Weekly Review #21

Brian Erikson hosted a couple of great guests on erNURSEpro. He discussed ED process improvement with Deb Delaney, and Delirium with Christina Shenvi.

Deb Delaney had some insight on improving ED through-put and made some specific suggestions about internal queues, flow facilitation, use of mid level providers, streamlined ancillary services, room utilization, huddle & hand-off processes, and communication. I've seen several departments use internal queuing, or intra-departmental waiting areas, to create a "fast-track" area and increase throughput of less acutely ill patients. The "flow facilitator" role is often performed by a charge nurse, in small departments this may work well, but in large centers, or during times of peak traffic it does not. Dedicating one person to this role, even if only during peak volume can help clear bottle necks, ensure patients are moving through the system, and ensure that the charge nurse isn't being removed from performing their function, I particularly like the push-pull model of moving patients, as well as bed-side handoffs and impromptu huddles. Delaney offers a few other suggestions, and likely has something that could be implemented at your department, a good review for any nurses working in a charge, or managerial role.

Brian also hosted a talk with Christina Shenvi, a physician and fellow in geriatric emergency medicine. Christina discusses a three step approach to patients with delirium: immediate stabilization and correction of rapidly reversible causes (hypoxia, hypovolemia, AMI), establishing a baseline for the patient (call family, support workers, or care home staff), and the process of ruling out possible causes of delirium using the DELIRIUM mnemonic (covered in weekly review #11). She then discussed possible causes, risk factors, and considerations for interacting with these patients. There are some great pearls on pain assessment, preventing delirium, and steps that can be taken to make an emergency department more friendly to geriatric patients. This is a great podcast, Brian includes some relevant links in the show notes, the discussion is straightforward and informative, and the content is applicable to almost all sub-specialties of nursing; if you're going to listen to only one podcast this week, make this the one!

http://www.ernursepro.com/#!ERNP-029-Become-a-Delirium-Rockstar-in-Your-Department/clp2/5636120a0cf2f97533d29a3d





There was a lot of FOAMed coverage this month on the new 2015 CPR/ECC guidelines. HEFTEMCAST, RebelEM, and BIJC, have all provided great summaries of the updates; but from a readability perspective I would like to highlight the review by Justin Morgenstern on First10EM. His post starts with a review of the evidence informing the changes, then discusses the key recommendations and changes by topic, starting with: CPR, medications, capnography, technology, post resuscitation care, and finally by special patient populations: pregnant, hypothermic, trauma, pediatric and neonate patients. The team at BoringEM also deserve a huge acknowledgement for their amazing infographic series which can be downloaded here, a fantastic review for any nurse that participates in cardiovascular resuscitation.

http://first10em.com/2015/10/21/acls-2015/

The Journal of Trauma and Acute Care Surgery published an analysis by Afshar et al., that examined the association of blood alcohol content with in hospital death, injury severity, and mechanism of injury. This is a retrospective examination of patients treated at an American shock trauma center between January 2002 and October 2011. The study assigned patients into 4 categories based on blood alcohol content (BAC): undetectable (<1mg/dL), moderate (1-100mg/dL), high (101-230mg/dL), or very high (>230mg/dL), then examined for severe injury (ISS >16), dichotomous injury pattern (blunt or penetrating), hypotension (MAP < 66mmHg), shock index (SBP/HR - greater/less than 1), and death.

There were 46,222 patient records examined, 44,502 (96%) had blood alcohol content (BAC) assessed, 12,535 (28.2%) were exposed to alcohol with the a median BAC of 167mg/dL (high). Baseline characteristics showed an increase in male representation with increasing BAC quartile (66, 77.5, 79.8, 83.1%). Patients with moderate BAC were more likely to have penetrating injury patterns (typically gunshot wounds), severe injury, hypotension, pulseless arrival, and in-hospital mortality compared to other groups. The very high BAC had the greatest proportion of blunt trauma, falls and fights, the lowest proportion of vehicle collisions, and the lowest odds for in-hospital mortality.

When I first read this research I was a little confused as to what it added to the overall knowledge of alcohol and trauma, other than to say that mechanism varied across intoxication levels. However when this research, on injury mechanisms by BAC quartile, is used in addition to previous research, on alcohol and mortality, we begin to understand why some of the noted effects are occurring. This may be interesting research for nurses working in trauma who are particularly keen on the epidemiology of trauma, but from a straightforward nursing perspective it has little to add to the general approach toward trauma patients.

http://www.ncbi.nlm.nih.gov/pubmed/26402540

I recently moved from a small rural ER to a large metro trauma center. On one of my first orientation shifts a patient in DKA was transferred to our department from a rural site. Some of the nurses made disparaging comments about the choice of SC insulin over IV insulin infusion, which started an interesting dialogue. Although I've typically seen these patients treated with IV insulin infusions I do know that the evidence, as well as CDA guidelines, acknowledge that either will produce similar outcomes. I've seen some support for the practice in EPMonthly, which acknowledged similar efficacy between the two, but a new review by EMPharmD offers not only a succinct review of the existing literature, but also a fresh perspective on titrating doses from rapid to a long acting insulin, an approach that if supported by evidence could significantly lower the amount of time and resources required to treat patients with DKA. A great read for nurses working ER/ICU or medicine, and one of my newly discovered favorite sources for FOAMed content.

http://empharmd.blogspot.ca/2015/10/just-little-prick-iv-vs-sq-insulin-for.html

On InjectableOrange Jesse Spurr hosted a post by fellow Canadian RN Jennifer Jackson on why nurses need to be politically active: to advocate for patients, to advance the nursing profession, and to effect change on our work environment - very timely given our recent federal election. He also posted some links and information for those lucky enough to attend the 2015 SMACC conference in Dublin.

I've reviewed a post by Ian on pre-filled syringes before and strongly feel that they are an effective way to prevent medication errors. One drug in particular where this is of concern is Epi. The differences in concentration between cardiac and anaphylaxis doses is 10 fold. Taft Micks offers a review on the differences between the two on  BoringEM, discussing the risks, and deciphering the labels of the two different doses.

EMin5 reviewed the different presentation, treatment and complications associated with parasitic skin infections. Anna Pickens reviewed the differences between scabies, lice (head, pubic, or body) and bedbugs. This five minute video offers up great photos, neatly summarizes the treatments, and includes a fantastic table that summarizes the video. An excellent review for emergency, correctional, camp, public health, or school nurses.

Weekly Review #17

This is an older post, by Micheal Douma, of a NENA presentation on abdominal-pelvic trauma. The presentation at it's core is a summary of basic hemorrhage control, and a discussion about the degree of force required to provide adequate compression to control hemorrhage. Specifically though Douma discusses controlling abdominal pelvic hemorrhage with External Aortic Compression (EAC). EAC is, in short, pressure applied to the aorta using a fist (landmarking from the umbilicus) with arms locked as though providing CPR. Effective aortic occlusion requires 80-120lbs of force, and requires constant pressure (Douma has a great graph on occlusion techniques).

Maintaining this pressure is of course difficult during transportation and resuscitation, so Douma covers some of the emerging technologies that seek to accomplish this task (REBOA, junctional clamps and tourniquets, and stasis foams). Unfortunately there is no discussion about when to use EAC, perhaps due to the research being in it's infancy, but it's something you might consider when faced with extremity or pelvic hemorrhage not controlled by binding, or tourniquet.

There are two messages here that I think are important for nurses: the first is obviously that there is a role for direct arterial pressure in hemorrhage control, which sometimes needs to be applied proximal to the injury, even if that means occluding the aorta. The second point is that controlling hemorrhage begins with basic techniques performed well, which requires a surprising amount of force - if your bandages are soaking through, you need to press harder. Douma quantifies what we would often teach in TCCC, the use of knees to provide this consistent pressure, he shows that it provides extremely effective transfer of weight, as an added benefit it frees your hands up for other tasks.

I often see hemorrhage control poorly performed (bandages aren't for absorbing blood, they're for providing pressure), I've seen the deadly consequences of pelvic trauma with overt or occult hemorrhage, and would encourage all nurses to pay attention to the messages in this post.

http://rescuescience.org/2015/06/06/nena-external-aortic-compression-presentation/




BoringEM had a post by Martin Badowski this week discussing delirium. Delirium is an acute, fluctuating change in cognition that effects ~10% of older adults in the ED, it's associated with a three fold increase in 6 month mortality and is identified in less than half of the patients (17-35%) who present with it. This post discusses the diagnostic strengths and weaknesses of different diagnostic tools (CAM, CAM-ICU, mCAM-ED, MMSE, DTS+bCAM), and offer a mnemonic to approach differentials: I WATCH DEATH

Infection - UTI, pneumonia,
Withdrawal - BZD, EtOH, hypnotics,
Acute Metabolic - Hyper/hypoglycemia, electrolyte derangement,
                           Toxins - Alcohol, recreational drugs, or prescription interactions,
                           CNS - Tumor/lesions, CVA, Infection,
                           Hypoxia - anemia, hypotension, pulmonary/cardiac failure,
                           Deficiencies - Thiamine, B12,
                           Endocrine - Adrenal, thyroid, parathyroid,
                           Acute Vascular - Shock,
                           Trauma,
                           Heavy Metals.

I have found other mnemonic a little easier to remember when it comes to assessing delirium (see AliEM post on Weekly Review 11), but this post really shines in it's discussion of the diagnostic tools, where it discusses the predictive value for each in detail. A great post for nurses working in emergency to brush up on delirium screening.

http://boringem.org/2015/09/07/medical-concept-delirium-tips-and-tools/

In an older post on Pacific Emergency Medical Training Doug Fraser discusses "big vs. small box" EMS education. The small box approach Fraser says is the classic protocol driven reductionist approach to EMS: defining your role by the "things you can do". On the other hand the "big box" approach to providing care requires that an appreciation of your role within the system as a whole, and by necessity the roles of others. This may mean building an understanding of procedures that are beyond your scope of practice, and understanding aspects of practice that you are not part of. When we do this he asserts we open the door to sharing knowledge with other professionals, we learn from them in either a direct or an indirect manner. and become better at our own job. He uses a person example of airway management, discussing how as a BLS paramedic he's learned the finer points of ventilating from anesthesiologists, while being able to bring new ideas to ALS paramedics. This idea spans all health care professions, and echos the very core message of FOAMed, as indeed upstairs care downstairs can only happen when we take an interest in what others are doing.

http://www.pacificemergencymedicaltraining.com/?page_id=15

Seth Trueger from MDAware contributed to the ongoing EM mindset series on emDocs. He discusses the role of addressing the mundane in EM, stratifying risk, and coordinating care, and his unifying theme of balancing limited time with clinical uncertainty is a great message for all healthcare providers. Truger discusses the mental process for deciding if patients need intervention, diagnostics, or transfer and suggests that if you're spending a prolonged amount of time making the decision you should probably err to the side of caution and go for it; this message I think is directly translatable to nursing. I've witnessed nurses debate calling a physician about a deteriorating patient: if there's that much question go ahead, do it, then use your mental effort and time doing something that helps the patient. His idea that the time spent doing something unimportant takes away from the you have to do something important is spot on, a great take home message.

http://www.emdocs.net/em-mindset-seth-trueger-resuscitation-risk-stratification-care-coordination/




There was a discussion on Taming the SRU by Matthew Stull about approaching the undifferentiated patient. This is a great discussion about how to perform a history and physical assessment in the ED, what he himself always does in clinical practice, and what can be omitted. I really appreciated the opening discussion about avoiding corollary information before assessing the patient. By avoiding reading too in depth into the chart Stull asserts that you're less likely to become biased toward the patient and their presentation. I think this is important because cognitive anchoring can easily lead a clinician to wrongly attribute signs and symptoms to chronic conditions and previous visits. I think this is a great message for nurses, we all have repeat patients who present with intoxication, but it doesn't mean that those people aren't presenting with acute conditions such as head injuries.

http://www.tamingthesru.com/blog/bread-and-butter/undifferentiated-patient

EMin5 discussed preparing for RSI using the SOAPME mnemonic (Suction, Oxygen, Airway, Positioning, Meds, Equipment/EtCO2). A nice succinct review of how to set up your equipment, medications, and patient.

It's been a couple of weeks since having a post on caring for obese patients. If you're needing a fix check out this EMC podcast. It has a great overview on adjusting your practice in relation to vitals, airway interventions, and medication dosing.

Check out the discussion on BIJC about the difference between hemoglobin and hematocrit values (spoiler alert: there is none).

There's some new research this week from Matthew Douma on the efficacy of "double-barreled" dual IO therapy, there's a nice review of this research on the Trauma Pro's blog.

A St.Emlyn's post discussed strategies for maximizing your sleep. It offers suggestions on sleep hygiene, discusses the negative consequences of sleep deficit, and offers tips for adjusting to rotating day night schedules. This is something many nurses may find helpful.

And finally, a 7 year prospective population study in China published in the BMJ found that those who more frequently ate spicy food had lower all cause mortality than those who did not. This study includes a large number of patients (half a million) and examined consumption of fresh or dried chili when assessing for spicy food. There are of course a number of factors (urban vs rural) that could be confounders in this study, and it's not really FOANed per-se; but hey it's a reason to eat some hot wings this weekend.

Weekly Review #16

In the first of two posts this week on SVT BoringEM reviewed a Canadian EMS treat and release trial for SVT. Calgary EMS sought to determine if uncomplicated SVT could be treated in the prehospital environment, and to determine what the 72hr complication rate would be. EMS treated a total of 40 individuals, for 75 episodes (of a possible 225) of SVT. There was only one multiply co-morbid individual presented to hospital following EMS treatment, although that the one individual presented a total of 14 times, there was no incidence of cardiac arrest, defibrillation, or cardioversion required. There were unfortunately 22 EMS errors in following the protocol; but on a whole it would appear that a treat and release model of managing SVT may be worthwhile. From a nursing perspective this doesn't change practice; it may however suggest that there could be some additional research coming, a large scale trial, with longer follow up period, and potentially a increased nurse role if treating SVT is delegated to non-medical colleagues.

http://boringem.org/2015/08/28/cjem-infographic-prehospital-management-of-uncomplicated-svt/




Rick Body discussed a trial published in the Lancet this month that examined the effects of modifying the valsalva maneuver on rates of converting SVT. This modification was first documented in a small 2010 study, but this is the first intention to treat trial. There were 214 patients included in each arm (traditional vs. modified valsalva). The valsalva maneuver in this trial was a forced exhalation at 40mmHg for 15 seconds, the modification was the addition of laying the patient supine and performing a passive leg raise immediately following the valsalva maneuver. The data showed a doubled success rate in the modified valsalva group (43% vs 17%), which translated to a reduced requirement for adenosine (57% vs. 80%). This could translate to significant improvements in patient care, as receiving adenosine can be quiet psychologically traumatic. This research is fantastic news for patients as well as care providers: it's a no cost intervention, with no obvious risk or side effects, that more than doubles our odds of being able to treat patients without causing distress. Great stuff worth a read for all care providers!

http://stemlynsblog.org/the-revert-trial/




There were two great posts this week by Ian Miller from the Nurse Path one detailing the use of a running narrative, the other discussing CPR. A running narrative of the care you're providing Ian suggests is important for two reasons: It informs the patient of what you're doing, and it helps to keep you focused on the task at hand. I would also suggest that in addition it helps to keep your teammates abreast of what you're doing: particularly important during a code, or while working in a trauma team- although you may want to be a bit more brief in these scenarios than what Ian describes. His second post, on improving CPR, is an observation of the interruption of quality CPR during the patient transfer from the ambulance  to ED. Ian proposes that rather than waiting to transfer the patient from the ambulance stretcher to resuscitation stretched in the resuscitation bay, the transfer be made in the ambulance bay, so that the EMS team is not attempting to provide poor quality compressions while walking beside the patient. Once the patient is on the resuscitation stretcher a member of the resuscitation team than straddles the patient and "hitches a ride" while performing CPR. This is something I've seen performed in practice, and it works quiet well, provided there is advanced warning of the arrest, the personnel available to do so, and room in the ambulance bay.

http://thenursepath.com/2015/09/01/improving-quality-of-cpr-between-ambulance-and-resuscitation-room/

http://thenursepath.com/2015/08/29/give-a-running-narrative-of-your-care-delivery/

An article by Colleen Bockhold and Sherron Cumpler discussing pulmonary related transfusion reactions was published in Nursing this month. They discuss the two leading causes of transfusion related death: transfusion related circulatory overload (TACO), and transfusion related acute lung injury (TRALI). They begin by discussing how to recognize TACO (evidence of fluid overload, hypertension, respiratory distress, etc); discuss strategies for preventing TACO (close monitoring and conservative transfusion rates); and how to manage patients who develop TACO (diuresis, and respiratory support). They than move to discussing differing theories of the inflammatory process of TRALI, and the process of pulmonary damage: interstitial leakage, and resultant pulmonary edema. Signs and symptoms of pulmonary edema are described (SOB, hypoxia, tachycardia, etc), prevention strategies are discussed (antigen screening, and leuko-reduction), and treatments are reviewed (supportive). This is an open access article, is clearly written and easily understood, and provides a succinct review of transfusion reactions.

http://journals.lww.com/nursing/Fulltext/2015/09000/Responding_to_pulmonary_related_blood_transfusion.10.aspx

Emergency Physician Monthly published an article written by Paul Rostykus that suggests D10W may be superior to D50W in the management of hypoglycemia. In a great example of dogmalysis Rostykus compares the amount of glucose, the tonicity, and the effectiveness and safety of D50W and D10W. He makes a great argument for using the more isotonic D10W, highlighting that it is less likely to cause tissue necrosis in the event of extravasation, and is less error prone than D50W in pediatric patients as it doesn't require dilution. In trials patients who received D10W received less total glucose and are were less likely to experience hyperglycemia, yet had no difference in recovery time. Anything that's safer, easier, and as effective is worth consideration. Great read, another example of low (no) cost modifications to care that can translate to better outcomes.

http://epmonthly.com/article/d10-may-be-better-than-d50-for-acute-hypoglycemia/

There was a brief post on using FOAMed to keep up to date in EM on HEFTEMCAST. Likely these tips are old news for most, but for those just joining the FOAM/FOANed communities it's well worth a visit as it offers some suggestions on how to access content.

Where I work the majority of chest tubes are removed by nurses, there was a video posted by regionstraumapro with some good tips on preparation, an explanation about why removing the tube during high intra-thoracic pressures (Valsalva) prevents air from entering the chest cavity. While you're there take a look at the IO resources that are posted.

There was a great video posted on PHARM about removal of body piercings. This video has everything you could possible want: cheesy infomercial music, a how to guide for removing piercings (from: ears, noses, eyebrows, tongues, nipples, bellybuttons, sadly nothing below the belt), how to remove each type of piercing (rings, barbells, labrets, and those cheerio looking spacers), workarounds to avoid removing jewelry, and an overly serious jaws-of-life wielding firefighter. FOAM/FOANed fromage at it's finest!

This week BoringEM examined pediatric nicotine toxicity. There's a rising trend in e-cigarette use, as well as nicotine poisonings. Nicotine is rapidly absorbed, has no antidote, and e-cigarette refills contain a lethal dose. This post describes presentations, treatments (supportive with a limited role for activated charcoal). This is a concise overview of nicotine toxicity, and describes the hazards of e-cigarettes well, worthwhile for anyone working in emergency.

Weekly Review #15

I've worked in sites that use recorded shift reports - they're ridiculous: first you spend 10 minutes recording it, then I spend 10 minutes listening to it, and then we end up talking about it for another 10 minutes so you can answer my questions and give me updates. 30 minutes instead of just a 15 minute in-person handover! I've always hated them; but now I have some evidence to support my dislike for them: an article by Judymae Ofori-Atta discussing the superiority of person to person bedside reports (BSR). Bedside reports are given between nurses in the presence of the patient and family they've been shown to improve work flow and patient safety, as well as patient involvement and satisfaction: a win all round, and applicable to all nurses. Hopefully this helps you bury the voice recorder for good!

http://journals.lww.com/nursing/Fulltext/2015/08000/Bedside_shift_report__Implications_for_patient.20.aspx

There was an online article published in the Journal of Emergency Medical Services by Douglas Dixon and Darren Braude on managing the airway of bariatric patients. Nursing considerations of bariatric patients has become a recurrent theme here: last week I discussed a REBELCast review of the accuracy of the Broslow Tape in estimating weight in obese children, and a review from the Nurse Path post on surgical considerations in weekly review 8. This article focuses specifically on airway management. Dixon and Braude start with a brief overview of the epidemiology of obesity and the physiological changes that accompany it: a reduced functional residual capacity due to decreased chest wall compliance and reduced diaphragm movement. Because of these changes obese patients will more quickly become hypoxic and will need extra attention paid to optimizing their ventilatory effort. They make some suggestions on positioning (ramped, or reverse trendelenberg), discuss how three handed BVM ventilation may be necessary to maintain good mask seal and overcome increased airway resistance, how to provide apneic oxygenation with high flow nasal cannula, and how drug dosing for RSI may need to be adjusted from total to ideal body weight (the Nurse Path post has a great overview of this). This is a good starting point if you're looking for tips for bariatric patients, and a good reminder to attend to patient position, especially for nurses working in the ED where patients may not always be able to adjust the position of the cot on their own.

http://www.jems.com/articles/print/volume-40/issue-8/features/bariatric-airway-management-is-about-more-than-intubation.html?cmpid=jemsnowenl08202015&eid=288528567&bid=1157558  




There was a great mnemonic (MADE NICER) created by Anali Maneshi and Matthew Cherian posted on BoringEM this week. It's a mnemonic to help assess possible differentials for geriatric patients presenting with weakness:

Medication - Screen for medication causes: steroids, statins, antipsychotics, diuretics, insulin, opioids, and sedatives; assess for recent dosage changes,
Anemia - Either due to blood loss (overt or occult), or impaired production malignancy, nutritional deficiency,
Dehydration - Diarrhea, diuretics, or vomiting,
Endocrine - Hyper/hypoglycemia, adrenal insufficiency, hypothyroidism can all cause glucose/electrolyte derangement,
Neurological conditions - Acute (stroke, SAH) and chronic conditions (lesion, MS, Parkinsons, etc) can result in weakness,
                                 Infection - Any infection can result in weakness,
                                 Cardiac - Presyncope from cardiac cause, angina or atypical MI presentation (malaise), and CHF may present as weakness,
                                 Electrolyte imbalance
                                 Rheumatological - SLE temporal arteritis

The typical ED will see a large number of geriatric patients, they're less capable of tolerating challenges to their systems, may be multiply co-morbid, and may have medications masking or contributing to their physical findings; having a mnemonic to help work through differential causes for a common presenting complaint is useful for all ED nurses when attempting to triage a vague complaint.

http://boringem.org/2015/08/24/tiny-tips-weakness-made-nicer/

There's been an increasing number of deaths in Canada recently from intentional and unintentional use of fentanyl. There is starting to be some reaction from the medical community, as studies are showing a 4% mortality rate associated with prescribed large doses of opioids. However there is still a large volume of diverted narcotics that are finding their way into other recreational drugs. The news is likely not news for many; but it is an excellent segue to highlight some more research on low dose titrated naloxone for opioid toxicity in the ED. A summary and how to for titrated naloxone can be found in a post by ALiEM. Worth a read for nurses working in the ED, also worth remembering is that obtunded patients without a history of narcotic use may still have unintentionally ingested fentanyl. . 

http://www.cbc.ca/news/canada/edmonton/alberta-slow-to-react-to-sharp-rise-in-fentanyl-deaths-critics-say-1.3191075



There was a podcast by Brian Ericson on erNURSEpro posted this week discussing hyponatremia, one of the most common electrolyte imbalances seen in the ED. The discussion begins with a discussion about the difference between acute and chronic hyponatremia, classification and explanation of  the differences between hypo/hyper/normo-tonic and hypo/hyper/eu-volemic hyponatremia. There is a discussion about the causes of hyponatremia: pre-renal (excess sweating/diarrhea/burns etc); versus renal (CRF/addisons disease/etc), neurogenic causes (SIADH), treatment, as well as the complications associated with correcting sodium. Brian discusses the difference in acute vs. chronic hyponatremia, and offers a great clinical pearl on suspecting hyponatremia in seizing patients who are not responding to benzo's. This is a great podcast, a little too in depth to fully absorb while driving; but worth the 25 minutes when you have some time to dedicated to listening. 

http://www.ernursepro.com/#!podcast-episodes/c1enr

I came across a blog called Rescue Science) by Matthew Douma with some great posts that I'm looking forward to reviewing in more detail in coming weeks. There's some standout posts on dead space in IV extensions, methods for pushing adenosine, and a fantastic review of the role for external aortic pressure in junctional bleeds to check out. Some of these have been out for a while, but they're directly applicable to nursing practice, thorough and well written. An awesome resource, I'm looking forward to future posts.

Check out Injectable Orange this week for a review of Sketchy EBM. I would also like to congratulate Jesse on winning the Symplur Signals Research Challenge. 

Ian Miller from the Nurse Path has 28 step guide to hanging an IV that is pretty well spot on for your first shift back, as well as some tips for handling messy situations. I'm glad to see you up and running on Facebook again!

CriticalEd had a discussion about the role of a "nurse curator" in staff development: what it is, what the role would include, what to call it etc. An exciting idea to suggest a formalized role for FOANed in clinical practice. Give it a read, he's looking for feedback and suggestions if you have any.