients who may warrant knee imaging. The goal is to apply these rules to make your decision. If no criteria are met, imaging is not indicated.


Answering yes to one of these questions mandates imaging:

n Age 55 or over

n Isolated tenderness of the patella (no other bony tenderness)

n Tenderness at the fibular head

n Unable to flex knee to 90°

n Unable to bear weight both immediately and in the ED (4 steps; limping is OK)


Evidence-Based Practice

n Rules have been prospectively validated on multiple occasions in different populations and in children and adults.

n Numerous studies found sensitivities for the Ottawa knee rules of 98%-100% for clinically significant knee fractures. One study did find a sensitivity of just 86%.

n Specificities for the Ottawa knee rules typically range from 19% to 50%, though the rule is not designed/intended for specific diagnosis.

n When used appropriately, the amount of knee x-rays obtained can be reduced by around 20%-30%.

n The Ottawa knee rules are useful in ruling out fractures (high sensitivity) when negative, but poor for ruling in fractures (many false positives).


The creators of the rules at University of Ottawa offer these tips:

n Tenderness of patella is significant only if an isolated finding.

n Use only for injuries less than seven days old.

n Bearing weight counts even if the patient limps.


Precautions from the creators of the rules:

n Do not use on patients under 18.

n Clinical judgment should prevail if examination is unreliable because of intoxication, an uncooperative patient, distracting painful injuries, and diminished sensation in legs.

n Always provide written instructions.

n Encourage follow-up in five to seven days if pain and ability to walk is not better.


The Ottawa knee rules should be applied to all patients 2 and older with knee pain/tenderness in the setting of trauma.


Why Use It

n Patients without criteria for imaging by the Ottawa knee rules are highly unlikely to have a clinically significant fracture and do not need plain radiographs.

n Application of the Ottawa knee rules can reduce the number of unnecessary radiographs by 20-30 percent, which has proven to be cost-effective for patients without reducing quality of care.


Implementation of the Ottawa knee rules would be associated with meaningful reductions in societal health care costs in the United States and Canada without a reduction in quality of care.


Jim weighs in: Most ED patients expect an x-ray of a painful knee, especially if it was traumatized. Most clinicians can readily tell if an x-ray will be helpful, but meeting patient expectations is an important goal. If you are not going to order an x-ray, make sure the patient understands your reasoning and agrees with your tactics. Don’t fight with the patient about an x-ray. Decision rules and your exam are most important, but no exam takes the place of an x-ray to settle the issues in a borderline case. Finally, remember that a CT scan/MRI sees much more than a plain x-ray, so always keep open the possibility that one of these tests may be necessary if the pain, mechanism, and findings suggest an internal injury, symptoms continue, or x-rays are equivocal.


Stay tuned for next month’s Procedural Pause Blog, when we show you how to tap this knee! Can you tap it? Yes, you can.



Facebook Twitter

Monday, August 03, 2015

This blog teaches procedures, with its case studies and videos intended to help you perfect your technique and strengthen your confidence. This month we explore issues related to procedural patient impact. How will your intervention positively or negatively affect patient outcome? What happens when we decide to step in and complete a procedure?


A risk is always inherent when a provider undertakes a procedure, no matter how insignificant. Carefully, we weigh the pros and cons of the potential procedure with our patients. Will our intervention cause a positive effect or outcome? Our goals are to repair, resolve, or restore whatever may have gone wrong. That means there might be some sort of suffering along the way.


Or does it? There is a potential for any procedure to have a poor outcome. Our interventions are intended to help, not hurt the patient under our care.


Patient Impact: Pain Control

Pain control can make a major difference in every procedure, and is a best practice for our patient. Procedures can be completed more effectively and without distraction when a patient has less pain. And we are less likely to make a mistake, stop early, or prolong the procedure when we can perform without interruption. Pain control may even lead to better cosmetic outcomes because the patient is more relaxed, calm, and cooperative. Technique is only half the battle.


Vaginal Abscess I&D

It is impossible to maintain perfection 100 percent of the time. Poor patient compliance, financial hitches, unrealistic treatment times and department goals, lack of materials, and lack of follow-up, knowledge, and staff all contribute to poor patient outcomes. Procedural complications are not always simply chalked up to poor technique.


No one is perfect. Every day is a learning experience, and we do what we can with the resources we have. You will succeed by embracing basic concepts, using proper equipment, and not cutting corners. Part of that understanding is to use proper pain control, especially when draining a painful, sensitive vaginal abscess, as seen in this video:


Click here to watch the video on vaginal abscess.


During one incision and drainage of an abscess, the patient experienced horrific and traumatizing pain, and she returned two days later with a larger reaccumulated abscess, which had to be excised and drained for a second time. This was not happy news for the patient or the providers involved. The abscess may have reaccumulated despite our initial interventions. It may have returned, however, because it was not appropriately drained or treated the first time. Perhaps adequate drainage was limited because of pain. And she reported during a follow-up call one month later that she had painful and unsightly scar tissue.


Why did the patient have a poor outcome?

§ The patient’s pain was poorly managed during the procedure. It did not allow us to complete the procedure appropriately.

§ Our ED does not stock Word drainage catheters, which are best used for treating labial and Bartholin cysts/abscesses.

§ The nurse had to leave the room for a trauma, and we continued the procedure without pain medication.

§ Local anesthesia was not successfully achieved.

§ She had poor positioning during the procedure.

§ The patient was very fearful.

§ The patient was nauseated and vomited during the procedure, creating concern for aspiration and removing conscious sedation as an option.

§ The vaginal abscess was not completely drained because the patient was unable to tolerate additional procedure time secondary to lack of pain control.

§ The patient stated on the second visit that she felt abused by this procedure, which caused her significant stress. She stated that the physician never asked her if it was OK to discuss medical history in front of her abusive husband, and she had no chance to talk about more personal issues.

§ She felt we poorly explained the technique and rushed through it.

§ The provider performing the procedure answered her phone three times.

§ The patient spoke Spanish only, and though we used an interpreter, her discharge paperwork was in English.

§ The patient did not know how to take her own temperature and did not understand she should return for a fever of 104°F.

§ The pain medication and antibiotics made her vomit at home, so she never took the right doses.

§ The patient could not afford clindamycin anyway.


How do we fix these issues?

The majority of these issues are easy to resolve. This patient may have had a better outcome if the following issues were addressed:

§  You aren’t the boss, so you can’t fix staffing numbers, but don’t start any procedure unless you know you have the right people available to help you. Make the patient wait for an urgent procedure until you all can be ready to start without interruptions. Forget about your length of stay.

§  If the procedure is emergent, escalate this concern to the charge nurse or another provider and intervene early. You are in charge of the patient.

§  Always discuss a full history and perform a full physical before completing any procedure. This means if you are doing a procedural sedation, consider full cardiac and respiratory assessments. Call respiratory for a patient who might crump from COPD issues or orthopedics for an 86-year-old with afib and a dislocated hip. Maybe that one can be done in the OR.

§  Discuss all procedures (to your best ability depending on urgency) with the patient and a witness.

§  Have the patient sign and acknowledge the risks and benefits on a consent form. Don’t have her sign just for legal purposes. Have her sign so she understands what is going to happen.

§  Use an interpreter. Translate the paperwork into the patient’s language. We suggest Google Translate or another professional application your department allows.

§  Discuss pain control methods with the patient, and provide excellent pain management and local anesthesia.

§  Insert an IV for difficult procedures, such as labial or vaginal abscesses. Give patients adequate IV pain medication before the procedure and before local anesthetic infiltration.

§  Often forgotten, adding 1 ml of bicarbonate to 7-8 ml of lidocaine significantly reduces pain of lidocaine infiltration without compromising anesthetic effect.

§  Inject slowly and give enough lidocaine the first time to adequately block pain of the procedure. Consider a field block. It’s OK to use more lidocaine (generously through the incised skin edge) once the procedure causes pain.

§  PO challenge the patient before she is discharged. Consider an antiemetic.

§  Sit down and explain how the next 48 hours should look and feel for the patient.

§  Consider social work interventions for uninsured patients.

§  Use the right equipment.

§  Stockpile some discharge paperwork for common procedures or create a document on your computer that highlights your instructions. EPIC, for example, has information about cellulitis. Add some thoughtful additions and touches of your own, and save those as smart phrases. If you use paper charting, spend 10 minutes at home drafting a strong discharge packet. It will prevent patient bouncebacks and save an unbelievable amount of time.

§  Note that your involvement in your patient’s care does not stop at discharge. Make a follow-up call the next day for patients about whom you are particularly concerned. It takes almost no time at all to do, and your patients will be so thankful.



During a busy shift, it is easy to forget or forgo comfort measures or seize a patient teaching opportunity. Slow down! Pause for a minute to provide patients better pain management during uncomfortable and invasive procedures. Not only will it relax your patients, but their ensured and controlled comfort will make your job easier. It is the rare patient who will not benefit from pre-procedural IV opioid analgesia. Be generous!


Evidence-Based Practice Pearl

The most painful procedures for ED patients are nasogastric intubation, abscess incision and drainage, fracture reduction, and urethral catheterization, according to a study of more than 1,000 patients receiving the top 15 emergency department procedures. (Ann Emerg Med 1999;33[6]:652.) The study also showed that overall use of anesthetics before these procedures was low.


It is often noted that pediatric patients do not receive appropriate analgesia in the emergency department and as outpatients because of inadequate dosing. If you decide to give pain medication to pediatric patients, give them the proper dosage and discuss this with the parents.


Facebook Twitter

About the Author

James R. Roberts, MD & Martha Roberts, ACNP, CEN

James R. Roberts, MD, is the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine at the Drexel University College of Medicine, both in Philadelphia. He is also the chairman of the editorial board of Emergency Medicine News, and has written InFocus for more than 25 years.

Martha Roberts, ACNP, CEN, is an acute care nurse practitioner for Johns Hopkins Medicine at the Sibley Memorial Hospital in Washington, DC, an adjunct faculty associate and clinical instructor of nursing at the Malek School of Health Professions, Marymount University in Arlington, VA, and is Dr. Roberts’ daughter.

Visit their Facebook page at

Blogs Archive