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Dear editor
JOURNAL OF EMERGENCY NURSING
S t u d i e s of t h e efficacy of HBO in clostridial m y o n e c r o s i s are m a d e difficult b y its relatively infreq u e n t o c c u r r e n c e , e s t i m a t e d to b e a p p r o x i m a t e l y 1200 c a s e s p e r year. 1 This fact, a l o n g w i t h t h e man~/ v a r i a b l e s t h a t i n f l u e n c e p r o g n o s i s (e.g., elderly, debili t a t e d , s y s t e m i c t o x e m i a , t r u n c a l vs. e x t r e m i t y i n v o l v e m e n t ) h a s m a d e a s s e s s m e n t of t h e effectiven e s s of HBO t h e r a p y difficult. 2-4 The only t h e r a p e u t i c r e g i m e n t h a t h a s b e e n s t u d i e d in d e t a i l h a s b e e n a n a p p r o a c h t h a t u s e d surgery, a n t i b i o t i c s , a n d HBO. This r e g i m e n of c o m b i n e d t r e a t m e n t r e s u l t e d in g r e a t e r survival of s t u d y a n i m a l s t h a n s u r g e r y a n d a n t i b i o t i c s alone. 5 Clinical r e p o r t s of u s e of al] t h r e e m e t h o d s of t r e a t m e n t s h o w i m p r o v e d t i s s u e s a l v a g e a n d a n overall m o r t a l i t y r a t e of 16%. D e a t h s in t h i s p o p u l a t i o n w e r e m o s t l y c o n f i n e d to t h o s e w h o s e initial p r e s e n t a t i o n w a s in e x t r e m i s a n d w i t h involvem e n t of t h e trunk, l, 6, 7 R e p o r t s s h o w i n g lower mortality r a t e s (15% or less) w h e n HBO t h e r a p y w a s n o t u s e d h a v e only b e e n r e p o r t e d in p a t i e n t s p r i m a r i l y w i t h i n v o l v e m e n t of t h e e x t r e m i t i e s w h o w e r e t r e a t e d p r o m p t l y a n d w e r e n o t in e x t r e m i s . The only c o m p a r i s o n of t r e a t m e n t h a s b e e n s e v e r a l r e p o r t s t h a t d e s c r i b e t r e a t m e n t r e s u l t s before a n d after HBO t h e r a p y w a s m a d e available. T h e f i n d i n g s of t h e s e r e p o r t s s h o w t h a t t i s s u e loss a n d m o r t a l i t y w e r e r e d u c e d w i t h a d j u n c t i v e HBO therapy. 4 T h e d i a g n o s i s of c]ostridial m y o n e c r o s i s is difficult. Initial e m e r g e n c y t r e a t m e n t involves r e s u s c i t a tion a n d stabilization of a potentially u n s t a b l e patient. However, o n c e t h e d i a g n o s i s is m a d e a n d t h e p a t i e n t ' s condition is d e e m e d "stable" enough, a transfer to an HBO facility should b e considered. This t r e a t m e n t , c o m b i n e d w i t h t h e m o r e a c c e p t e d m o d a l i t i e s of s u r g e r y a n d antibiotics, m a y b e lifesaving.--Thomas
T. Levins, RN, CEN, CCRN, PHRN, Institute for Environmental Medicine, Philadelphia, Pennsylvania References
~ •
1. Hitchcock CR, Demello FJ, Haglin JJ. Garr~rene infection: new approaches to an old disease. Surg Clin North Am 1975;55:1403-10. 2. Darke SG, King AM, Slack WK. Gas gangrene and related infection: classification, clinical features and aetiology, management and mortality--a report of 8 cases. Br J Surg 1977;64:104-12. 3. Hart GB, Lamb RC, Strauss MB. Gas gangrene: a collective review. J Trauma 1983;23:991-5. 4. Caplan ES, Kluge RM. Gas gangrene. Arch Intern Med 1976;136:788-91. 5. Demello F J, Haglin J J, Hitchcock CR. Comparative study of experimental Clostridium perfringens infection in dogs treated with antibiotics, surgery, and hyperbaric oxygen. Surgery 1973;73:936-41.
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6. Holland JA, Hill GB, Wolfe WA. Experimental and clinical experience with hyperbaric oxygen in the treatment of clostridial myonecrosis. Surgery 1975;77:75-8. 7. Hart GB, Lamb RC, Strauss MB. Gas gangrene: a 15-year experience with hyperbaric oxygen. J Trauma 1983;23:9951000.
Dear Editor: We r e a d w i t h i n t e r e s t t h e C a s e R e v i e w in t h e A u g u s t i s s u e r e g a r d i n g clostridial m y o n e c r o s i s (gas g a n g r e n e ) ( J E m e r g N u r s 22:272-3). T h e p a t i e n t d e s c r i b e d in this article clearly d i d n o t s u r v i v e this e p i s o d e b e c a u s e of t h e level of i n v a s i o n into t h e tissues. However, w e w o u l d like to d i s a g r e e w i t h t h e s t a t e m e n t , "the e f f e c t i v e n e s s [of h y p e r b a r i c oxygen] h a s n o t b e e n e s t a b l i s h e d . " T h e goals of HBO t h e r a p y a r e a s follows: (1) i m p r o v e m e n t of t i s s u e o x y g e n a t i o n n e c e s s a r y for w o u n d healing, (2) r e d u c t i o n of e d e m a a n d i m p r o v e m e n t of o c c l u s i v e arteritis, (3) i m p r o v e m e n t of p h a g o c y t i c f u n c t i o n b y s t i m u l a t i n g o x y g e n d e p e n d e n t killing m e c h a n i s m , a n d (4) l e t h a l i t y to strict a n a e r o b e s ) HBO t h e r a p y alone is b a c t e r i c i d a l for c e r t a i n a n a e r o b e s , i n c l u d i n g Clostridium perfringens, 2 t h e m o s t c a u s a t i v e o r g a n i s m of clostridial m y o n e c r o s i s . We a g r e e t h a t s u r g i c a l i n t e r v e n t i o n a n d a n t i b i o t i c s are t h e m a i n s t a y s of t r e a t m e n t , b u t HBO t h e r a p y is a r e c o g n i z e d a d j u n c t to t h e s e . In o n e s t u d y c o m p a r i n g clostridial m y o n e c r o s i s in d o g s w i t h a n d w i t h o u t HBO t h e r a p y (in c o m b i n a t i o n w i t h s u r g e r y a n d antibiotics), t h e survival r a t e w a s 95% a n d 70%, r e s p e c t i v e l y (p = 0.05). 3 More t h a n 1200 c a s e s of clostridial m y o n e c r o s i s t r e a t e d w i t h HBO h a v e b e e n d o c u m e n t e d . 4 HBO t h e r a p y c o m b i n e d w i t h s u r g e r y a n d a n t i b i o t i c s h a s t h e following benefits: (1) d e m a r c a t i o n of t h e b o r d e r of h e a l t h y a n d u n h e a l t h y t i s s u e , t h u s g u i d i n g s u r g e o n s w i t h excisions, (2) r e d u c t i o n of t h e e x t e n t of a m p u t a t i o n r e q u i r e d in clostridial m y o n e c r o s i s involving a n extremity, a n d (3) s u b s t a n tial i m p r o v e m e n t in p a t i e n t s w i t h s y s t e m i c illness, often after one or t w o t r e a t m e n t s . 5 In the N e w England Journal of Medicine, Tibbles a n d E d e l s b e r g 5 d i s c u s s e d clostridial m y o n e c r o s i s a s a d i s e a s e in w h i c h t h e w e i g h t of s c i e n t i f i c e v i d e n c e s u p p o r t s HBO a s a n effective a d j u n c t i v e therapy. We w o u l d c o n c u r w i t h t h e a u t h o r s t h a t e m e r g e n c y n u r s e s s h o u l d b e a w a r e of t h e early s i g n s of clostridial infection. Its p r o m p t r e c o g n i t i o n could definitely c h a n g e p a t i e n t o u t c o m e s . A s p a t i e n t advoc a t e s , w e s h o u l d also help e d u c a t e our c o l l e a g u e s , i n c l u d i n g p h y s i c i a n s , r e g a r d i n g t h e i m p o r t a n c e of a d j u n c t i v e HBO therapy. For m o r e i n f o r m a t i o n r e g a r d i n g HBO facilities, contact the Undersea and Hyperbaric Medical Society, Inc., in K e n s i n g t o n , Maryland, at (301) 9422980 (8 AM to 5 PM, EST), or t h e Divers A l e r t Network,
JOURNAL OF EMERGENCY NURSING
D u k e U n i v e r s i t y , D u r h a m , N o r t h C a r o l i n a , a t (919) 684-8111 (24-hour emergency resource).--Ann
Eubanks, R1V, CCRN, Critical Care Clinician, and Anne Marie Bennett, RN, C, MSN, Clinical Specialist, Springhill Memorial Hospital, Mobile, Alabama References 1. M a d e r J. Mixed anaerobic a n d aerobic soft tissue infections. In: Davis JC, Hunt TK, editors. Problem wounds: the role of oxygen. N e w York: Elsevier Science Press, 1988:153-72. 2. Hill GB, O s t e r h o u t S. E x p e r i m e n t a l effects of h y p e r b a r i c oxygen on s e l e c t e d clostridial species, I, in vitro studies. J Infect Dis 1972;125:17-25. 3. Demello F J, Haglin J J, H i t c h c o c k CR. C o m p a r a t i v e s t u d y of e x p e r i m e n t a l Clostridium perfringens infection in dogs t r e a t e d w i t h antibiotics, surgery a n d h y p e r b a r i c oxygen. Surgery 1973;73:936-41. 4. H e i m b a c h RD. Gas g a n g r e n e . In: Kindwall EP, editor. Hyperbaric m e d i c i n e practice. Flagstaff (AZ): Best, 1994: 373-94. 5. Tibbles PM, E d e l s b e r g JS. Hyperbaric oxygen t h e r a p y [review articles]. N Engl J M e d 1996;334:1644-6.
Charge nurses asked to sign charts for patients cared for by LPNs and EMTs: Advice sought
Dear Editor: Personnel in our emergency department include l i c e n s e d p r a c t i c a l n u r s e s (LPNs) a n d e m e r g e n c y medical technicians (EMTs) to assist the registered n u r s e i n c a r i n g for p a t i e n t s . T h e e m e r g e n c y d e p a r t m e n t p r o v i d e s s e r v i c e s for m o r e t h a n 3 5 , 0 0 0 p a t i e n t s p e r year. C h a r g e n u r s e s of t h i s 2 7 - b e d e m e r g e n c y d e p a r t m e n t a r e r e q u i r e d t o s i g n t h e c h a r t s of p a t i e n t s w h o h a v e b e e n c a r e d for b y t h e L P N or EMT. T h e c h a r g e n u r s e h a s f r e q u e n t l y s i g n e d c h a r t s of p a t i e n t s w h o m s h e h a s n e i t h e r s e e n n o r a s s e s s e d . S o m e of our nurses, including myself, are very uncomfortable with this situation. I would appreciate your insight and advice on t h i s m a t t e r . B e i n g u n s u r e of t h e l e g a l r a m i f i c a t i o n s a n d r e s p o n s i b i l i t i e s , I w o u l d like t o d e v e l o p s o m e g u i d e l i n e s for o u r department.--Christine Swartz,
RN, CEN, Jamestown, N e w York
FUTURE SITES AND DATES OF ENA ANNUAL MEETINGS Annual Meeting 1997--Atlanta, GA Atlanta Marriott Marquis General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Atlanta Marriott Marquis Inforum Scientific Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
September 3-4 September 5-7
1998----Denver, CO Colorado Convention Center General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scientific Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1999--- Washington, DC Washington Convention Center General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scientific Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
September 9 10 September 11-13
September 29-30 October 1-3
2000--Chicago, IL Hyatt Regency Chicago General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Navy Pier Scientific Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
September 20-21 September 22-24
2001--qDrlando, FL Omni Rosen Hotel General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Orange County Convention Center Scientific Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
September 12-13 September 1~16
Leadership Symposium 1997--New Orleans, LA New Orleans Marriott . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
March 14-(16
1998--Dallas, TX Wyndham Anatole Hotel . . . . . . . . . . . . . . . . . . . . . . . .
.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
February 20-22
February 1997
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S t u d i e s of t h e efficacy of HBO in clostridial m y o n e c r o s i s are m a d e difficult b y its relatively infreq u e n t o c c u r r e n c e , e s t i m a t e d to b e a p p r o x i m a t e l y 1200 c a s e s p e r year. 1 This fact, a l o n g w i t h t h e man~/ v a r i a b l e s t h a t i n f l u e n c e p r o g n o s i s (e.g., elderly, debili t a t e d , s y s t e m i c t o x e m i a , t r u n c a l vs. e x t r e m i t y i n v o l v e m e n t ) h a s m a d e a s s e s s m e n t of t h e effectiven e s s of HBO t h e r a p y difficult. 2-4 The only t h e r a p e u t i c r e g i m e n t h a t h a s b e e n s t u d i e d in d e t a i l h a s b e e n a n a p p r o a c h t h a t u s e d surgery, a n t i b i o t i c s , a n d HBO. This r e g i m e n of c o m b i n e d t r e a t m e n t r e s u l t e d in g r e a t e r survival of s t u d y a n i m a l s t h a n s u r g e r y a n d a n t i b i o t i c s alone. 5 Clinical r e p o r t s of u s e of al] t h r e e m e t h o d s of t r e a t m e n t s h o w i m p r o v e d t i s s u e s a l v a g e a n d a n overall m o r t a l i t y r a t e of 16%. D e a t h s in t h i s p o p u l a t i o n w e r e m o s t l y c o n f i n e d to t h o s e w h o s e initial p r e s e n t a t i o n w a s in e x t r e m i s a n d w i t h involvem e n t of t h e trunk, l, 6, 7 R e p o r t s s h o w i n g lower mortality r a t e s (15% or less) w h e n HBO t h e r a p y w a s n o t u s e d h a v e only b e e n r e p o r t e d in p a t i e n t s p r i m a r i l y w i t h i n v o l v e m e n t of t h e e x t r e m i t i e s w h o w e r e t r e a t e d p r o m p t l y a n d w e r e n o t in e x t r e m i s . The only c o m p a r i s o n of t r e a t m e n t h a s b e e n s e v e r a l r e p o r t s t h a t d e s c r i b e t r e a t m e n t r e s u l t s before a n d after HBO t h e r a p y w a s m a d e available. T h e f i n d i n g s of t h e s e r e p o r t s s h o w t h a t t i s s u e loss a n d m o r t a l i t y w e r e r e d u c e d w i t h a d j u n c t i v e HBO therapy. 4 T h e d i a g n o s i s of c]ostridial m y o n e c r o s i s is difficult. Initial e m e r g e n c y t r e a t m e n t involves r e s u s c i t a tion a n d stabilization of a potentially u n s t a b l e patient. However, o n c e t h e d i a g n o s i s is m a d e a n d t h e p a t i e n t ' s condition is d e e m e d "stable" enough, a transfer to an HBO facility should b e considered. This t r e a t m e n t , c o m b i n e d w i t h t h e m o r e a c c e p t e d m o d a l i t i e s of s u r g e r y a n d antibiotics, m a y b e lifesaving.--Thomas
T. Levins, RN, CEN, CCRN, PHRN, Institute for Environmental Medicine, Philadelphia, Pennsylvania References
~ •
1. Hitchcock CR, Demello FJ, Haglin JJ. Garr~rene infection: new approaches to an old disease. Surg Clin North Am 1975;55:1403-10. 2. Darke SG, King AM, Slack WK. Gas gangrene and related infection: classification, clinical features and aetiology, management and mortality--a report of 8 cases. Br J Surg 1977;64:104-12. 3. Hart GB, Lamb RC, Strauss MB. Gas gangrene: a collective review. J Trauma 1983;23:991-5. 4. Caplan ES, Kluge RM. Gas gangrene. Arch Intern Med 1976;136:788-91. 5. Demello F J, Haglin J J, Hitchcock CR. Comparative study of experimental Clostridium perfringens infection in dogs treated with antibiotics, surgery, and hyperbaric oxygen. Surgery 1973;73:936-41.
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6. Holland JA, Hill GB, Wolfe WA. Experimental and clinical experience with hyperbaric oxygen in the treatment of clostridial myonecrosis. Surgery 1975;77:75-8. 7. Hart GB, Lamb RC, Strauss MB. Gas gangrene: a 15-year experience with hyperbaric oxygen. J Trauma 1983;23:9951000.
Dear Editor: We r e a d w i t h i n t e r e s t t h e C a s e R e v i e w in t h e A u g u s t i s s u e r e g a r d i n g clostridial m y o n e c r o s i s (gas g a n g r e n e ) ( J E m e r g N u r s 22:272-3). T h e p a t i e n t d e s c r i b e d in this article clearly d i d n o t s u r v i v e this e p i s o d e b e c a u s e of t h e level of i n v a s i o n into t h e tissues. However, w e w o u l d like to d i s a g r e e w i t h t h e s t a t e m e n t , "the e f f e c t i v e n e s s [of h y p e r b a r i c oxygen] h a s n o t b e e n e s t a b l i s h e d . " T h e goals of HBO t h e r a p y a r e a s follows: (1) i m p r o v e m e n t of t i s s u e o x y g e n a t i o n n e c e s s a r y for w o u n d healing, (2) r e d u c t i o n of e d e m a a n d i m p r o v e m e n t of o c c l u s i v e arteritis, (3) i m p r o v e m e n t of p h a g o c y t i c f u n c t i o n b y s t i m u l a t i n g o x y g e n d e p e n d e n t killing m e c h a n i s m , a n d (4) l e t h a l i t y to strict a n a e r o b e s ) HBO t h e r a p y alone is b a c t e r i c i d a l for c e r t a i n a n a e r o b e s , i n c l u d i n g Clostridium perfringens, 2 t h e m o s t c a u s a t i v e o r g a n i s m of clostridial m y o n e c r o s i s . We a g r e e t h a t s u r g i c a l i n t e r v e n t i o n a n d a n t i b i o t i c s are t h e m a i n s t a y s of t r e a t m e n t , b u t HBO t h e r a p y is a r e c o g n i z e d a d j u n c t to t h e s e . In o n e s t u d y c o m p a r i n g clostridial m y o n e c r o s i s in d o g s w i t h a n d w i t h o u t HBO t h e r a p y (in c o m b i n a t i o n w i t h s u r g e r y a n d antibiotics), t h e survival r a t e w a s 95% a n d 70%, r e s p e c t i v e l y (p = 0.05). 3 More t h a n 1200 c a s e s of clostridial m y o n e c r o s i s t r e a t e d w i t h HBO h a v e b e e n d o c u m e n t e d . 4 HBO t h e r a p y c o m b i n e d w i t h s u r g e r y a n d a n t i b i o t i c s h a s t h e following benefits: (1) d e m a r c a t i o n of t h e b o r d e r of h e a l t h y a n d u n h e a l t h y t i s s u e , t h u s g u i d i n g s u r g e o n s w i t h excisions, (2) r e d u c t i o n of t h e e x t e n t of a m p u t a t i o n r e q u i r e d in clostridial m y o n e c r o s i s involving a n extremity, a n d (3) s u b s t a n tial i m p r o v e m e n t in p a t i e n t s w i t h s y s t e m i c illness, often after one or t w o t r e a t m e n t s . 5 In the N e w England Journal of Medicine, Tibbles a n d E d e l s b e r g 5 d i s c u s s e d clostridial m y o n e c r o s i s a s a d i s e a s e in w h i c h t h e w e i g h t of s c i e n t i f i c e v i d e n c e s u p p o r t s HBO a s a n effective a d j u n c t i v e therapy. We w o u l d c o n c u r w i t h t h e a u t h o r s t h a t e m e r g e n c y n u r s e s s h o u l d b e a w a r e of t h e early s i g n s of clostridial infection. Its p r o m p t r e c o g n i t i o n could definitely c h a n g e p a t i e n t o u t c o m e s . A s p a t i e n t advoc a t e s , w e s h o u l d also help e d u c a t e our c o l l e a g u e s , i n c l u d i n g p h y s i c i a n s , r e g a r d i n g t h e i m p o r t a n c e of a d j u n c t i v e HBO therapy. For m o r e i n f o r m a t i o n r e g a r d i n g HBO facilities, contact the Undersea and Hyperbaric Medical Society, Inc., in K e n s i n g t o n , Maryland, at (301) 9422980 (8 AM to 5 PM, EST), or t h e Divers A l e r t Network,
JOURNAL OF EMERGENCY NURSING
D u k e U n i v e r s i t y , D u r h a m , N o r t h C a r o l i n a , a t (919) 684-8111 (24-hour emergency resource).--Ann
Eubanks, R1V, CCRN, Critical Care Clinician, and Anne Marie Bennett, RN, C, MSN, Clinical Specialist, Springhill Memorial Hospital, Mobile, Alabama References 1. M a d e r J. Mixed anaerobic a n d aerobic soft tissue infections. In: Davis JC, Hunt TK, editors. Problem wounds: the role of oxygen. N e w York: Elsevier Science Press, 1988:153-72. 2. Hill GB, O s t e r h o u t S. E x p e r i m e n t a l effects of h y p e r b a r i c oxygen on s e l e c t e d clostridial species, I, in vitro studies. J Infect Dis 1972;125:17-25. 3. Demello F J, Haglin J J, H i t c h c o c k CR. C o m p a r a t i v e s t u d y of e x p e r i m e n t a l Clostridium perfringens infection in dogs t r e a t e d w i t h antibiotics, surgery a n d h y p e r b a r i c oxygen. Surgery 1973;73:936-41. 4. H e i m b a c h RD. Gas g a n g r e n e . In: Kindwall EP, editor. Hyperbaric m e d i c i n e practice. Flagstaff (AZ): Best, 1994: 373-94. 5. Tibbles PM, E d e l s b e r g JS. Hyperbaric oxygen t h e r a p y [review articles]. N Engl J M e d 1996;334:1644-6.
Charge nurses asked to sign charts for patients cared for by LPNs and EMTs: Advice sought
Dear Editor: Personnel in our emergency department include l i c e n s e d p r a c t i c a l n u r s e s (LPNs) a n d e m e r g e n c y medical technicians (EMTs) to assist the registered n u r s e i n c a r i n g for p a t i e n t s . T h e e m e r g e n c y d e p a r t m e n t p r o v i d e s s e r v i c e s for m o r e t h a n 3 5 , 0 0 0 p a t i e n t s p e r year. C h a r g e n u r s e s of t h i s 2 7 - b e d e m e r g e n c y d e p a r t m e n t a r e r e q u i r e d t o s i g n t h e c h a r t s of p a t i e n t s w h o h a v e b e e n c a r e d for b y t h e L P N or EMT. T h e c h a r g e n u r s e h a s f r e q u e n t l y s i g n e d c h a r t s of p a t i e n t s w h o m s h e h a s n e i t h e r s e e n n o r a s s e s s e d . S o m e of our nurses, including myself, are very uncomfortable with this situation. I would appreciate your insight and advice on t h i s m a t t e r . B e i n g u n s u r e of t h e l e g a l r a m i f i c a t i o n s a n d r e s p o n s i b i l i t i e s , I w o u l d like t o d e v e l o p s o m e g u i d e l i n e s for o u r department.--Christine Swartz,
RN, CEN, Jamestown, N e w York
FUTURE SITES AND DATES OF ENA ANNUAL MEETINGS Annual Meeting 1997--Atlanta, GA Atlanta Marriott Marquis General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Atlanta Marriott Marquis Inforum Scientific Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
September 3-4 September 5-7
1998----Denver, CO Colorado Convention Center General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scientific Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1999--- Washington, DC Washington Convention Center General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scientific Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
September 9 10 September 11-13
September 29-30 October 1-3
2000--Chicago, IL Hyatt Regency Chicago General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Navy Pier Scientific Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
September 20-21 September 22-24
2001--qDrlando, FL Omni Rosen Hotel General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Orange County Convention Center Scientific Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
September 12-13 September 1~16
Leadership Symposium 1997--New Orleans, LA New Orleans Marriott . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
March 14-(16
1998--Dallas, TX Wyndham Anatole Hotel . . . . . . . . . . . . . . . . . . . . . . . .
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February 20-22
February 1997
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