ED Unscrewed

www.impactednurse.
com
emergency
nursing
unscrewed
no fluff | no guff | no duff
Copyright Ian Miller 2008. -1-

www.impactednurse.com
CONTENTS:
Introduction from a screwup nurse........................................................................3

How to handle the workload..................................................................................4
How to nurse the machines. .................................................................................4
How not to make a medication error. ....................................................................6
How to manage a needle stick injury. ...................................................................7
How to catheterize a male. ...................................................................................9
How to catheterize a female. ..............................................................................11
How to remove a penis that is stuck in a zipper..................................................13
What is mean arterial pressure? .........................................................................15
Where to place that cannula. ..............................................................................16
How to place a cannula.......................................................................................18
How to secure a cannula. ...................................................................................19
How to tell if your patient is playing possum. ......................................................21
How to manage a patient having a CAT scan.....................................................23
Tip: lip balm and oxygen. ....................................................................................25
How to use nitrous oxide.....................................................................................25
Minimizing Violence with STAMP AID.................................................................27
How to use the rectal trumpet. ............................................................................29
How to handle the smell of poo...........................................................................30
How to immobilize a suspected spinal injury.......................................................32
How to manage hypothermia. .............................................................................34
How safe are air bubbles in the IV line?..............................................................36
How to manage paediatric fever. ........................................................................37
How to keep ‘eyes on’ your patients. ..................................................................39
How to assess a child: Respiration. ....................................................................41
How to assess a child: Circulation. .....................................................................43
How to remove a stuck ring. ...............................................................................44
10 tips for staying sharp in the Emergency Department. ....................................45
How to cure persistent hiccups. ..........................................................................48

Introduction from a screwup nurse.
A nurse is the most profound of fulcrums between the patient

and the care they require.
And it is the intimacy of the bedside nurse that effects the
most powerful leverage of all.
– ian miller.
I am the first to admit it. I am a screwup nurse.

I am the reason they print handle with care on life suport equipment. I constantly bump into
catastrophies and trip over delicacies.
My brain always seems to run a lot slower than the events unravelling around it.
It’s sorta like nursing inside a jar of molasses.
So I have to work pretty hard to unscrew my practice. To meet the level of care that is demanded
from the speciality of emergency nursing. To do justice to my colleagues. To strive to deliver my
care from a container of integrity and competence.
So here I present some of the lessons I have learnt from my own litany of sagacious screw-up’s
in the hope it might help you unscrew your own nursing practice.
Remember: righty tighty….lefty loosey.
DISCLAIMER:
This manual is by no means intended as a textbook or reference to best practice or
evidence based nursing.
Oh no, that would be up to you to explore for yourself (after all it’s free….and you get what you
pay for…no?)
Think of it more as some advice from an experienced ( but far from an expert) friend.
Listen to my stories and pointers, and then go and cross-check against your hospital policies,
textbooks and latest journal publications.

How to handle the workload.
The ED is a wild and stressful environment that constantly bombards each of our senses with a
storm of demanding stimuli.
And every nurse who works out on the floor for longer than 30 seconds will begin to feel the slip
and the suck.
The slip is that uneasy sensation that the workload is getting away from you. There are just
too many tasks that need to be done. As they pile up in your arms you begin to loose traction and
slip downhill. The further you slip the more momentum you build, and the harder it is to get back
on top.
The sicker your patients, the greater the slope.
The trick in not slipping is to constantly re-prioritize or Triage your tasks. Keeping the high value
tasks ( ie attending to tasks that will have a direct impact on patient outcome) under control will
give you an anchor. Constantly asking yourself what is the next important thing I need to do? And
realizing that sometimes you will need to let some things just slide on past you.
And of course, the best way to avoid the slip is to rope up with your colleagues.
The suck is that insatiable neediness that you experience from your patients. These needs
can generate suction ranging from the urgent, such as a patient needing de-fibrillation; to the
important, such as someone needing to talk; to the mundane, such as somebody needing a cup
of tea.
All patients in the emergency department will suck.
The suck can quickly drain your batteries, and the trick is letting the suck pull you in the right
direction at the right time.
Sometimes you will find yourself completely immersed in your patients needs. At other times it is
actually more therapeutic to work against the suck.
The important thing to remember is the suck cannot hurt you. It is easy to imagine that with all
this neediness around, it will suck you dry. It is easy to develop compassion fatigue and mental
exhaustion and to begin to resent the suck.
But the skill of nursing is to realize you are only a conduit for the care you deliver. Your patients
cannot actually suck anything out of you unless you let them.
It takes a long time to learn this.
How to nurse the machines.
Health-care is becoming more and more complex. Increasingly nurses are having to manage a
patient that is encapsulated by a multiplex of highly technical life support equipment. A labyrinth
of ventilators, monitors, infusion pumps, defibrillators, patient controlled analgesia devices,
automated CPR machines, Glucometers, blood gas analysis machines, CPAP, BiPaP.
Machinery entangles our work.

Equipment that needs to be maintained and operated with a high degree of precision, for unlike
other complex computer systems, when life support equipment crashes you are about to lose
more than just data.
And if all that hardware wasn’t enough, there are the peripheral data gathering programs, and
patient tracking programs, and rostering software programs that all must be appeased.
It almost seems as if there are more people in the health system interested in the data than the
patients. There has become an almost insatiable thirst for the collection of data and statistics.
From studies to audits to records to key performance indicators, nurses must collect, and enter
vast oceans of data.
So. How do we break free from the robots steely grip? How do we manage all this technology
without loosing the human touch?
Here are some quick thoughts on how to nurse in the machine:
Focus on the patient, not the machine.

Patients in the emergency department are sick. And the sicker they are, the more their monitoring
equipment will try to compete for your attention.
In most instances you can learn far more from spending your time fiddling with the patient rather
than the machine they are attached to.
Start at the center and work out.

Your patient is the center. When the ventilator or the monitor is alarming, first look at your patient.
Begin with: Airway. Breathing. Circulation.
Start troubleshooting from the ABC’s and from there work your way back out to the equipment.
Don’t send in a machine to do a nurses job.

Not every patient you care for will need to be plugged into a monitor. Many patients in the ED get
hooked up to monitoring equipment they really don’t need.
Ask yourself: what level of monitoring does this person actually require? Does that lady with a
fractured hip waiting for a ward bed still need full cardiac monitoring? Does that man with the
tendon laceration really need 30 minute blood pressures?
If in doubt, read the manual.

Try to get to know the machines. Have you seen the manuals that come with these things? Five
hundred and twenty six pages of technical specs, warnings and legal disclaimers. I just want to
know where the batteries go!
Most staff are only familiar with only a small portion of the full capabilities of most monitoring and
interventional equipment.
Take time to distill some of the key operating functions out of those voluminous instruction
manuals laying around gathering dust as they prop up a computer monitor. Become a super user.
Make sure you understand how to change basic parameters and trouble-shoot simple problems
with your equipment.
Remember: KISS ME (Keep It Simple but Show Me Everything)
Alarm silence is the devils button.

Most monitoring equipment will have some form of alarm silence that will cut the klaxons for 60 or
90 seconds. In our acute care ward, each of the 20 beds has its own monitoring equipment and it
is pretty easy to get caught up walking around silencing all the alarms only to have the first alarm
start up again.

Instead of hitting the silence button as a reflex action, take a moment to try and correct the cause
of the alarm.
Don’t become a robot.

Don’t ever misplace the art of taking a manual blood pressure, or palpating a pulse, or (heaven
forbid) actually counting the patients actual respirations.
Traditional Tibetan doctors spend years learning how to diagnose a multitude of patient
conditions by simply concentrating on the qualities and characteristics of their patients radial
pulse and examining their oral mucosa.
Imagine if todays doctors and nurses were to take the time to sit down and spend 3-4 minutes
quietly holding the wrist of their patients, feeling the blood pulse under their touch.
The human body is a much more complex and reliable piece of monitoring equipment than
anything you will find hanging on the walls of the ED.
Don’t let your patient catch a computer virus.

Have you ever been hooking your patient up to some piece of equipment only to discover the
cables slash sensors slash tubes are smeared with gobs of blood slash sputum slash unidentified
gross particulate matter. It can be pretty embarrassing to you. It can be pretty harmful to your
patient.
Keep the surfaces of the equipment clean. Refer to those voluminous manuals for acceptable
cleaning protocols.
Know where the silicone ends and the flesh begins.

There is no doubt that all this technology can be beneficial in improving the quality of patient care.
And the future will hold far greater injections of technology into our profession. Multi-national
companies and start-up businesses are all queued up behind those big pharma drug reps to
peddle that next whiz bang, cannot do without piece of technology to the hospitals.
Hey, show me the machine that will help me remove a bedpan topped with a shimmering
meniscus of diarrhoea from the sweaty buttocks of an obese demented patient…….and I will be
all ears.
How not to make a medication error.
Study published in the Medical Journal of Australia, interviewed medical staff to explore some of
the causes and conditions that led to medication errors in a busy Emergency Department in
Western Australia.
Every medication error was associated with one, and usually more than one, error-producing
condition.
Overall, 16 subjects (61.5%) reported one or more personal factors having an influence at the
time of the error, including staff being busy, tired and/or engaged in multiple tasks, and hence
being potentially distracted. Several admitted to feeling stressed, usually because of the heavy
workload, and, in two cases, personal issues were thought to be contributory. Commonly, staff
were working after hours (eight instances) or in unfamiliar hospital areas (five instances) or
attending a patient who was not their prime responsibility (eight instances). Changeover in staff
seemed important in four cases, and eight staff were unfamiliar with the patient at the time of the
error.

Problems with communication were reported by 10/15 doctors and 6/7 nurses. In the case of
doctors, this was generally between teams at the time of handing over care. In the case of
nurses, communication problems occurred mainly within the nursing team. Junior medical staff
also reported lack of guidance from senior colleagues (seven reports), sometimes resulting from
junior doctors’ reluctance to bother a busy colleague or their low expectation of receiving a helpful
response to a request for advice. Two doctors felt pressured by nursing staff to increase sedation
in older patients.
What are the most important things you can do to protect yourself against medication errors?
Nurse with aggressive defensiveness: the compressed and pressured zeitgeist of the
emergency department is skewed to siphon potentially catastrophic errors straight into your
underpants. Be vigilant always. And encourage a culture of pro-tection (yourself) and co-tection
(your colleagues).
Advocate for developing an information rich environment. Easy access to current hospital
medication policies, drug guidelines and relevant information at the point of medication
dispensing.
Be attentive. When handling medications try to punch a little space in your multi-exponential-
tasking of urgent things that need to be done hours ago. Slow down and turn on your lights.
Medication. Meditation. Nearly the same word.
Be accountable: When you do make an error (not if, but when), the worse thing you can do is to
ignore it or try to cover it up. Immediately let your supervisor, the patients doctor and the patient
know.
Be supportive. Nobody gets out of a career in nursing without a medication error or two sagging
in their underpants. It is the worst feeling in the world.
Even worse than getting a needle stick injury.
How to manage a needle stick injury.
It is more like a shock than a stick.
Another Saturday night, another rather intoxicated and uncooperative assault *victim*.
You have just completed a venipuncture and as you begin to withdraw metal from flesh the
patient executes a flailing crocodile roll. His arm slaps against yours and the needle slices
through latex and deep into your finger.
The sharp sting of the needle is accompanied by the sensation of your bowel squirting out your
rectum like silly-string. Yes, it is definitely an awful moment for any nurse or doctor.
At some stage in our career many of us will receive a needle-stick injury. Over the twenty years
that I have been working in the emergency department, I have had eight. Incredibly, three of
those were during the resuscitation of a single patient. Thank-you very much Dr Zhivago*.
(*not his real name.)

These days needle-stick injuries are much more easily preventable. Many needle-less systems
have been developed to eliminate the need for sharps in activities such as drawing up antibiotics
and administering IV medications. Sharps bins should be in abundance in the work environment
ensuring rapid and safe disposal of contaminated equipment.
Unfortunately, we still need to puncture our way through the skin to take blood, insert cannulas,
deliver intramuscular injections and access a multitude of bodily cavities.
risk of infection.
In most cases the actual risk of transmission of a blood borne pathogen following a needle-stick is
extremely low. The most commonly transmissible diseases of concern to nurses are the human
immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV).
Hepatitis B: Of these HBV is the most transmissible, with a risk of infection following exposure of
around 6-30%. (Staff that have achieved immunity after being covered with the hepatitis B
vaccine are practically immune.)
Hepatitis C: Infection from HCV following a needle-stick is around 1.8%.
HIV: Risk of becoming infected with HIV is a mere 0.3%.
Of course the chance of transmission occurring is dependent of several factors including:

The viral load of the source person at the time of transmission.
The volume of infected blood transferred.
Standard precautions:
Always observe standard precautions. If you practice nothing else, practice this: every single
patient you look after is HIV positive, is oozing with Hepatitis, Syphilis, and crawling with MRSA.
Got that? Now protect yourself accordingly:
Wash your hands. Before and after any intervention.

Gloves, and eye protection, without exception.
Use safety needles and cannulas. If your hospital is not using some form of safety
cannula, you should definitely throw a big tantrum.
Needles should go directly from patient into sharps bin in one motion. Never leave a
sharp lying around to take care of *in just a second*.
Never, ever try to re-sheath or re-cap a needle.
100% attention when handling sharps.
200% attention when handling butterfly needles. They are springy little buggers and will
flick around and bite you given half a chance.
Once bitten:
If you do experience a needle stick injury, immediately wash the site well with water. Squeezing
or milking the site is of little benefit.
You should then activate your own hospitals policy for post occupational exposure management.
Remember, the risk of transmission is determined by the type of exposure rather than the
patient’s risk factors.
You and your patient will probably both need blood taken for serological testing for hepatitis B
surface antigen (HBsAg), and HIV as soon as possible.
Depending on your immunization status you may need to have a course of HBV vaccine and a
dose of hep B immunoglobulin.
If a significant exposure to HIV has occurred, retroviral drug prophylaxis should be offered
promptly. Use of such post exposure prophylaxis is not to be treated lightly and expert guidance
should be sought. Read up on your own hospitals policy.

The needle and the damage done:
Having the statistics on your side does not lessen the anguish of sustaining a needle-stick injury.
I remember several years ago (before we had safety cannula’s) a member of our staff was
stabbed in the palm with a large trocar needle as she was collecting up a pile of rubbish left on an
IV trolley. At that time we had an HIV positive patient on the ward who had recently been
cannulated. No one knew if this was the needle used on him.
Everything turned out OK, but the mental stress placed on this nurse was significant.
No matter how low-risk the needle stick injury may have been it may still cause you significant
distress. If this is the case you should seek professional counseling.
How to catheterize a male.

Penis and vagina. Its sort of like Mac and Windows.
Catheterizing female patients can be exasperatingly tricky, it’s just all so complicated.
Penises on the other hand seem much more user friendly. Sleek and functional. Of course as a
penis owner, I may be biased. But all is not as it seems….even they are not without their own
perils and pitfalls.
heads up:
Peni come in all shapes and sizes. I’ve seen little old men with members requiring a stepladder
and safety harness to catheterize, I’ve seen dicks decorated with studs and rings and distracting
tattoos, and I’ve seen strutting young dudes with Percys’ that look more like vaginas. This is just
the way of the world.
But whatever you encounter, remember that your patient is probably feeling pretty uncomfortable
with the thought of you stretching them into an anatomically erect position before ramming a
garden hose down their dangly bit. Make sure you explain the procedure and provide
reassurance, privacy and professionalism.
Note: There are some important signs to look for in an acute trauma patient before you attempt a
catheterization. First, the doctor should have performed a PR exam to check for a high riding
prostate. Second there must be no bleeding from the urethra. Both signs of a possible urethral
rupture. Do not catheterize these patients. Seek assistance from a medical officer.
The normal male urethra leaves the bladder at the trigone. It then passes through the prostate,
burrows its way down the length of the penis and emerges at the tip of the glans. But not always.
In the condition known as hypospadias, the urethral meatus can open anywhere along the ventral
aspect of the shaft of the penis giving it the descriptive nickname of a “whistle dick”.
the preparation:
Once you have assembled your equipment as per your hospital policy you can position the
patient laying comfortably on his back with legs slightly apart.
Perform a thorough hand wash and then don sterile gloves.
Most catheterization kits contain a second pair of sterile gloves to place over the first pair. You
can then remove the outer pair once you have swabbed the site.

Swab the shaft of the penis. Take the penis in your non-dominant hand and gently retract the
foreskin (around 1 in 6 males worldwide are circumcised). Swab the glans… and swab around
the urethral meatus.
Discard used swabs into the bin you have placed close by.
Carefully remove your outer gloves. Pick up the fenestrated towel or drape. Rather than having
the Willy poking through the hole in the towel, I prefer to fold it in half ( the towel, not the Willy )
forming a slot that can then be slid onto the penis from below. The penis then flops down onto the
sterile field.
rocket science:
OK. Let us proceed.

Grasp the penis just below the glans with the thumb and first finger of your non-dominant hand.
Lift it upwards, perpendicular (or should that be perpen-dick-ular? ) to the abdomen. This
straightens out the urethra, which normally follows a sort of ‘S’ trajectory in a flaccid penis.
Inform the patient that this next bit is going to feel a little weird. And cold.
Using the applicator syringe slowly squirt the entire contents of Xylocaine jelly (around 10 mls)
into the urethra.
Do not pick up the syringe and say “I am just going to inject some local anaesthetic into your
penis!” Most males will think you are about to stick a giant needle into their privates and have a
cardiac arrest.
Once the urethra has been filled with anaesthetic jelly, squeeze the urethra closed between your
thumb and finger (to stop the gel oozing out) and make a little polite conversation.
Most nurses rush ahead ramming the catheter home before the anaesthetic has had a chance to
work. This is painful, causing the patient to tense-up and increase resistance to the passage of
the catheter. Local takes around 3 minutes to work properly, although that is a long time to be
discussing the latest sports results with a bloke whilst holding his penis in your hand. So at least
wait a bit.
Now, lift across the catheter in its tray, and lay it on the sterile field.
Pick up the catheter with your dominant hand while your other hand re-applies gentle traction,
lifting the penis back to attention.
Insert the tip of the catheter into the urethral meatus and advance it cautiously down the urethra,
feeding it from the tray so as not to contaminate it.
There are 2 potential roadblocks to a smooth catheterization. The first is the external sphincter
and the second is the prostate. If resistance is felt, ask the patient to try and relax as if he were
having a pee.
If there is still resistance, you can gently apply a little more traction to the penis and push a little
harder….but that’s about it. If the catheter will still not advance you should remove it, try again
with a slightly larger size or notify the medical officer.
Once the catheter advances smoothly, continue to feed it in. All the way up to the hilt. You want
to make sure that you are not about to blow the balloon up in your patients urethra (You will know
if this happens because his fist will rapidly fill your entire visual field).
Inflate the balloon with 10mls of sterile water and connect the catheter to the drainage bag. Once
the balloon is inflated, you can gently pull the catheter back until it stops.
Do not be alarmed if there is not an immediate flow of urine from the catheter. All that anaesthetic
jelly tends to clog the end of the catheter and it may take a minute or so before it ‘melts’.
Secure the catheter to the patient as per your hospital policy and clean up. Be sure you roll the
foreskin back over the glans if you pulled it back during swabbing, to prevent a swelling and
constriction known as paraphimosis which could, if left untreated, lead to gangrene of the penis.
Copyright Ian Miller 2008. - 10 -

Not a pretty sight.
How to catheterize a female.
preparation and positioning:

Preparation is the key.
Obtain consent from your patient and inform her of what she should expect to experience.
If you are a male nurse always have a female nurse present during the procedure. And realize
that having a strange male nurse swan diving into your privates will probably be quite traumatic
for most female patients.
Position the patient by asking her to draw her knees up with ankles together, and then relax and
let her knees drop to either side. The other nurse can assist with maintaining comfortable
positioning. (Make sure the patient remains covered whilst you are scrubbing up to guard against
this.)
At times patients will be unable to co-operate or unable to comply due to injury and you will have
to improvise on the best way to obtain an access trajectory.
Assemble catheterization equipment as per your hospital policy.

Remember, studies have found that Lignocaine gel substantially reduces the procedural pain of
female urethral catheterization by comparison with use of a water-based lubricating gel.
Quality lighting of the area will show you what is what and where is where. Take time to position a
good light source.
scrub up:
Perform a thorough hand wash and then don sterile gloves.
Most catheterization kits contain a second pair of sterile gloves to place over the first pair. You
can then remove the outer pair once you have swabbed the site.
Clean along the length of each of the labia majora. Use a new swab for each pass, in a smooth
front to rear action to minimize risk of contaminating your work with bowel flora. Discard used
swabs into bin which you have placed close by.
Using your non dominant hand, separate the labia majora and clean the labia minora in the same
way. Next, swab in a downwards motion between the clitoris and the vagina.
OK. Now cautiously remove your outer gloves and discard.
Pick up the fenestrated towel and drape the patient.
Once again with your non dominant hand separate the labia. With your dominant hand pick up
the catheter. It’s showtime.
pass the catheter:

In females the urethra is relatively short (around 4cm). The urethral opening or meatus is usually
located in the superior fornix of the vulva, between the clitoris and the vagina.
Sometimes it is easy to spot, looking like a small stoma or a dimple or a slit….and sometimes it
looks more like a needle….in a soggy, pink, mushy, haystack. Good luck.

Once you think you have the meatus in your sights hold the catheter in your dominant hand and
gently introduce it into the urethra. This may cause some discomfort to the patient so take care.
At this point you can ask her to take a deep breath in and relax as if she was having a nice pee.
It is not uncommon for the catheter to slide off some mysterious bit of anatomy that was not the
meatus after all, and end up in the vagina.
Never mind. Leave the catheter in situ and try again with a new one.
TIP: Difficulty locating the urethra? here is a tip from the British Journal of Urology.
The index finger of the non dominant hand is inserted into the vagina. The urethral orifice can
then be palpated on the anterior vaginal wall, and the finger can be held there to both block the
vagina and guide the catheter in to the correct position.
Now I have never tried this, and sticking a finger into a patient’s vagina is extremely invasive. But,
following explanation to the patient it may prove helpful if absolutely all else fails.
When you hit a bull’s-eye ( and try not to yell out “bull’s-eye!”) you will get a return of urine.
Advance the catheter a further 4cm just to make sure you are well within the bladder before
inflating the balloon.
Inflate the balloon with sterile water (check the catheter pack for correct amount. Usually 10mls)
and then apply gentle traction to bring the balloon up snug against the trigone ( the area where
the urethra leaves the bladder.).
Connect the catheter to the urinary drainage bag.
Tape the catheter as per your hospital policy. Make sure that there is enough slack in the system
that any movement of the patients legs does not put traction on the catheter.
Clean up the whole area, and document your procedure in the nursing notes including size and
type of catheter… and don’t forget to remove that bundle of 4 or 5 *missed attempts* splaying out
of her vagina. Good grief! It looks like the back of my stereo down there.
The whole art of urinary catheterization is to minimize the risk of introducing a urinary tract
infection; so take time to prepare and clean the area as well as developing a sound aseptic
technique.

How to remove a penis that is stuck in a

zipper.
There is no pain like the pain of having your Willy caught in the gnashing talons of your zipper.
And I am talking from personal experience here.
Call the police, call the rescue helicopter, call the priest.
So how exactly do you get a penis extracted from those interlocking mechanical incisors of
death?
Entrapment of the penile foreskin in a zipper occurs far more often than you might imagine. And it
often leads to medical staff swooping in with an armada of local anesthetics, lubricants and
surgically sharp objects.
Well here are two tried and tested methods:
The Chomp and Squeeze Method:
The first method was reported in Indian Paediatrics. It involves using a wire-cutter or pair of heavy
duty trauma scissors to make two transverse cuts along the margin of the zipper (figure 1) and
then attaching a pair of pliers carefully over the faceplate of the zip fastener, and compressing
firmly(figure 2).
The pliers squeeze open the two faceplates “loosening the interdigitation of the teeth” allowing
the prepuce to fall away. Hopefully still connected to the rest of the penis.

The authors assure us that this method results in “instant-aneously” solving the problem.
I dunno…move in on my John Thomas with heavy duty cutting implements and pincing tools, and
your problems might just be beginning…aneously or otherwise.
The Screw-This Method:
Reported in Pediatric Emergency Care, this method involves a common flat-head screwdriver
inserted between the outer and inner faceplates of the zipper. The prepuce is usually only
trapped on one side of the zipper so insert the screwdriver in the opposite side. The screwdriver
is then twisted firmly to open up the faceplates and… Free Willy.
Most ED’s have a screwdriver laying around and they are certainly far less intimidating.
In fact, the procedure could be carried out at home.
Simple, DIY penis extraction. Thats what I like.

What is mean arterial pressure?
We all diligently watch our patients blood pressure,

recording it in our observation charts…but do we pay
enough attention to the mean arterial pressure (MAP)?
That innocent little number placed in brackets or hiding off
to one side of the monitor screen.
What the heck is that number? Is it important? Should I
record it?
MAP is defined as the average arterial blood pressure during a single cardiac cycle.
The reason that it is so important is that it reflects the haemodynamic perfusion pressure of the
vital organs.
how is it calculated?
The simple way to calculate the patients MAP is to use the following formula:
MAP = [ (2 x diastolic) + systolic ] divided by 3.
The reason that the diastolic value is multiplied by 2, is that the diastolic portion of the cardiac
cycle is twice as long as the systolic. Or you could say, it takes twice as long for the ventricles to
fill with blood as it takes for them to pump it out….. at a normal resting heart-rate.
In a bradycardic or tachycardic patient this relationship between systolic and diastolic values
changes, and the formula is not as accurate. When using non-invasive BP monitoring (BP cuff
around the patients arm) the monitor uses this formula to determine the MAP, so it is less
accurate in the unstable patient.
During invasive monitoring of BP (using an arterial line) a complex formula is used that is way
beyond my understanding to attain a much more accurate and real time value.
OK, if you must know… it is obtained via Fourier analysis of the arterial waveform, or as the time-
weighted integral of the instantaneous pressures derived from the area under the curve of the
pressure-time.
Whatever.
do I need to watch it?

Definitely. I guess a rough analogy would be that the MAP is the oil gauge for your patients
motor.
A MAP of at least 60 is necessary to perfuse the coronary arteries, brain, and kidneys. Normal
range is around 70 - 110 mmHg.
It is a vital sign to monitor anytime the patient has a potential problem with perfusion of his
organs. Some examples (and there are many more) might include:
• a patient with septic shock on vasopressors.

• head injured patients.
• Cardiac patients on vasodilator (GTN) infusion.

• Patient with a dissecting abdominal aneurysm who needs to have his BP controlled within
a narrow range so as not to cause increased bleeding.
In a head injured patient, the brain is at risk of ischemic injury due to insufficient blood flow if the
MAP falls below 50. On the other hand, a MAP above 160 reflects excess cerebral blood flow and
may result in raised intercrainial pressures.
is it true that women are worse than men at reading a MAP?

Now, if you think I am brave enough to tackle that question you must be crazy!
Where to place that cannula.

Here are some tips based on my own personal experience. You may well disagree with them, or
you may have some better ideas of your own. Let’s have a look.
Preparation.
I think 80% of the trick in performing a successful cannulation is in taking time to prepare your
equipment and selecting the best available site.
Selection:
• Long and Large: You want to pick a large vein and then put a large cannula into it. In the
emergency department setting we often need to deliver large volumes of fluid over short
times. The larger the vein and the larger the cannula, the less resistance to rapid flows.
• Pure and Pink: There should be no evidence of thrombosis or damage to the valves
from previous attempts at cannulation. The target area should be well perfused. It should
not be in a zone of acute burns, wounds or infection.
You should avoid attempting to cannulate over a bony prominence.
• Safe and secure: You should also consider both the security of the cannula and the
comfort of the patient when considering placement.
A cannula placed at the cubital fossa is likely to kink off every time the patient bends their
arm. It can also be quite uncomfortable.
Similarly, a cannula placed in the back of the
hand is also likely to kink with movement of the
hand. For some reason placing cannulas in the
back of a patients dominant hand seems to be a
favourite site for junior doctors.
scope the lay of the land.

OK. Before we begin machete-ing our way into the
circulation, let us tighten up the tourniquet and give the
veins a little time to fill.
Some people swear by using an inflated BP cuff instead
of a tourniquet to really buff up those veins.
Other tricks used to get a little vein-o-erection include

placing warm towels over the area, briskly tapping or slapping the area, letting the arm hang
down over the edge of the bed (before applying tourniquet) , and even using vasodilatory creams
such as Nitrobid paste ( this sounds a little dicey to me).
Start by inspecting the non-dominant arm, but if you cant find anything jumping out at you, check
the other arm.
Don’t forget to inspect the entire surface of the arm. Quite a few times I have battled to get a line
in only to find veins the size of a garden hose on the underside of their arm.
Never underestimate the importance of palpating. More experienced cannulators will probably tell
you that they rely more on feel than on sight when searching for a vein.
ground zero.
Once the veins are on show… look to see if you have one
that bifurcates ( like the inverted Y pictured). These veins are
simply begging to be cannulated, and its a simple matter of
inserting your needle through the bifurcation and up into the
root vein. Sweet.
One mistake many people make when attempting to access

a straight vein is to approach from above. More often than
not the vein will *roll* away from the needle. Particularly in
older patients with more, well, older connective tissues.
Approach from the side whilst at the same time stabilizing
the vein with your other hand by applying gentle traction to
the skin.
Over time you can develop quite a sensitivity to the actual

layers of resistance.
The skin will often require some force to pierce, but don’t push too hard. Once through the skin
the needle will advance easily until you feel a subtle ‘pop’ as you enter the vein.
Advance the needle slowly to avoid skewering right through the vein. Known as pranging the
vein.

How to place a cannula.
The ability to place a cannula is indeed an art. And like all art it should be elegant, unhurried and
appreciated.
Step 1. Preparation:
Take a few moments to gather all the equipment that you might need. Bounding over to the bed
like a Jedi Knight on heat with only a Jelco in one hand and a cap in the other is unprofessional,
dangerous, unhygienic and produces bad karma. Set up properly using the provided trolleys.
Open a cannulation pack and assemble jelco, blood tubes, culture bottles, tape etc….oh yes, it’s
kinda embarrassing when you forget the cap. Think of this as a sort of Japanese tea ceremony.
Slow down. Be the cannula.Next, prepare the person. Make sure you inform the patient of your
intentions. And while you’re about it, how about explaining exactly why you need 20mls of his
blood (not just “to run some tests”).
never hurry a cannulation, and always always observe universal precautions.
Apply gloves and eye protection. If I ever see you put a cannula in without personal protective
equipment, a spanking will be imminent.
Select a good insertion site. A 20g in the back of the hand can be a pain in the anus for the
patient, especially if it is in his dominant hand. It’s fiddly and frequently occludes with dorsiflexion.
There are usually plenty of veins on the forearm…..well at least have a look. And don’t forget the
basilic veins hiding under the forearm.
Make sure you shave the area with a surgical shaver if he/she is a hairy fellow. The tapes will
adhere better and remove easier. Don’t use a disposable razor that might damage skin integrity.
Confucius say; “pulling out arm hairs of big man sure way to hear sound of one hand slapping.”
If the patient is diaphoretic, a bit of Tinc Benz around the insertion site before taping and covering
the cannula will ensure security.
Put some sort of protective surface down under the site to catch the spillage. A big blob of blood
left on the patient’s sheets is poor form, and there is nothing as embarrassing as putting up the
bed-side to find the railing covered in blood from a previous patient.
Select the largest cannula you can confidently insert into the selected vein. Remember: the larger
the lumen the larger the flow rate that may be achieved. Size does matter.
Step 2. Insertion:
…… now Grasshopper, take a slow breath, focus, and think positive, beautiful thoughts.
You see, if you think you might prang the vein, you will probably be right. It sometimes helps to
slowly chant the ancient Australian Zen mantra: gowin-yabugger gowin-yabugger (….its better to
do this silently to yourself).
Use your non dominant hand to stabalize the patients arm. Try to enter the vein from the side
rather than from above as it will tend to roll away from the needle. Aplying gentle traction to the
skin will help steady a rolling vein. The more cannulations you do the more you will learn to feel
whats going on through the cannula rather than by sight.

Look for a flashback of blood in the trocar hub. Remember the cannula tip sits a couple of
millimeters behind the point of the trocar, so once you have a flash back, advance it just slightly to
ensure the cannula is in the lumen of the vein.
Now holding the trocar stationary, smoothly slide the cannula into the vein.
Immediately dispose of the trocar into a sharps bin and cap the cannula.
Once you have it in….it’s time to take some blood. Use a vacuette or similar system to collect
blood safely. And for goodness sake pay attention. This is a risky proceedure and believe me,
you will not forget your first needle stick injury.
Once you have enough blood, inject a few mls of saline into the cannula to ‘lock’ it.
Apply the dressing as per your department’s policy. Make it elegant. For extra bonus points write
the date of insertion in pen on a steri-strip and stick it over the dressing.
Step 3. Cleanup:
Dispose of your sharps, cleanup your mess (including blood spilt on the trolley, the bed, the
nurse, the walls), thank the patient and disappear like a Ninja into the night.
How to secure a cannula.

How many times have you come across a canula that has fallen out, or is half out, or has become
kinked. Or is at risk of becoming infected.
Obtaining IV access if a pretty important skill to be mastered in the Emergency Department. And
those with sharpshooter IV insertion under pressure, inevitably earn a certain respect amongst
their peers.
But IV security is often given little attention. There is no point in getting it in unless you can keep it
in.
There are a hundred different ways to secure an IV cannula. And there are many commercially
available devices that do a great job. But what if you don’t have such things available?
What if you only have the basics?
Let’s look at my way.
First things first:

The first point is to slow down and take a little time
to secure the cannula. Many people make the
mistake of switching off once the line is in and
slaphazardly sticking it down with a little tape.
Believe me you will be saving yourself a whole lotta
extra work by making sure the line is secure in the
first place.
Here we have our freshly inserted cannula (it is

sticking out of the skin a little further than we would
like, just to illustrate the taping technique).

The first step is to place a Steri-strip (or similar sterile tape) under the cannula. You want it sticky
side up which I have shown in green.
Remember, this should all be done aseptically…. and manipulating sticky tapes with latex gloves
on is definitely an art.
Slide it up nice and snugly where the cannula enters the skin.
So far….so good:
Next you want to fold up both corners of the Steri-
strip to form a ‘U’ around the insertion site.
Make sure you leave a little sticky surface

exposed on either side of the cannula.
This surface will stick to the sticky surface the next
Steri-strip providing 360 degrees of *grippage*
around the cannula.
It is this 360 degree contact around the cannula

that makes it so secure.
Next:
Take another Steri-strip and place it (sticky side
down) over the top of the cannula.
Gently ‘pinch’ around the cannula with forefinger

and thumb to bond the two sticky surfaces.
If the patient is very diaphoretic (or as we say in

the ED…. sweaty), you can apply some Tinc
Benz or Friars Balsam to the skin. This is an
antiseptic solution that dries very tacky and
guarantees a secure dressing even with profusely
sweaty patients.
Nearly there:
Now, place a piece of Op-site or
Tegaderm or similar adhesive dressing
over the top of the whole thing. Make sure
it does not obstruct or stick to the IV bung
or IV tubing.
Once again, press it down firmly and

gently pinch around the cannula to secure
it good and proper.

Another cannula secured:

Finally. For extra security and to stop the bung
from catching on bedsheets and ripping out,
place another Steri-strip over the top of the
bung.
If you are connecting the IV line apply this last

strip after the connection.
Loop the IV so it is travelling back towards the
patient and secure it with some tape.
If the patient is restless or confused, you may

need further IV security by using wide
Elastoplast and/or bandages.
Make sure you dont tape the IV line directly to

the dressing as it will pull the whole thing apart
when you are trying to change the line.
For bonus points, write the size of the cannula and the insertion date on a sticky label and attach
to the Op-site.
How to tell if your patient is playing possum.

I was a virginal student nurse looking after this young dude, and I was worried. He had been
dropped off at the ED by a *friend* after an afternoon of drinking that culminated in a ding dong
argument. He was not responding to my attempts to rouse him.
I quickly notified the senior doctor on duty who wandered over. After leaning over and examining
the patient for a few moments he glanced over at me, took hold of the mans left nipple and
twisted it up to volume level 11.
Wide eyed the man sprang up in bed and, via remote nipple control, the doctor actually
maneuvered him completely off the bed and into a chair.
“I think he was faking it.” And he left to look after sick people.
There are many reasons why people who present to the ED play possum. Ranging from
withdrawing into themselves after a traumatic event, to attention seeking behaviors, to psychiatric
illness, to attention avoiding behaviours.
If your gut feeling is that your patient is feigning it, you are probably right. But you are not
definitely right.
I remember looking after a young girl that I was convinced was a total hyperventilating, hysterical,

attention seeking brat.
In fact she had a large brain tumor.
There are many potential causes of a decreased level of consciousness in your patient. Here is a
mnemonic to help you remember them:
A- alcohol, acidosis, anoxia

E - epilepsy, environment
I - insulin (diabetes)
O - overdose
U- uremia (metabolic), underdose
T - trauma, toxins, tumors

I - infection (sepsis)
P - psychiatric disorders
S - stroke (CVA)
So the short of it is, a patient playing possum should still be managed as an unconscious patient
until a definitive diagnosis of pseudogenic coma can be made.
They should have a full neurological assessment (Glasgow Coma Score) and Airway, Breathing,
Circulation requirements must be anticipated.
Once you have stabalized the ABC’s there are a few tips you can use to determine if your patient
is a possum:
the sternal rub:

Vigorously grind your knuckles against the patients sternum. This causes what is known in the
business as noxious stimuli, and will usually rouse the pretenders.
the finger press:

Take your pen and press it hard against one of the patients nail beds. This really hurts.
the hand drop:

With the patient lying supine. Lift their hand above their face at a distance of about 20-30 cm. And
let it drop. A patient pretending to be unconscious will invariably readjust the trajectory so the
hand falls away from their face.
the eye flicker:

Gently run your finger along the patients eye lashes. If they are bogus, their eyelids will tend to
flicker.
the reveal:
Gently open the patents eyes. Any resistance to eye opening is a tell.
Once open, the possum may roll his eyes back up into his head until you can only see sclera

(known as Bell’s phenomenon) or move around in short well defined (geotropic) tracking
movements.
With patients who have a true decreased level of conciousness, passive eyelid opening is easy
and is followed by slow eyelid closure. Blinking also increases in possum patients, but decreases
in true coma.
The eyes of patients who are unconscious may have a neutral position or exhibit a roving gaze
where the eyes slowly scan back and forth across the visual field.
One paper I read suggests holding a mirror up in front of the patients open eye and observing for
a pupil constriction when they look at themselves.
the ignore:
Once you have finished evaluating your patient, place them in the recovery position and go about
your business. Lack of interaction either drives possums crazy and they just have to take a peek
to see what is going on, or the lack of attention overwhelms them and they *wake up* in order to
get a little interaction.
the wasabi woo-woo:

Save up those small packets of wasabi next time you have Japanese take away. Open the
patients mouth and squirt.
I’m kidding, I’m kidding.
Actually, it is important not to be judgmental or to ridicule these possum patients. You are not
going to score a bonus point for tricking them or catching them out.
The patient is behaving in a way that, to them, seems totally appropriate or necessary within their
current situational experience.
The ability to maintain a compassionate and professional attitude towards their care will often
result in a patient that ends up responding in a therapeutic way.
Trick them out, and you may simply end up with a bed full of trouble.
How to manage a patient having a CAT scan.
cat as in catastrophe:
You have just spent the last 30 minutes working to stabilize this multi-trauma patient.
Intubated and ventilated with full spinal precautions, skewered with chest tubes and plugged with
combines. They lay amongst a distillery of tubes and infusions. The room is a mess. It looks as
though a meatballs and tomato soup truck has crashed through an office supply shop and into a
telephone exchange.
But at least the patient is now stable.
And so they are off to scan-land.
From the recourse rich, controlled environment of the resuscitation room… up the corridor, and
over to another food chain altogether. If anything is going to go wrong with your patient, it will
probably happen half way through their abdominal CT scan.
Here are some tips to help you prepare for any impending CAT-astrophe:

pack before you go.
Make sure you take time to assemble all the equipment you might need:
• ACLS equipment. Dont forget an Airviva.

• Drugs. If your patient is paralized they will inevitably wake up half-way through their scan.
Draw up some non-depolarizing muscle relaxant such as Vecuronium to take with you.
Some staff refer to this as the Keep’em down Kit.
• Take some extra fluids.
• Portable monitoring equipment (check the batteries).
tackle the tubes.

Its a pretty good idea to try and untangle that macramé cocoon of IV tubing from around your
patient before you leave. At the very least make sure all lines are securely anchored to your
patient. Identify a line that will be suitable for CT staff to use for administering any IV contrast (ie.
a dedicated saline line).
Find out if your patient requires oral contrast prior to an abdominal CT. If he is unconscious this
will need to be administered via a Naso-Gastric tube.
invite the boss.

If you are taking an unwell / unstable patient to CAT scan, make sure you have an experienced
doctor along for the ride.
ABC comes way before X-ray.

CT staff are always in a hurry. They have plenty of ward scans to attend to and you have just
messed up their schedule. But. Take time transferring the patient form bed to CT table. Before
clearing out of the room and beginning the scan, check:
• Airway is secure and patent.

• Adequate ventilation is being delivered.
Check all ventilation tubing is secure with enough slack to cover the expected range of
movement of the patient through the scanner.
• Ditto the IV tubing.
• Observations are all stable.
Oh… and one piece of advice (from personal experience), check to make sure the patients
catheter bag is not still attached to his bed before sliding him across.
I’m just saying.
don’t join the party.

You know, for some reason the control room of the CT scan is like a kitchen at a party. It always
seems to fill up with people who haven’t seen each other for a long time and have a lot of
catching up on gossip to do. Often you cant even swing a CAT in there.
Try not to get distracted by the party and keep your eyes on the prize. Make sure you have clear
sight of the monitoring equipment.
Continue to document the patients observations.

Watch for any disconnections or pulling of lines as the patient moves through the scanner.
Remember… your patient has now entered the tunnel of death. Anything that is going to go
wrong will now do so.
When you finally do leave the CT room, you should have left this greasy mark where your nose
has been pressed up against the glass (really).
Tip: lip balm and oxygen.

Here is a quick tip.
If you are having trouble getting a child to tolerate an oxygen mask, or you need to deliver nitrous
oxide via a mask, smear a little flavored lip balm into the inside of the mask to provide a *juicy*
pleasant smell.
If you purchase a selection of different flavors you can then ask the child to help you decide which
flavored oxygen they will get to breathe.
How to use nitrous oxide.
Nitrous oxide ( N2O ) is the oldest known anesthetic agent. It was discovered by Joseph Priestly
in 1772 and was first used to provide relief during dental extractions.
Nitrous oxide is a tasteless colourless gas that is rapidly absorbed into the bloodstream where it
acts on areas of the brain and spinal cord that are rich in morphine sensitive cells.
Although commonly known as laughing gas, the use of N2O for procedural sedation is no
laughing matter and should only be instigated by staff members experienced in its management.
Indications:
• Relief of pain from muscular-skeletal injuries.
• Reduction of joint dislocations.
• Adjunct to lignocaine in laceration repair.
• Adjunct to other analgesia in wound care and dressing.
• Child at risk. (CAR) assessment.
• Adjunct to analgesia during child birth.
• Migraine.
Contra-indications:
• Pressure effects: N2O Does increase the volume of gas in body cavities such as the
middle ear, the pleural space, the sinuses and the GI tract so it should not be used if
there is any risk of:
Intracranial air
Bowel obstruction.
Middle ear infection / recent middle ear surgery
PE
• Decreased level of conciousness (LOC).

• Child < 5 yrs.
• Early pregnancy. In some animal studies N2O has been proved to be directly
teratogenic due it inactivation of Vit. B12
• B12 deficiency. As above.
• Immunosuppression.
• IV sedation or narcotic in the last hour.
• Fasting < 90 minutes. N 2 O causes nausea and vomiting in about 10% of cases. As the
patient will be drowsy, it is important to use a clear mask on the circuit so you can keep a
close eye on the airway.
• Psychiatric disturbance.
Set-up:
Make sure you have an informed consent from the patient prior to beginning the procedure.
Assemble your Nitrous oxide machine as per ward policy. The machine consists of a facemask
that attaches via tubing to reservoir bag and blender. The blender permits the user to titrate the
N2O to oxygen ratio, and to adjust the flow rate. (Administering as little as 40% N2O is usually
enough to produce confusion and sedation.)
Most N2O machines also have some form of scavenger system. As N2O is a heavier than air
gas, any leakage will tend to settle on the floor. A significant amount can quickly accumulate in a
poorly ventilated area, and as mentioned, it may be teratogenic. A scavenger tube placed on the
floor will collect this residue and remove it via wall suction.
The patient should be placed on a cardiac monitor, pulse oxymetery and have full ACLS
equipment available. Suctioning should be also be available and at close hand. There must be a
minimum of 2 experienced staff, one to administer the N2O and to manage the patient’s airway,
and one to perform the procedure.
N2O may cause desaturation, airway obstruction or even apnoea.
The procedure:
A baseline set of observations should be obtained prior to commencing. Observations should be
obtained every 5min during the procedure, paying careful attention to the patient’s airway status
and level of consciousness (LOC). N2O may cause desaturation, airway obstruction or even
apnoea.
The doctor should begin the N2O at 50% for no less than 3 minutes. If at that time sufficient
sedation has not been achieved it can be slowly ramped up to a maximum of 70%. Remember:
one of the causes of inadequate sedation may be a leak in the circuit or poor seal of the face
mask.
Recovery:
Following the procedure, the patient should be placed on high flow oxygen and observed closely
until baseline LOC returns. If being discharged home, the patient should be observed until they
can safely mobilize.
Document the procedure in the patient’s notes including:
• Max % of N2O administered.

• Duration of procedure.
• Effectiveness
• Complications

Tips:
Prior to administering N2O to young children you might give them the mask to play with whilst you
are setting up. We also keep a variety of flavoured lip balms that we apply to the inside of the
mask. This gives the gas a pleasant smell and allows the child to choose which flavour gas he
would like to have.
Minimizing Violence with STAMP AID.

It has been well documented that violence in our emergency departments is on the rise. Violence
may be an actual assault, or it may manifest as aggressive, threatening or intimidating behavior.
It may come from the young man high on amphetamines or from the elderly female office worker.
A recent doctoral study completed in an Australian emergency department has developed a tool
to help nurses predict potential for imminent violence directed toward staff by patients, family
members or friends.
The study lead by Lauretta Luck has developed the acronym STAMP to help nurses categorize
behavior sets that may point to a raised potential for violent behavior. I have added my own tool
to help you defuse such a situation:
predicting violence with STAMP:

Stamp stands for staring, anxiety, mumbling, pacing.
Staring. Staring was flagged as an important indicator of violence potential. That prolonged,
intent, eye contact we have all experienced drilling into our backs as we go about our work, is a
good predictor of increasing anger.
Anxiety. The large number of emotional and physical stressors poking into the patient, can easily
push them into a space where their behaviour is not in character or control.
Pain, loss of control, fear, alcohol or drugs can all induce an internal environment fueled by acute
anxiety.
Indicators such as rapid speech, flushed face and hyperventilation were identified as predicting
trouble ahead.
Mumbling. When combined with other negative cues, mumbling or slurred and incoherent
speech, especially when composed of aggressive, negative statements about the waiting times or
service was another good predictor.
Pacing. Patients pacing around the waiting room or visitors pacing around patients beds was
found to be indicative of mounting agitation.

Averting violence with AID:
So you have a pretty sure feeling that you and your patient are headed for conflict. What can you
do? Well here is a tool I have come up with to minimize a situation of escalating violence.
AID stands for attend, inform, defence.
Attend. One of the big generators of anxiety amongst patients and relatives is the feelings of
*abandonment* they experience in the ED. Never mind if it’s the waiting room or a treatment
area, patients often perceive that they are not receiving the level of attention they need.
By making an effort give attention to these patients we can often diminish these feelings. Even if
we cannot meet all their perceived needs the very act of exercising authentic concern may be
enough.
Though it may not be an easy task, try not to avoid a patient that is beginning to show signs of
STAMP.
This simple act of attentiveness is often enough to de-escalate any anger and will often prove a
far easier interaction than trying to manage a later situation of overt hostile aggression.
Inform. Communication breakdown is another major cause of increasing aggression and

contributes to feelings of abandonment and loss of control.
When patients are waiting to be seen, or waiting for test results, or waiting for a ward bed to
become available, keep them informed of the expected delays and any changes to their position
in the queue. Listen to any questions they may have.
Tell them what has happened what is happening and what will happen.
Many emergency departments now have hand-outs or notices explaining both the Triage process
as well as preparing them to spend an extended time as they are treated in the ED. Make sure all
your patients have an opportunity to access this information.
Patients should also be informed with signage and handouts that aggressive behavior will not be
tolerated.
defence. Stay safe.

Never forget that even though we may be able to predict an escalation of emotions that may lead
to violence, it is much harder to predict how that violence might be expressed.
With a sustained exposure many ED nurses have desensitized themselves to low-level violence
and have a much higher threshold of acceptance than most people. This is a bad thing.
The fact is we should be promoting a zero tolerance for aggressive or violent behavior, period.
Agitated or aggressive patients are enveloped in a no-go bubble that extends the distance of their
outstretched arms. Never enter their bubble unless absolutely necessary.
Never let an aggressive person come between you and your exit strategy. Talk in a calm, even,
clear voice. Make any instructions short and unambiguous. Avoid prolonged eye contact if patient
is agitated or paranoid.
As I have advised before: When interacting with a potentially volatile patient it may be helpful to
try and see your self as an observer of the scene. Imagine yourself stepping *outside* the
situation looking on dispassionately. Watch how the relationship between the other you and the
patient is evolving. Remember all this anger is not yours unless you choose to react to it.

It’s not easy, but using this technique may help you from getting caught in the emotional wash
from an abusive patient and feeding the escalation with your own reactions.
It should be part of your ongoing professional development to establish a set of skills and
strategies for dealing with these sorts of scenarios. Many hospitals offer courses on dealing with
cases of professional assault which offer a combination of de-escalation strategies as well as
simple self defence techniques.
Reference:
STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments.
Lauretta Luck, Debra Jackson, Kim Usher
Journal of Advanced Nursing
Vol. 59 Issue 1 Page 11 July 2007
How to use the rectal trumpet.

Perhaps the three most terrifying words ever to be uttered during handover.
Profuse… watery… diarrhoea.
Forget gaping lacerations with arterial bleeds squirting like out of control garden hoses.
Forget intoxicated teenagers, projectile vomiting McDonalds with extreme prejudice.
Forget the shift coordinator begging you to work yet another double shift.
No…it is these three words that will drain the blood from the face of the most hardened ED nurse.
Profuse… watery… diarrhoea.
There is no doubt that it is an onerous and odorous business for the attending nurses, but for the
poor patient inflicted with this liquid catharsis, it is surely a miserable and demeaning experience.
From personal embarrassment to painful skin erosion around the buttocks and perineum. From
loss of dignity, to sepsis resulting from wound exposure to nasty organisms. Enter stage right with
a fanfare…..the Rectal Trumpet.
Take a size 7 or 8 nasopharyngeal airway and connect the tapered / beveled end to a urinary
drainage bag.
Temporarily clamp the drainage tube and use a syringe to pour olive oil through the airway into
the tubing taking care not to spill any onto the distal flange of the airway.
Release the clamp allowing the oil to drain into the urine bag. The tubing is now well lubricated.
If practical, position the patient on their side with knees drawn up to chest.
Warn the patient that the next step may be temporarily uncomfortable. Carefully pass the flange
end of the airway into the rectum.
Pull back gently until a slight resistance is felt.
Attach the urinary drainage bag to the bedside. Make sure it is all positioned so as not to produce
any tension on the tubing. (Taping the tubing to the patients leg may prevent this.)
There is no need for any other taping or securing of this system, it is simply held in place by the
resistance of the flange against the anal sphincter tone.
If the patient has severe abdominal distension the resulting pressure on the rectum may dislodge
the trumpet, likewise, excessive straining or forceful valsalva maneuvers may expunge the
trumpet, but otherwise it should usually remain in-situ.
Once passed, the trumpet should cause only a transient discomfort for the patient.
By adding the rectal trumpet to your kitbag of tricks, the words profuse watery diarrhoea will be,
ahem, butt music to your ears.

How to handle the smell of poo.
You all know the scenario; you roll your semi-conscious patient over only to discover a steaming
lumpy broth of diarrhoea that, thanks to the physics of capillary action, has oozed and squittered
its way into every fold and fossa betwixt and between.
Its way too late for the rectal trumpet, and now you and your colleagues will need summon your
full concentration to engage in that ancient nursing art of suppressing the gag reflex.
I don’t know why poo makes you gag. Scientists have postulated that it is to deter people from
eating it. Hey scientist people…..I got news for you.
And I don’t certainly don’t know why evolution could not have given nurses a break and made it
smell like lavender. But there you go.
Incidentally, this smell that threatens to release our lunch back into the wild, is caused by
bacterial action in the intestine which produces sulfur containing compounds, indole, skatole, and
hydrogen sulphide.
Nurses tend to become the wine connoisseurs of the fecal world. Just as there are many types of
poo. Malaena, gastro diarrhoea, constipation, green bubbling steamy poo, septic poo, each has
its own particular signature odor. Some seem to stimulate the gag more than others.
I once was helping to undress this drunken teenager when something fell out of her tracksuit
trousers onto the floor. I picked it up and thought it was a piece of wood. On closer inspection it
proved to be a chunk of *petrified* poo. It mus have been in there for months! And it had
absolutely no smell.
poo pointers:
OK. Here are some practical tips to help you through your next code brown.

surgical mask and peppermint.
This is perhaps the most effective method of odor eradication. A couple of drops of peppermint oil
on a surgical mask and you are *good to go* into even the most malodorous mess. Just take
care, too much peppermint and you will think you have been capsicum sprayed.
lip balm.
Flavoured lip balm or “Vicks Vaporub” are also quite effective options and easily carried in your
kit. Smear inside a mask or directly under your nose.
breathe through your mouth.

This is only vaguely effective. It does take the edge off the smell but doesn’t really take the
gagerosity out of the whiff. In fact I suspect that rather than smell it, you sort of taste it…… Urrch.
Sometimes the only option you will have.
face shield.
On our own ED we have disposable full face shields as part of our personal protective equipment.
These work quite well as you get a relatively fresh chunk of atmosphere trapped between the
shield and your nose. Also protects against cleanup spatter.
oxygen mask.
When we were both student nurses, a good friend of mine got himself in a world of trouble when
he was sprung by the senior nurse cleaning up a patient whilst wearing an oxygen mask. He told
me he found a Hudson mask running at 10 liters/min to be most effective.
The charge nurse was not impressed. Personally, I give him an A+ for ingenuity.
delegate.
Student nurses and new-grads. Its a tradition.
desensitization.
The more poo you do the better for you.
Veteran bedside nurses can scoop up handfuls of the stuff whilst deeply inhaling to discuss the
Beef Vindaloo they ate for dinner last night.
On the other hand, stand next to me during a clean-up and you will see beads of sweat on my
pale forehead as clench my jaw and concentrate with Herculean effort on not going:
bburrWAGGHHHHhhh…..uucGGAWWW……urrch!!! And loose not only my lunch, but any last
modicum of professional credibility that I may have left.

How to immobilize a suspected spinal injury.
Every year we see hundreds of patients with suspected spinal injuries or who require
precautionary spinal immobilization. A tiny weeny percentage of these are proven to have any
actual lasting damage. Complacency however, is not an option.
I once triaged an 11 year old who presented with persistent neck pain 3 days after a fall in Judo
class. He had an unstable C2 fracture.
Some mechanisms of injury that should be ringing your bells include:
• A pedestrian or cyclist hit with an impact

speed greater than 30km/hr.
• Occupant of motor vehicle involved in a
collision greater than 60km/hr.
• Fall more than 3 meters.
• Kicked by or thrown by a horse.
• Backed over by a car.
• Thrown over handlebars of a bike.
• Severe electric shock.
• Any significant trauma above the level of
the clavicles.
• Unexplained hypotension following
trauma.
• Obvious history of neck trauma .
• Midline tenderness or reluctance to move the neck.
• Neurological deficit.
Fit a rigid immobilizing collar.

Inform the patient of your concerns and that in all likelihood this will only be a precautionary
intervention that will be removed as soon as a more thorough assessment can be made.
You will need an assistant to immobilize the c-spine whilst you fit the collar.
If the patient has walked in to the department you might find it easier to fit the collar whilst they
are sitting on the edge of a bed. After fitting, carefully assist them to the supine position. We use
special slide sheets to minimize friction as we swivel them into position.
Remove any jewellery above the clavicles including necklaces, earrings, nose studs, tongue
studs and anything else that will interfere with x-ray views.
The Fitting. There are quite a few rigid collars available with slightly different sizing techniques.
Follow manufacturer’s instructions to obtain a snug symmetrical and effective fit.
Tie me up. Tie me down.

We used to use medieval lashings of tapes and bindings to immobilize the rest of the body to the
bed or spinal board. This only made the patient more anxious and uncomfortable leading to
increased movement.
Usually a couple of sandbags on either side of the head accompanied by appropriate analgesia
and thorough explanation will be sufficient. Remember, human beings are innately jiggly, fidgety,

headwagging animals so gently emphasize, in the nicest possible way, the catastrophic sequalae
of a spinal injury.
I’m going to be sick.

Once your patient is properly immobilized you must remain vigilant and attentive. Staring up at
the ceiling and not knowing what is going on will promote isolation and anxiety.
Once again explanation of your management plan is important. If you are going to leave the
bedside, ensure they have a call bell handy. Consider the use of an anti-emetic to manage
nausea and vomiting. Make sure you have suction equipment at the bedside in case this does
occur. You will also need to have a plan to initiate a rapid log roll of the patient onto their side if
they are vomiting. You will need a minimum of 3 people to do this, one to maintain spinal
alignment of the head and 3 to roll the body, so be prepared.
During transfer to x-ray etc. the patient must have a medical escort.
As I have mentioned appropriate and adequate pain relief is mandatory. Pressure area care
should be attended every 2 hours whilst the patient is immobilized (especially in the elderly), and
the collar should be substituted with a two-piece hard collar such as the Philadelphia collar if it is
to be utilized for longer than 6 hours.
Reassess their neurological status after any interventions.
The drunk or aggressive patient.

I tell you, the things we do that interfere with the process of natural selection.
No, seriously, the management of a drunk or aggressive patient with a suspected spinal injury is
a complex problem. Attempting to maintain spinal immobilization in these cases will often only
lead to increased movement of the neck. Sedation may be contraindicated if they have an
accompanying head injury, but if at high risk of spinal injury; sedation, paralysis and intubation
may need to be considered. Usually though, less intervention is best in achieving some balance
of spinal stability in these people.
Who to X-ray.
• Any patient who has a suspected spinal injury with an altered conscious state.

• Adequate assessment is difficult due to distracting injury or intoxication/sedation.
• Neck tenderness and/or pain.
• Abnormal neurological signs.
How to manage hypothermia.
It is mid winter. A jogger out for a Sunday morning run notices an unusual lump in the frost-
covered field and discovers a frozen teenager who had gotten drunk during the night and fallen
asleep on the grass.
Temperatures had been around minus eight overnight, and on arrival in the ED he was so cold he
had icicles on the end of his penis. Now that’s an icy-pole.
And would it be too crass to bring up the topic of snowballs?
I thought so.
This time of the year, many of our patients present with a low core temperature.
A patient is becoming hypothermic once their core body temperature drops below 35 C. For an
accurate temperature, a rectal probe is the preferred method.
But be careful…we once spent quite some time unsuccessfully attempting to re-warm a patient
only to find out that he had expunged the rectal probe in a frozen poop-cicle that was now laying
in hibernation on the bed.
• Mild hypothermia (32-35 C ): The body begins to shiver in an attempt to generate heat.
The central nervous system becomes depressed and apathy, ataxia and drowsiness may
develop.
• Moderate Hypothermia ( 27-32 C): The body gives up trying to shiver and becomes
unable to rewarm itself. Decreased level of consciousness ensues. The ECG may show a

prolonged QT interval and a J wave may be seen between the QRS complex and the ST
segment. The patient is quite likely to develop arrhythmias (particularly with stimulation
such as intubation or movement).
• Severe Hypothermia (27 C or less): Vital signs are depressed. Pt is comatose.
Passive re-warming:
The doctors will decide if the patient requires passive or active re-warming. Passive rewarming
involves the use of overhead heaters, warm blankets and devices such as the Bair Hugger that
blow warmed air over the patient. The aim is to warm up the patients environment. Don’t forget to
place warm blankets around the patients head. Estimates of the percentage of body heat lost
through the head vary between 7 to 50%.
Passive re-warming is used with mild hypothermia.
You should also be using warmed IV fluids in this situation.
Active re-warming:
Active re-warming is considered with temperatures less than 32 C. ( It may also be used in the
elderly or pts with cardiovascular instability).
Options for active re-warming include:
• Administering warmed, humidified oxygen (preferably via endotracheal tube).

• Peritoneal lavage with warmed fluids.
• Cardiopulmonary bypass with re-warming of the extracorporeal blood.
afterdrop:
Once re-warming has begun, the patient may experience afterdrop. This is a continued drop in
temperature as circulation improves and cold blood is washed in from the extremities.
Afterdrop can also be precipitated by a patient moving around excessively as they begin to re-
warm.
handle with care:

As I have mentioned, any sudden movement or jolting may trigger ventricular fibrillation, so be
particularly careful when transferring the patient across onto the resuscitation bed when they
arrive. Try to minimize moving the patient whilst re-warming. Take care during any intubation too.
Don’t give up until they warm up:

Icicles on his penis and balls of snow? If he is not dead he’ll sure wish he was.
Actually, many people presenting to emergency departments have made a full recovery from
severe hypothermia, so aggressive resuscitative efforts should be considered in this situation
(that is unless they are frozen solid or have catastrophic injuries).
Patients that have severe hypothermia may be refractory to many drugs as well as defibrillation
due to their glacial metabolism. So CPR may need to be prolonged.
Once the patients temperature has been re-warmed to 32°C an assessment to terminate
resuscitative efforts can be made by the team.
Remember: “A patient is not dead until they are warm and dead”

How safe are air bubbles in the IV line?
We’ve all seen it. Patients looking wide eyed and worried
at a small bubble of air as it travels down the IV line and off
into the mystery of their arm. “Don’t worry”, we assure
them… “its far too small to cause any problems”.
So exactly how dangerous are those little air bubbles? And
how much air would be needed to cause an adverse
event?
Or to put it simply: would 10mls of air injected into the IV
line by the evil ninja assassin disguised as Dr Singer (who
has been tied up and thrown in a linen skip), be enough to
kill our sleeping hero and stop him getting the girl?
Once a volume of air is introduced into a peripheral vein, it

can potentially make its way through to the Right Atrium
and Ventricle, and then on into the pulmonary vasculature.
Here air may occlude the microvasculature increasing
dead space and damaging the vessels endothelial lining.
This in turn, may trigger an inflammatory response
resulting in noncardiogenic pulmonary oedema and
bronchoconstriction. In animal studies, the ability of the
lung to filter air micro-bubbles fails when air enters the
circulatory system at a rate greater than 0.30 mL/kg per
minute
A large, rapidly-entrained bolus of air can fill the right atrium with air and cause an air lock, which
leads to obstruction of the right ventricular outflow tract, decreased venous return, and decreased
cardiac output. Myocardial and cerebral ischaemia soon follow.
Small amounts of air are probably absorbed by the plasma and haemoglobin, but larger amounts
have been associated with interfering with pulmonary gas exchange, and causing cardiac
arrhythmias.
Air bubbles may also occlude the micro circulation of other organs such as the brain, spinal cord
and the skin.
OK. So now you’ve really scared me. But how much is safe?
The online site www.emedicine.com states that more than 5mls per kg is needed to cause
significant complications. Although it states that as little as 20 mls (around the amount of air in an
unprimed IV line) has been reported to cause some problems.
Large amounts (of between 100 to 300 mls) have allegedly been fatal.
So those pesky little bubbles travelling down the tubing are probably not going to do any damage.
But never-the-less, it would be wise to take steps to minimize the risk of larger amounts of air
entering the system.
• Dont forget to prime the IV line! Sounds stupid, but it happens more often than you think.
• When hanging a new bag on an existing line, check to make sure the previous fluid
hasn’t run down the line leaving a large airspace.
• Do not place IV fluids down on the bed when transferring patients etc. Laying the drip
chamber down on its side only encourages air to enter the tubing.

• Expel any air from syringes of IV antibiotics, analgesia etc that you are about to
administer.
• And of course always check to make sure any drugs or fluids being injected into the line
are compatible with the fluid. Incompatible fluids may crystallize or form a sediment that
will cause similar problems.
priming tip:
Heres a quick tip.
When priming a new IV line, first invert the bag of fluids so you are spiking it from above.
Once you have inserted the giving set into bag of fluids open the roller clamp and gently squeeze
the bag expelling all the air from the top of the IV bag into the giving set. Keep squeezing until the
fluid from the bag is pushed up into the drip chamber.
Invert the bag back into its normal position and continue to prime the IV line.
Now, when your patients IV fluids are finished they will stop at the level of the bottom of the flask.
There will be no air in the bag to run down into the giving set necessitating a re-priming of your
line.
and another thing:

Never pull the cap off the spike with your teeth like they do on TV. It looks cool, but you run the
risk of contaminating the IV fluids with your oral flora (and, no doubt, fauna).
Do not let the patient end of the IV tubing drag around on the ground while you are spiking the
bag. It may be a hospital, but its still pretty dirty down there.
Do not let fluid squirt out onto the floor as you prime your line . Someone carrying a brimming
bedpan is sure to slip arse over nipples on your mess.
How to manage paediatric fever.

One of the things we could probably manage a little better as ED nurses is the management of
children presenting with fever.
As soon as little Miss Molly presents with even a slightly elevated temperature, many of us react
by immediately dousing it with doses of antipyretics or perhaps even tepid sponging in the belief
that this will fix the problem or prevent possible febrile convulsions.
Is this evidence based? Should we be aiming to have a dosed up department full of afebrile
children?
Lets see.
how hot is hot?

The first thing to say is that any paediatric patient presenting to the ED should not be discharged
home without a thorough assessment and review by a senior ED doctor. ALL neonates less than
4 months old who present with fever should have expert assessment without delay.
Children’s temperatures are in a constant state of flux, but a normal temperature is usually less
than 37.5C. Fever can be defined as a rectal temperature greater than 38.0C. (rectal

temperatures are the gold standard, but taking tympanic, oral or per auxilla is common practice.
As long as you are aware of the relative accuracies of these methods.)
The higher a child’s temperature, the more likely it is that they will have a serious bacterial
infection. But not always. Seriously septic children may be afebrile or have low grade fevers.
why hot is hot.

Most causes of infection (bacteria and viruses) are quite fragile and only able to survive in a very
narrow temperature range. Our immune systems are pretty clued on to this, and by raising the
bodies temperature, it makes a pretty hostile environment for the enemy combatants.
The down side of this is that it takes a lot of energy to fire up out furnace which may lead to
dehydration. It can also be quite uncomfortable.
Antipyretics: yea or nay?

In most cases the primary purpose of administering antipyretics is to increase the comfort of the
child. Although in one well known study (Kramer et al.), parents were unable to tell the difference
between panadol and placebo in improving the behaviour of their child.
The double-blind trial, based on the parents observations, analysed 225 febrile children’s mood,
comfort, appetite, fluid intake, activity and alertness.
“In the paracetamol treated group, activity and alertness significantly improved by one grade,
mood and eating improved but not significantly, while drinking was worse. The parents’
descriptions of comfort were equal in both groups. The duration of fever was the same in both
groups.”
The most serious reported risk of administering paracetamol is hepatotoxicity. This can occur if
too large a dose is given or too many doses are given (doses greater than 90mg/kg/day).
Children under the age of two, or who have pre existing liver disease are at greater risk.
What about those febrile convulsions?

It is true that febrile convulsions are caused buy…well, febrile-ness. But studies seem to suggest
that bringing the fever down has limited benefit in preventing recurrence or onset of seizures.
In a systematic review of the management of fever in children conducted by the Joanna Briggs
Institute it was noted that:
Of the total sample of 821 only one febrile convulsion (0.12%) was reported as occurring during a
study. This 12 month old child was in a “tepid sponging only” group and convulsed 90 minutes
after commencing treatment when her temperature was 39.7°C, 0.7°C higher than when
admitted. She had no history of febrile convulsions.
The review concludes that there is a lack of evidence in the literature to support the notion that
paracetamol reduces the incidence of febrile convulsions.
conclusion?
If the infant or child has a low grade fever and is not dehydrated or unduly distressed I would
consider their fever as part of their treatment. With the proviso that the parents are both informed
(there is a parent information sheet here) and supportive with this strategy.

Very high fevers should be managed based on the clinical situation. But as I have said they must
be reviewed by a senior ED doctor.
If paracetamol is to be administered: An initial paracetamol dose of 15- 20mg/kg could be given,
followed by three doses of 15 mg/kg over the next 24 hours if irritability continues.
[References: NSW Department of Health Clinical practice guidelines.

Australian prescriber: Paracetamol, overused in childhood fever.
Kramer MS, Naimark LE, Roberts-Brauer R, McDougall A, Leduc DG. Risks and benefits of paracetamol antipyresis in
young children with fever of presumed viral origin. Lancet 1991;337:591-4.
Joanna Briggs Institute: Management of the child with fever. ]
How to keep ‘eyes on’ your patients.
Case 1: Mrs Pepper is a seventy year old lady with slight dementia. During the night she
becomes disoriented and climbs over the bed rails, falling and fracturing her hip.
Case 2: Mr Haas, cannot reach his call bell or his urinal, eventually he can hold on no longer and
is incontinent.
Case 3: Mr Smith has an unwitnessed seizure lasting 5 minutes. He aspirates his hospital jelly
and develops aspiration pneumonia. Eventually he dies from respiratory complications.
All three incidents have one thing in common. They occurred because nobody was watching.
Most emergency departments these days are open plan affairs. A large room is bordered with
patient beds and some form of staff station sits at one end or perhaps in the center. But even in
an open plan setting, on a busy shift it is amazing how few patients can be seen at any one time.
Each bed area has a pull around curtain to ensure privacy during examinations and procedures.
One common problem arises when curtains are left pulled around a bed area, blocking not only
our view of that patient, but also obstructing the visibility of other patients along the row.

visual visibility.
When privacy is not required ensure that the curtains are pulled back.
You can draw them a meter or so from the wall on each side. Just enough to *blinker* the
patients from being able to see each other.
When the curtains are drawn around, just have a discrete peek to see if in fact they need to be.
Many doctors and nurses seem to have this habit of walking out after a patient examination
without opening the curtains. Not only does this block them from view, but it can make the patient
feel isolated and ignored.
Patients will sometimes ask to have the curtains pulled around for privacy. At night the lights from
other areas may be disturbing them. Explain that even though it is inconvenient, it is very
important that they can be observed at all times. Limiting the amount of visitors in the room may
help patients feel less like they are on public display. Acquiring a supply of earplugs and eye
masks (like the ones they give out on aircraft) may help with undisturbed rest.
The bottom line is there is no place for visual privacy in the ED. Sorry.
Overcrowding of our emergency departments often necessitates cramming patients into any
available nook or cranny. This is fraught with danger. If patients are located “around a corner” or
“out in a corridor” they must be checked on frequently.
Remember: There is only ever a few seconds between resting comfortably in bed and laying
unconscious on the floor in a pool of blood. I shit thee not.
audio visibility.
Not only do patients need to be visible to the eye, they need to be visible to the ear.
Patients should always have access to a call bell or buzzer.
Noise in the ED should be minimized (good luck with this one) so that alarms are not masked by
the background din. That is; there should be a low signal to noise ratio.
Alarm parameters should always be correctly set to minimize unnecessary or false alarms.
Never assume someone else will check on that alarm. Never assume that someone else will
respond to that feint “nurse…nurse” coming form the other side of the room.
blocking visibility.
Of course there are instances when patients will need to be made *in-visible*. When patients are
grieving or dying or being interviewed by police, to give a few examples.
Ideally these sort of things should take place in a separate area with a high level of attentiveness.
But most of the time it is vital that you can see that your patients are behaving. Just try walking
around the unit during your next shift and opening up all the curtains. See what a difference that
simple act makes?
Out of sight is not out of mind. Give your patients half an opportunity and they will get up to no
end of mischief.

How to assess a child: Respiration.
Lucky for us that they build children as tough as Tonka Trucks. Even so, when they do crash and
burn, they tend to do so quickly without much warning, and in the emergency department. Here
then to help you out, is a brief guide in making a rapid paediatric respiratory assessment.
effort of breathing.
It takes only a moment to recognise an increase in a child’s
effort of breathing
• Respiratory rate: an increase in respiratory rate

indicates possible airway disease or metabolic
acidosis. Conversely, a slow respiratory rate can be
an ominous sign indicating breathing fatigue,
cerebral depression or a pre-terminal state.
• Recession: as paediatric patients have a more
compliant chest wall (that is, it is not as rigid as an
adults) any increased negative pressures generated
in the thorax will result in intercostal, sub-costal or
sternal recession. Greater recession = greater respiratory distress.
But be careful, as children will tire from an increased effort of breathing much faster than
adults, and as they do, these recessions will decrease.
• Stridor: is usually more pronounced in inspiration but may also occur during expiration. It
indicates an upper airway obstruction. Always consider the possibility of an inhaled
foreign body if you can hear stridor.
• Wheeze: Indicates lower airway narrowing and us usually more pronounced during
expiration. Increased wheeze does not = increased respiratory distress. And once again,
wheeze will subside as the patient becomes exhausted.
• Grunting: a grunting child is a bad thing. It is an attempt to keep the distal airways open
by generating a grunted positive end-expiratory pressure. It is a sign of severe respiratory
distress. Grunting may also be seen in children with raised intercrainial pressure.
• Use of accessory muscles: the child may begin using the sternomastoid muscle to
assist with breathing. In infants this may lead to bobbing of the head. Looks cute, but
isn’t.
• Gasping: a gasping child is really really bad. Get help.
•
efficacy of breathing.
Next we need to assess how effectual all this increased work of
breathing is. Look for the degree of chest excursion (or in infants
abdominal excursion) which will give you some idea of how
much air is going in and out.
Auscultate for decreased or asymmetrical breath sounds. And
while you’re there, listen for any adventitious (out of place)
noises.
Pulse oximetry will give you a good indicator of the efficacy of

breathing. We want it to be between 97-100% on room air. If it

drops below 95%, begin oxygen therapy ASAP.
Pulse oximetry is not very accurate if the patient is shocked or below readings of 70%, but by the
time the saturation is dropping this low you will be too busy kaking your uniform to worry about
equipment accuracy.
The other thing to remember is children with elevated carboxyhaemaglobin levels (smoke
inhalation from a house fire, for example) may have a falsely normal SaO2 and yet be
significantly hypoxic.
heart rate.
Increased heart rate may indicate shock, or hypoxia. or fever,
or anxiety.
Bradycardia is defined as a heart rate less than 60 or a
rapidly falling heart rate with poor systemic perfusion. Bad,
bad, bad.
Cardiac compressions will need to be commenced in infants
with HR<60 and poor perfusion. You will probably be
experiencing a holy crap moment at this time and be hesitant
to begin CPR. If in doubt, just do it. *Unnecessary* chest
compressions are almost never damaging.
skin colour.
Hypoxia will lead to peripheral vasoconstriction and eventually cyanosis. Once the cyanosis is
evident centrally (think Smurf), the child is probably getting close to respiratory arrest.
A child with congenital heart abnormalities may remain cyanosed despite oxygen therapy.
mentation.
As the child’s respiratory distress evolves, they will become distressed and anxious. This will be
followed by increasing drowsiness as fatigue grows. And the best way to assess mentation is to
ask the parents.
Which leads us seamlessly to the golden rule of paediatric assessment: always, always listen to
the parents. If they are concerned about their child’s condition so should you be.

How to assess a child: Circulation.
The total circulating volume of a 1 year old is roughly the same as the amount of water you pour
on your indoor pot plant. At about 80mls/kg it doesn’t take much loss before you have a
significantly shocked baby on your hands. With circulatory function failing, oxygen and nutrients
are not reaching the cells and cellular waste products are not being cleared.
Circulatory assessment is therefore a very important skill to develop in order to recognise the
early signs of a shocked child.
heart rate:
Increased heart rate may indicate shock, or hypoxia. or
fever, or anxiety.
Bradycardia is defined as a heart rate less than 60 or a
rapidly falling heart rate with poor systemic perfusion. Bad,
bad, bad.
Cardiac compressions will need to be commenced in infants
with HR<60 and poor perfusion. You will probably be
experiencing a holy crap moment at this time and be
hesitant to begin CPR. If in doubt, just do it. *Unnecessary*
chest compressions are almost never damaging.
pulse volume and blood pressure:

A good indicator of general perfusion can be made by palpating peripheral and central pulses. A
poor central pulse with absent peripheral pulses is a sign of significant shock.
Remember: when fitting a blood pressure cuff to a childs arm it is vital to select the correct cuff
size. The width of the cuff should cover no less than 80% the length of the upper arm.
The child’s blood pressure is a much less sensitive indicator, as it may remain *compensated*
until circulatory collapse is imminent. You can estimate the expected systolic blood pressure with
the following formula: BP= 80+(age in years * 2).
A very low BP is a warning of imminent cardiac arrest, get busy!
capillary refill:
A slow capillary refill time indicates poor skin perfusion. Press down firmly with your finger on the
sternum for 5 seconds and release. ( alternatively you can use the nail bed or soles of the feet.) A
normal capillary refill should occur within 2-3 seconds. Capillary refill time is not a useful indicator
in the hypothermic patient.
Other effects:
Decreased perfusion will lead to an inability of the cells to *take out the trash*. The resulting
metabolic acidosis will result in an increased respiratory rate and tidal volumes (without other
signs of respiratory distress such as recession) as the lungs try and blow off carbonic acid.
The skin may appear mottled or marbled and cold to touch.

Decreased level of consciousness. Drowsiness and/or agitation may increase as cellular
perfusion decreases. The most sensitive indicator of changes in mental state is of course the
parents.
Decreased urine output due to decreased perfusion of the kidneys. Less than 2ml/kg/hour in
infants and 1 ml/kg/hour in children is a red flag. Once again ask the parents for any history of
decreased output.
As babies and infants develop significant circulatory compromise it is not exactly rocket science
to pick that they are sick. As they begin to die they begin to look dead. But the sensitivity to pick
up on early signs of shock is more of an art, and will make a big difference in outcome.
How to remove a stuck ring.

Another day, another trick of the trade.
Today we have a patient presenting with a very painful wrist after slipping on the icy driveway as
she was retrieving her Sunday paper.
She has no obvious deformity and no neurovascular compromise but her hand is quite swollen so
we better get that ring off whilst we still can.
….but curses! It doesn’t seem to want to slip over her knuckle, even after an obscene lathering of
KY jelly.
Now it transpires that this ring has a lot of sentimental as well as monetary value…..so before we
reach for the ring cutter let us offer them this option..….
step 1.
First pass a decent length of strong suture material (we
actually have some thick fishing line set aside for just this
purpose) under the ring.
Have the longer end on the distal side of the ring.
This method should never be considered if you suspect a
fracture of the finger.
step 2.
Take this distal end of the string and begin wrapping it
snugly around the finger. Continue wrapping around and
around, spiralling over the knuckle and down the finger.
This can become a little uncomfortable (nurses code for
painful) for the patient, so try to do this smoothly and
quickly. Let them know it might hurt a bit but will probably
save their ring from a costly trip to the jewellers.

step 3.
Next, and this requires a little practice, hold the distal end of
the string against their finger, grab the proximal end.
Unwind the string, moving around the finger, whilst pulling
firmly and maintaining tension.
Continue pulling on the string and unwinding it ‘over’ and
‘around’ the ring…..with a little luck the ring will slowly slide
down and off the patient’s finger earning you some rightful
admiration. (Keep the ring cutters handy in case it becomes
too uncomfortable or fails to budge.)
We have an electric ring cutter that will slice through most rings if we need to get them off in a
hurry.
step 4.
Now..give it a quick polish. (KY Jelly brings jewellery up a treat.) Present the intact ring to her,
quickly reassess the neurovascular status of the finger and calmly proclaim, “just doing my job
ma’am …..just doing my job.”
Walk a way with a barely perceptible swagger in your step.
10 tips for staying sharp in the Emergency

Department.
What do you think are the 10 most important guidelines for a nurse working in the ED?
Here is one set of commandments I found on the mountaintop, but I hand it over to you for any
suggested modifications, disagreements or additions.
(Hmm…The management of narcotic seeking patients might be worth discussing.)
ONE: always document the care you deliver.

Legal Requirements
Your documentation must reflect the patient’s care status (condition/treatment) and include
nursing interventions and outcomes of care.
Documentation must demonstrate accountability of practice.
Remember: The Clinical Record provides proof of the quality of care given to a patient and is
admissible in court as a legal document. If it isn’t documented it didn’t happen.
The Process
Clinical notes must meet the following criteria:
• they must be legible.

• they must be dated, timed and followed by author’s signature and designation.

• they must be a clearly identified signature. If your signature looks like spaghetti, print your
name in brackets afterwards.
• each page must be labelled correctly,
• you must use only approved abbreviations as per hospital protocols. Here are some
examples of acceptable medical abbreviations …not
Precisely document any information reported to a medical officer that relates specifically to a
change in a patient’s condition.
Record arrival date, time and mode of arrival. Obtain a thorough history and nursing assessment.
Document any pre-existing conditions including allergies and their reactions.
Thorough and appropriate documentation of haemodynamic observations including pain score.
TWO: listen to parents.

While it is true that some parents completely loose the plot over a microscopic splinter in the little
toe, most do not. After performing a quick assessment of the child listen closely to the parents
story.
THREE: reassess your patient after giving treatment.

Its all part of the nursing process. You can think of it as A Delicious PIE.
• Assessment.
• Diagnosis.
• Planning.
• Implementation.
• Evaluation.
Always reassess to gauge the efficacy of your current treatment.
FOUR: never assume a patient who is behaving erratically is

drunk.
Oh boy, this can be a tough one.
FIVE: never ever ignore your gut feelings.

Is it an impending calamity? Or is it last nights vegetable vindaloo?
Either way, ignore it and the outcome will be the same.
SIX: never deviate from safe and ethical nursing practice.

The Code of Ethics for nurses in Australia was first developed in 1993. In 2000, a conglomeration
of nurses from the Australian Nursing Council, the Royal College of Nursing and the Australian
Nursing Federation stayed up late for quite a few nights nutting out the current code:
1. Nurses respect individual’s needs, values, culture and vulnerability in the provision of
nursing care.
2. Nurses accept the rights of individuals to make informed choices in relation to their care.
3. Nurses promote and uphold the provision of quality nursing care for all people.

4. Nurses hold in confidence any information obtained in a professional capacity, use
professional judgement where there is a need to share information for the therapeutic
benefit and safety of a person and ensure that privacy is safeguarded.
5. Nurses fulfil the accountability and responsibility inherent in their roles.
6. Nurses value environmental ethics and a social, economic and ecologically sustainable
environment that promotes health and well being.
SEVEN: do not accept a doctors orders without question if you

have a problem with them.
Doctors are sometimes dumb as stumps. Just like us.
EIGHT: work as a team.

1. There is no “I” in: emergency department. There is, however, a “team”.
2. There are more than enough “I”s in: I’m in deep shit again.
NINE: filter for suspicions of child, spouse or elder abuse.

Our hospital’s Health Child Protection Policy requires all its staff to make a mandatory report to
Care and Protection Services should they suspect non-accidental injury, sexual abuse, emotional
abuse or neglect in the course of their work.
It happens more than you would wish.
TEN: pain is a four letter word.

Get rid of it. I remember in the bad old days we used to leave our patients rolling around in
agony until a doctor could get to them under the pretence that if we got rid of the pain, the doctor
would not be able to properly assess them. What a load of bollocks.
No patient should be left in pain. Use a visual or numeric analogue scale (VAS) to obtain a
subjective rating of the pain from the patient. Try not to be judgemental of their response. Think
they are narcotic seeking? Makes no nevermind. Control the patients subjective discomfort and
then you can sort out the rest.
(if the patient has known, documented history of repeated narcotic seeking behaviours, they
should have a management plan developed in co-operation with drug and alcohol, and pain
management specialities.)
There are many different strategies for effective pain management (which I will leave for another
post.) and a wide spectrum of interventions that can be implemented.
How much should I give? In cases of severe pain. Many nurses are hesitant to give large
accumulated doses of narcotic analgesia in case they kill their patient or get them addicted. Here
is a quick guide as to a safe analgesia regime:
1. Observe them closely.

2. Keep giving aloquats of narcotic analgesia as per your hospital protocol until A) the pain
score approaches zero OR B) they are too drowsy to give you a pain score.
3. If pain remains uncontrolled consider patient controlled analgesia.(PCA)
4. Ensure you have oxygen, airway adjuncts and Naloxone available.

How to cure persistent hiccups.
The list of possible cures for hiccups is long and embroidered.

But as emergency department nurses we need to ask the pressing question: what are the
evidence based options?
Francis Fesmire, a specialist in emergency medicine who works from the University of Tennessee
College of Medicine famously published a paper titled: “Termination of intractable hiccups with
digital rectal massage” in Annals of Emergency Medicine (vol 17, p 872)
By stimulating the vagus nerve, Fesimire successfully blocked the stimulus that had been causing
a 27 year old man to suffer persistent hiccups for over 72 hrs.
Hiccups result from a mysterious reflex stimulus generated within the spinal cord between C3 and
C5. This in turn triggers a sudden spasm of the diaphragm and accessory inspiratory muscles
followed by an abrupt glottic closure. Other than causing episodes of acute paroxismal social
awkwardness, no one knows what purpose this reflex serves.
Back in the emergency department, Dr Fesmire attempted the usual vagal manuvers including
valsalva , carotid sinus massage, and digital eyeball compression, all with little effect.
Then in one of those moments of dazzling lateral inspiration he attempted a “slow
circumferential” rectal massage, this intrusion into the vagal back passage produced an
immediate and lasting effect.
A few years later a second paper was published in the Journal of Internal medicine to wit:
A 60-year-old man with acute pancreatitis developed persistent hiccups after insertion of a
nasogastric tube. Removal of the latter did not terminate the hiccups which had also been treated
with different drugs, and several manoeuvres were attempted, but with no success. Digital rectal
massage was then performed resulting in abrupt cessation of the hiccups. Recurrence of the
hiccups occurred several hours later, and again, they were terminated immediately with digital
rectal massage. No other recurrences were observed. This is the second reported case
associating cessation of intractable hiccups with digital rectal massage. We suggest that this
manoeuvre should be considered in cases of intractable hiccups before proceeding with
pharmacological agents.
Importantly, Dr Fesmire’s latest research evidence now concludes that the overwhelming
stimulation of the vagus nerve during orgasm is even more effective in the treatment of intractable
hiccups.
With one important caveat: the combination of rectal stimulation and orgasm may be so powerful
as to lead to the production of anti-hiccups.
The danger being that if hiccups and anti-hiccups were to collide a catastrophic explosion could
result.
So next time your patient presents with a severe case of hiccups you should inform them that
they need a little sex. Stat.
And they then only need come into the emergency department should they explode.

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www.impactednurse.

Copyright Ian Miller 2008. -1-

Introduction from a screwup nurse........................................................................3

Copyright Ian Miller 2008. -2-

Introduction from a screwup nurse.

A nurse is the most profound of fulcrums between the patient

I am the first to admit it. I am a screwup nurse.

Remember: righty tighty….lefty loosey.

Copyright Ian Miller 2008. -3-

How to handle the workload.

How to nurse the machines.

Copyright Ian Miller 2008. -4-

Here are some quick thoughts on how to nurse in the machine:

Focus on the patient, not the machine.

Start at the center and work out.

Don’t send in a machine to do a nurses job.

If in doubt, read the manual.

Alarm silence is the devils button.

Copyright Ian Miller 2008. -5-

Don’t become a robot.

Don’t let your patient catch a computer virus.

Know where the silicone ends and the flesh begins.

How not to make a medication error.

Copyright Ian Miller 2008. -6-

How to manage a needle stick injury.

It is more like a shock than a stick.

Copyright Ian Miller 2008. -7-

Of course the chance of transmission occurring is dependent of several factors including:

 Wash your hands. Before and after any intervention.

Copyright Ian Miller 2008. -8-

How to catheterize a male.

Copyright Ian Miller 2008. -9-

OK. Let us proceed.

Copyright Ian Miller 2008. - 10 -

How to catheterize a female.

preparation and positioning:

Assemble catheterization equipment as per your hospital policy.

pass the catheter:

Copyright Ian Miller 2008. - 11 -

Copyright Ian Miller 2008. - 12 -

How to remove a penis that is stuck in a

The Chomp and Squeeze Method:

Copyright Ian Miller 2008. - 13 -

The Screw-This Method:

Copyright Ian Miller 2008. - 14 -

What is mean arterial pressure?

We all diligently watch our patients blood pressure,

do I need to watch it?

• a patient with septic shock on vasopressors.

Copyright Ian Miller 2008. - 15 -

is it true that women are worse than men at reading a MAP?

Where to place that cannula.

scope the lay of the land.

Copyright Ian Miller 2008. - 16 -

One mistake many people make when attempting to access

Over time you can develop quite a sensitivity to the actual

Copyright Ian Miller 2008. - 17 -

How to place a cannula.

never hurry a cannulation, and always always observe universal precautions.

Copyright Ian Miller 2008. - 18 -

How to secure a cannula.

First things first:

Here we have our freshly inserted cannula (it is

Wash your hands. Before and after any intervention.

A- alcohol, acidosis, anoxia

T - trauma, toxins, tumors