A structured approach to low back pain. Thorough evaluation is the key to effective treatment

When a patient comes to you seeking relief from low back pain, do you picture endless numbers of office visits with no improvement, no matter what you prescribe? Your anxiety may be well founded, but there is hope. By understanding and applying basic principles for management of low back pain, you can increase your comfort level and improve patient outcomes. In this article, Dr. Biewen presents a no-nonsense, step-by-step approach to evaluation and treatment that can take the worry out of your next low back pain appointment.     

Handling and disposal of infectious waste in the office setting

Anyone who generates infectious waste must now comply with infectious waste regulations, which vary throughout the nation and are changing rapidly. The orthopaedic nurse in the office setting must keep informed of these changes, and may also be the key to complete and correct compliance with the rules and regulations. Following a proper infectious waste protocol in the office requires an understanding of the infectious waste rules and guidelines as they apply in your state. Before choices can be made on how to comply with the guidelines, you need to assess your practice and the kinds of waste it generates.     

Calculations in apheresis

It's important to work smoothly with your apheresis equipment when you are an apheresis nurse. Attention should be paid to your donor/patient and the product you're collecting. It gives additional value to your work when you are able to calculate the efficiency of your procedures. You must be capable to obtain an optimal product without putting your donor/patient at risk. Not only the total blood volume (TBV) of the donor/patient plays an important role, but also specific blood values influence the apheresis procedure. Therefore, not all donors/patients should be addressed in the same way. Calculation of TBV, extracorporeal volume, and total plasma volume is needed. Many issues determine your procedure time. By knowing the collection efficiency (CE) of your apheresis machine, you can calculate the number of blood volumes to be processed to obtain specific results. You can calculate whether you need one procedure to obtain specific results or more. It's not always needed to process 3× the TBV. In this way, it can be avoided that the donor/patient is needless long connected to the apheresis device. By calculating the CE of each device, you can also compare the various devices for quality control reasons, but also nurses/operators. J. Clin. Apheresis 30:38–42, 2015. © 2014 Wiley Periodicals, Inc.     

Know your public: the importance of the EMS provider in community and media relations

In the hundreds, and even the thousands, of hours that are spent in EMS training, none of the time is dedicated to community relations and public information. You have learned how to provide a service, but not how to sell the product. We relate to stories about physicians who were unsuccessful because of a poor "bedside manner." The patient's perception of you has very little to do with your score on the final exam or the terminology used as you explain an illness. You are judged by the same rules by which store clerks, telephone operators, waitresses and all others in the field of public service are gauged everyday. You may never do great things, but you can do small things in a great way. Just calling 911 is not enough to save a life. The very idea that we can get everywhere in the nick of time to snatch victims from the jaws of death is a fallacy. You most be concerned with the training provided for the lay public as you are with your own continuing education. There is no better way to make your service more effective than to train your entire community to save lives. There are many reasons why you should know how to deal with the media. A strong relationship can be formed simply by knowing how to make their job easier. Following the golden rules for news releases and interviews help us all appear more professional. The career of an EMT is in metamorphosis. You have been accepted by the patients you served and your fellow members of the medical community. Now you must continue to evolve as practitioners; your skills must change to meet the demands of modern medicine, and your knowledge base must continue to increase as new information becomes available. The one thing that must remain the same is your total commitment to patient care.     

Avoid construction nightmares by taking charge of the process and setting rules

A construction crew in your ED guarantees some level of disruption, but you can keep your department functioning well by hiring contractors familiar with health care settings and establishing ground rules up front. The ED manager must be firm about patient safety and unnecessary disruptions. You can reasonably expect contractors and their crews to behave appropriately in your ED. Don't stop construction work unless necessary, or you may incur costly penalties.     

Elder abuse--a family experience.

Abuse happens every day to elderly and disabled individuals either through ignorance or design. Protecting your patient or loved one requires you to be suspicious of everyone who has access to the patient, even other family members. It is the most difficult and demanding task you will ever undertake. Our story is a long and emotional one, If you wish to read an account of our experiences, please visit my Web site at www.iannarino.us/elderabuse.     

The 1979 Presidential Address. American Physical Therapy Association.

As I close this address, I do so with a certain sense of sadness about leaving a leadership team in a very exciting time of our professional history. I retire from this office with great faith in the leadership that will follow and with the optimism that the future will hold numerous excitements for our profession. The motivation and interactions that you have provided have caused me to dream of physical therapy in a manner I could have never envisioned on my own. Oh, how I thank you for the pleasures I have derived! I hope my remarks of today will serve to stimulate your dreams, your goals, inasmuch as the combination of our dreams and goals will bring greater fulfillment to the profession of physical therapy in the years that lie ahead.     

Shock in the operating room

Many factors may contribute to producing a shock state within the surgical environment. The classic causes of shock--hypovolemia, cardiac failure, and sepsis--occur commonly in the operating room. Additionally, concurrent surgery and anesthesia may contribute to produce clinical shock. Surgery may produce hypovolemia from "third space" loss and/or from blood loss. Some anesthetic drugs, by inhibiting the autonomic nervous system, impair the body's ability to compensate for hypovolemia, cardiac failure, or sepsis. Other entities such as tension pneumothorax, drug allergy, or mechanical factors produced by surgical exposure may contribute to hemodynamic compromise of the patient. Shock that occurs outside the surgical suite may also be produced by a variety of insults. One or more factors may contribute to inadequate tissue perfusion, thus making diagnosis of the cause(s) of shock a clinical challenge. Presented in this review is an anesthesiologist's approach to shock on a macrocirculatory level. Two important concepts are vital to this approach. First, one must act immediately to restore adequate perfusion to the brain and heart when confronted with a patient in shock. This is possible without knowing the specific cause(s) of the poor perfusion. Second, a rapid, accurate diagnosis of the cause(s) must be made if the patient is slow to respond to the initial therapy. Through the use of pulmonary artery catheterization, the factors producing any given shock state may be identified, and appropriate therapy may be instituted and monitored.     

Everyday EMS leadership

As EMS professionals, you influence others every day by your actions, knowledge and the way you communicate. You lead teams in critical moments in people's lives; you make a difference. Your attitude, the manner and effect of your communication and your actions will determine whether you will influence people and become a true leader. Become a better paramedic/EMT and leader by ensuring that your influence on others is positive rather than negative. No matter who you are or your position, start today to build your team, put others first and follow your vision.     

Evaluation and reporting requirements of the disability examiner

Critics of the system within which IMEs occur might argue that there is in fact no such entity as a truly impartial evaluation because the practitioner always is aware of the source of payment for the visit and will color opinions in favor of that payor. Nonetheless, the ethical practitioner has no problem whatsoever refuting that rather cynical attitude. First, payment for any type of clinical visit must come from somewhere. Most importantly, always keep in mind what is in the best medical interest of the person you are examining, and you will avoid virtually all ethical dilemmas. To illustrate obvious examples, if a claimant has the objective impairments of herniated disc with associated radiculopathy, it makes no medical sense, and would certainly be unethical, to allow unrestricted RTW to a physical job. That clearly would not be in the best interest of a patient you were treating, nor should that be your opinion for an IME. Similarly, a person without any objective impairment documented after careful search is not well served by a continuing program of medications, time off work, useless modalities, and a growing "sickness" frame of mind. That would definitely not be in their best interest, and your opinion for a treatment case or for an IME should reflect that without hesitation. Once you make a consistent habit of always invoking what you truly believe to be in the best medical interest of the examinee, the long-term interests of the other involved parties will also be well served as a consequence. The insurance company will not be asked to either continue paying treatment and wage replacement costs for someone who could safely work, nor will it be forced to accumulate the unnecessary expenses of recurrent injuries to an injured worker returned to work prematurely. By faithfully adhering to the simple principle of not swaying from the best interest of the examinee, you might lose referral business from some sources. Certain employers, case managers, insurance carriers, attorneys, or others might want to rely on your opinion in all cases, perhaps to conclude that claimants are rarely if ever impaired (or at least not from work or auto accident-related events). Your practice and your reputation are much better off without that business. A well-planned and carefully performed IME, resulting in a detailed, understandable, and defensible report with the elements outlined in this article, will serve you and your referring sources well.     

Routes to modify the impact of stress]

The combined effects that daily frustations and tensions have upon you depend, among other factors, on the evaluation you make of the importance of your needs as well as your confidence in your abilities. This effect is equally dependent upon your evaluation of the availability, quality and adequacy of your support system. To minimize the effects of stress, it is important to develop your internal and external resources. Stress management requires more than learning relaxation techniques. It demands the development of certain attitudes that will eventually influence your entire life. This includes the development of a realistic perception of situations and demands the realization that you can only do your best, keeping in mind your knowledge, and resources as well as the context of the moment. Stress management is time management. The management of your energies is related to your resources, your values, your needs and your priorities. The bottom line is the management of your life. Daily, nurses confront the challenge of discovering their own way of gathering information, of resolving problems, of planning pleasant activities, of benefiting from those surrounding them, as well as generating ideas, thoughts and emotions. Caring for patients must also include taking care of one's self.     

Imperatives for the future of critical care nursing

In the past, nursing has tended to rely on others to predict the professional future and to suggest specific actions and strategies to make that future a reality. Each of us entered nursing practice with a vision of what the profession of nursing is. Although we may have become distracted in the interim, each of us continues to have a desired vision of the future. Critical care nursing practice can either serve as the basis for innovative leadership in the continuing evolution of autonomous nursing practice or it can continue on an evolutionary track of critical care medical practice implemented by nurses. If your vision of the future is one in which critical care nurses engage in more than the implementation of pharmaceutical and medical treatment regimens, then your vision is worth making a reality. If you believe that critical care nurses make unique and valuable patient care contributions--greater than simply retooling with every technologic advance--you need to help other nurses begin to consider your perspective. Contrary to what many people believe, the future does not just happen. Someone, whether it be a nurse, a physician, or another professional, determines by action or failure to act what the future will hold. Each nurse needs to accept responsibility for the current state of nursing. We each own a piece of nursing's future practice. I want to be sure that my piece of the future matches my vision for critical care nursing. I challenge each of you to acknowledge your vision and to begin to take action to place that vision into critical care nursing's future.     

Nutrition-focused physical assessment

Although it may seem that the nutrition-focused physical examination adds more time to the visit, the exam can be done in less time than a complete physical assessment. With practice, it can be built into your routine visit without adding significant additional visit time. The benefit of this type of examination will more than pay off in determining a baseline assessment that will allow a comprehensive plan of care to be developed. In the long-term, initial and continual assessment of a patient's nutritional status and progression toward appropriate outcomes will actually help your patient and you save you time and money and will result in less complications and better outcomes.     

Providing experiences for student nurses: perspectives for cooperating hospitals

What are the pros and cons of your hospital cooperating with a school of nursing by providing clinical experiences for students? This article discusses the human and material resources that must be available to provide the student with the maximum benefit from the experience. In addition to certain costs inherent in providing this type of support, the authors explore the advantages of having students in terms of recruitment potential, continuing education of staff, and staff satisfaction. Guidelines presented here will help you make a decision about starting a student clinical experience or enhance your management of an existing clinical experience program.     

Pathway leadership: a mature framework for teams

Shared Governance has been a successful organizational design for Central Baptist Hospital. We are addressing critical issues that impact our success, with involvement and facilitation of the employees who make up the organization. It will continue to change as our environment and system evolve. The movement from a traditional organizational structure and culture to one of embracing shared decision making gives leaders today an additional stressor. It is difficult to critically analyze your organization when you are faced daily with the external pressures of health care competition and the internal daily pressures of operations. It takes extra effort and introspection to recognize that you and your management team must undertake new and different behaviors to lead your organization into the next millennium. One thing is clear: If you do not create an environment that is flexible and able to accommodate change, your competitor will!     

Pharmacologic issues in the management of septic shock

Despite our increased understanding of the biochemistry and physiology of sepsis, the treatment of septic shock remains a challenge. Initial management of septic shock entails urgent and emergent stabilization of the patient followed by broad-spectrum, empiric antibiotic therapy. After volume resuscitation, vasopressors or inotropic therapy or both may be necessary to restore perfusion. Adjunctive therapies and monitoring strategies may be helpful in preventing complications in the intensive care setting. Additional research and clinical trials are needed to identify supportive interventions that may affect the outcome of the septic patient.     

Infection-control basics. A common sense review for EMS personnel

Infection-control principles and practices based on science and common sense have been around for thousands of years. They've proven effective. If you know how a disease is transmitted, then you'll know what PPE to use to block transmission. Viruses don't multiply or survive for long outside a living host, so they may be present on a given surface, but in low numbers--and most often not numbers large enough to cause infection. However, hepatitis B virus can survive up to seven days in the presence of dried blood; that's why contaminated equipment must be cleaned as soon as possible after use. If it's not possible to use PPE in a given situation or it fails, then post-exposure medical follow-up and treatment can protect you. Ensuring there's an effective communication network in place for reporting an exposure to your DO is essential. Your agency should verify that hospitals are aware of their responsibilities under the Ryan White Law to share patient testing information if an exposure event occurs. The DO's role includes working with hospitals to provide proper medical follow-up, rapid patient testing and counseling for the exposed provider. Your DO is your advocate. Each and every component of your department's exposure control plan assists in reducing the risk for acquiring an infection on the job. Risk reduction and risk management are both vital. Ultimately, the responsibility lies with you--the provider--to know infection-control principles and practice good habits.