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The dirty bomb: management of victims Of radiological weapons.

On June 10, 2002, Attorney General John Ashcroft announced the arrest of Al Qaeda terrorist Jose Padilla for his involvement in planning a radiological bomb attack on the United States. Two weeks later, the International Atomic Energy Agency (IAEA) reported that almost any country in the world can obtain materials needed to develop a dirty bomb, or radiological dispersal device, and more than 100 countries have inadequate programs to prevent the theft of these radioactive materials (Kobyakov & Florquin, 2002). Osama Bin Laden has proclaimed that it is a "religious duty" for Muslim states to obtain nuclear weapons to attack the West. Intelligence sources believe that to date, he has managed to obtain conventional weapons in the form of dirty bombs (Karon, 2002).

The Dirty Bomb

A dirty bomb is a conventional explosive loaded with radioactive isotopes. It is designed to explode and spread nuclear material in order to contaminate a certain area. This weapon is intended more to terrorize than to destroy a population (Karon, 2002). Based on a number of possibilities in designing a dirty bomb, its manufacture is well within the capabilities of most terrorist groups. Terrorists could build a small bomb from a stick of dynamite and a small amount of radioactive material. Filling a backpack, a small automobile, or a large truck with explosives and radioactive material would yield bombs of various size (Harris, 2002). Sources of radioactive material for a bomb can be obtained from hospital radiation therapy (cobalt-60, cesium-137), nuclear power fuel rods (uranium-235, plutonium), and university and other laboratories that conduct scientific research using radiography and gauging devices (cobalt-60, cesium-137, iridium-192, radium-226) (United States Army, 2000). Abandoned nuclear batteries in the former Soviet Union contain strontium-90, a highly potent radioactive isotope. Even smoke detectors found in private homes have small amounts of radioactive material and would provide low-level radiation for a small dirty bomb (Harris, 2002).

The effects of a detonation would depend upon the size of the conventional bomb and the amount of radioactive material packed into it. Unlike a nuclear weapon, the dirty bomb would not release the radioactivity in a massive burst of energy, Instead, the radioactive dispersion would act as a toxic chemical in which the accumulated radiation would eventually prove harmful or fatal (United States Army, 2000). According to Michael Levi, a pbysicist and director of the Federation of American Scientists' Strategic Security Project, a recent computer simulation of a dirty bomb attack on New York spread radioactive fallout over 60 city blocks. Immediate casualties and property damage would result from the explosion. Radioactive contamination would leave the area uninhabitable for decades and cost tens of millions of dollars for relocation of the population and cleanup of the site (Warrick, 2002).

Blast Injuries

An explosion is caused by the conversion of a solid or liquid into gas, resulting in an extremely rapid release of energy. High explosives, such as dynamite (trinitrotoluene [TNT]), are designed to detonate very quickly through a transformation of the physical space that was once occupied by the solid or liquid material into gasses that fill the same volume. This process occurs instantaneously under extremely high pressure. The detonation generates a pressure pulse carried as a blast wave in all directions (Wightman & Gladish, 2001). Injuries from the blast are divided into four types:

* Primary blast injuries occur as the direct effect of overpressure on tissue. Since air-filled structures are more easily compressed than fluid-filled or solid structures, primary blasts affect the lungs, gastrointestinal tract, and ears.

* Secondary blast injuries are caused by flying debris that strikes victims.

* Tertiary blast injuries result from a high-energy explosion that sends people flying through the air, eventually striking other objects.

* Miscellaneous blast injuries include all other injuries resulting from a blast. Any type of blast can ignite a fire, cause structural damage, and cause buildings to fall. Injuries resulting from these types of damage would be classified as miscellaneous blast injuries (Lavonas, 2001).

Primary blast injuries to the lungs typically manifest as pulmonary contusions. Unless the victim is in a confined space, these contusions are located on the side of the lung nearest the approach of the blast wave. Victims in a confined space will have bilateral, diffuse contusions. The extent of pulmonary damage is directly proportional to the velocity of chestwall displacement at the impact of the blast wave. Larger blast impulses can produce hemopneumothorax, traumatic emphysema, and alveolovenous fistulas that can lead to bronchopleural fistulas and arterial air embolism. Severe blasts can lead to cardiac contusions of esophageal rupture (Wightman & Gladish, 2001).

Pulmonary injuries are the most common fatal blast injuries among initial survivors. Blast lung may present initially with signs and symptoms of apnea, bradycardia, and hypotension, but has been reported as late as 48 hours following the explosion. Other signs and symptoms of pulmonary injury include dyspnea, cough, hemoptysis, and chest pain (Centers for Disease Control [CDC], 2003).

Damage to the gastrointestinal tract occurs for the same reasons as lung injuries. The leading pathology is hemorrhage, anything from small petechiae to large hematoma. The colon is the most common site for hemorrhage, perforation, rupture, shearing, and lacerations; testicular rupture can also occur (CDC, 2003). Clinical manifestations of GI injury include absent bowel sounds, bright red blood from the rectum, guarding, rebound tenderness, abdominal pain, nausea, vomiting, diarrhea, and tenesmus, which is an intense but ineffective desire to evacuate (Wightman & Gladish, 2001).

Primary blast injuries to the auditory system can affect both the inner and middle ear. Perforation of the tympanic membrane (TM) is the most common middle ear injury. Signs of injury that present initially include hearing loss, tinnitus, pain, vertigo, ruptured TM, and bleeding or mucopurulent exudates from the injured canal (CDC, 2003). TM rupture may indicate that serious injuries, such as lung or intestinal blast injuries, may have occurred. However, intact TMs do not necessarily imply that more serious injuries have not occurred (Lavonas, 2001).

An individual far from the scene of the blast can receive secondary blast injuries from flying debris propelled into the air by the blast wind. Possible injuries include neck and torso trauma from impalement, as well as blunt and penetrating trauma (Argyros, 1997). Large fragments can cause direct amputations of limbs. After propelled fragments strike tissue, they can exhibit a tumbling effect that can increase the amount of tissue damage. Blast fragments often force environmental debris into the wound, further complicating tissue contamination. Blast winds also can hurl a body into the air until it strikes of becomes impaled on an object. A victim can tumble along the ground, sustaining fractures, crush injuries, amputations, abrasions, and contusions (Covey, 2002).

When a building or other structure collapses as a result of stress waves and pressure differentials from the initial blast, resulting mechanical injuries occur. In fact, 97% of the deaths from the Oklahoma City bombing were a direct result of collapse of the Murrah Federal Building (Wightman & Gladish, 2001). Those victims who do survive may sustain blunt or penetrating trauma, fractures, and burns from falling buildings or secondary fires (Covey, 2002).

Radiation Exposure

Rescue personnel initially approaching the scene of a terrorist event involving a dirty bomb should use caution and look for signs of hazardous materials. The command post should be set up at a safe distance (approximately 150 feet) upwind and uphill of the site to prevent the wind from contaminating the clean area. Personnel should notify authorities and hospitals, and use personal protective gear (gowns, gloves, masks), dosimeters, and survey meters as available. A control line should be established near the ambulance, and personnel should remain within the control (contaminated) area. An ambulance cot with clean sheets on the clean side of the control line should be available for patients without radiation exposure or for those who have been decontaminated. Ambulance personnel transporting clean patients should be clean, as well (Oak Ridge Associated Universities, 2000).

Patients with life-threatening injuries should be immediately evacuated and considered contaminated. Radioactive contamination is never immediately life-threatening and decontamination can occur once life-threatening injuries are treated (City of New York, 2003). Once life-threatening injuries have been ruled out, the amount of the victim's radiation exposure should be measured by a Geiger counter, if available, at the control line. If contamination is confirmed, clothing should be removed and the patient transferred to the clean side and transported to the nearest emergency room. Wounds should be exposed and covered with sterile dressings (Oak Ridge Associated Universities, 2000).

Preparing the Emergency Room

In the event of a radiological emergency, the hospital's Radiological Response Plan should be initiated and the Radiological Response Team, if available, notified. Team members have received specialized training and practiced scheduled drills with emergency response teams, and are familiar with the hospital's protocol for treating radiological casualties (Oak Ridge Associated Universities, 2000). Ropes and signs can be used to control the emergency room area by specifying routes and identifying clean and contaminated areas. Entrance and exit areas should be monitored by security to prevent the spread of contamination as well as unauthorized access. Wrapping patients in cloth sheets can provide movement of victims with minimal spread of contamination (Mettler & Voelz, 2002).

Emergency room staff can ensure their safety by wearing appropriate protective gear. Standard precautions should be incorporated to include gown, mask, gloves, cap, eye protection, and waterproof shoe covers. Surgical gloves should be taped down at all seams and cuffs and covered by a second pair of gloves so that they can be easily removed and replaced. Each team member should be assigned a dosimeter, if available, for measuring individual radiation exposure (Oak Ridge Associated Universities, 2000).

Decontamination

The area must be resurveyed to assess levels of radiation. Wounds must be decontaminated first. Each wound should be exposed, draped, and flushed with copious amounts of sterile saline or water. Once the wound is considered clean, a waterproof dressing should be applied and decontamination of the rest of the body begun by washing with mild soap and water. Radiation, like dirt, can be washed away by gently cleansing the body. Contaminated burns are treated like any other burns after they are adequately flushed with sterile saline. Once the patient has been decontaminated, open wounds must be surgically closed. Ambulatory patients can decontaminate themselves by showering with soap and water. All contaminated articles, including staff protective gear, should be placed in plastic bags inside the contaminated room and the room identified with special signs "Caution, Controlled Area--Do Not Enter." The contaminated room should remain secured until the radiation officer or health physicist clears the area (Oak Ridge Associated Universities, 2000).

Initial Management

Triage of mass casualties in the field is essential to expedite the movement of victims who have the greatest chance of survival. Rescue personnel often use a simple triage and rapid treatment (START) technique involving a brief assessment of respiration, perfusion, and mental status (RPM). The rescuer can use this technique to move through victims in seconds, quickly assessing respiratory rate and effort, pulse, and mental status, including ability to follow commands. Each victim is placed into a specific category with universal color codes: (1) immediate or emergent (red), (2) delayed or urgent (yellow), (3) minimal or "walking wounded" (green), and (4) expectant or dead/dying (black). During this quick assessment and categorization, the only interventions performed are the opening of an obstructed airway and direct pressure over obvious external bleeding (Marx & Hockberger, 2002). Victims with amputated body parts who show no sign of movement of response should be considered dead. Victims who are apneic, without a palpable pulse, and have dilated pupils should be considered dead, and CPR at the scene is never indicated (Stein & Hirshberg, 1999).

Management of blast injuries begins with the initiation of life support, to include airway, breathing, and circulation. An open airway and cervical spine precautions should be maintained for unconscious victims with inadequate airway or respiratory compromise. High-flow oxygen is administered via non-rebreather or bag valve mask with assisted ventilations. The only chance for survival of victims experiencing severe respiratory compromise in the field is the availability of advanced life support. Control of hemorrhage is essential to prevent complications from shock. If direct pressure fails, a tourniquet should be applied proximal to the bleeding site and clearly marked with time of placement. Open wounds should be covered with dressings and bandages, and intravenous rehydration started for victims who are hemodynamically compromised (Stein & Hirshberg, 1999).

Fractures should be aligned with splints and backboards when supplies are available. With mass casualty incidents, supplies quickly become scarce. Splinting limb-to-limb of securing patients to stretchers is appropriate until definitive care is available (Stein & Hirshberg, 1999).

Management

Except in rare instances, the typical dirty bomb will disperse low levels of radiation. These levels would be well below those expected to cause observable medical problems. Once life-threatening injuries have been stabilized and the patient adequately decontaminated, nurses should obtain a thorough history to include the patient's location relative to the center of the blast. The victim in an enclosed space tends to have more serious injuries. One closest to the blast will be exposed to greater pressures and have a higher incidence of blast-related injuries. A thorough physical exam with special attention to the lungs, abdomen, and tympanic membranes will be necessary. Nurses should remember that the presence of tympanic membrane injury due to an explosion indicates that a high pressure wave was present. A correlation between TM damage and organ damage should be considered. Nurses should assume that wheezing or dyspnea associated with a blast injury is from a pulmonary contusion, and the patient should be prepared for necessary chest x-rays. Abdominal pain may be indicative of abdominal organ injury, and the patient should be prepared for abdominal computerized tomography (Lavonas, 2001). The patient should be monitored frequently for pain, which should be adequately controlled by the use of parenteral opioids such as morphine (Morphitec[R]), meperidine (Demerol[R]), fentanyl (Sublimaze[R]), and remifentanil (Ultiva[R]) (Marx & Hockberger, 2002).

A patient with radiation exposure will need initial laboratory tests to include a stat complete blood count (CBC), which should be repeated every 4 to 6 hours for 24 to 48 hours, with close monitoring of the lymphocyte count. Nausea and vomiting are seldom experienced with low levels of radiation exposure and hospitalization is usually not necessary. The patient is managed by close observation, and frequent CBCs with differentials are obtained. Depending on the level of radiation exposure and injuries sustained by the blast, the patient may be managed in the hospital until stabilized. With milder cases, outpatient monitoring is appropriate. Blood, urine, feces, and any other samples taken initially should be retained for examination by pathologists and public health officials if necessary. Each sample should be labeled with the patient's name, date, time sample was collected, location, and size of sample. All staff should maintain standard precautions and should wear gloves while obtaining specimens from patients (Department of the Army, 2001; Skorga et al., 2003).

Delayed Health Effects

Delayed health effects include carcinogenesis, cataracts, chronic radiodermatitis, and decreased fertility, which may appear months to years after radiation exposure. These effects can involve all tissues and organs (Department of the Army, 2001). Radiation overexposure increases the risk and probability of developing cancer. The type of cancer that develops depends on the area irradiated, dose, patient age, and other demographic factors. With the low-level dose range, the greatest risk is the development of benign and malignant tumors and leukemia years after the event. Radiologic-induced tumors are histologically and clinically indistinguishable from spontaneously occurring tumors. It is difficult to determine how great a risk this low-level exposure produces due to the high background risk of developing cancer over a lifetime (Department of the Army, 2001).

Dirty bombs can disperse all types of radiation (including alpha, beta, gamma, and neutron) through solid, liquid, gaseous, or vapor forms. Neutron irradiation is more likely to produce cataracts, even at relatively low doses. Cataract formation begins at the posterior portion of the lens and continues until the lens is covered. It is the most common delayed effect from radiation exposure. The rate of growth and degree of opacity depend upon the amount and type of radiation exposure (Department of the Army, 2001).

The testes and ovaries are only temporarily affected by low-level radiation exposure. Male sterility due to damaged spermatogonia can occur after 15 cGy (centiGray, a unit of radiation measurement) of local or whole body irradiation. This usually occurs 2 months after irradiation because this is a maturation depletion process. Testosterone levels are unaffected. Female reproductive organs are more resistant to radiation exposure (Department of the Army, 2001).

Psychological Effects

Nurses should keep in mind the overwhelming psychological impact that a dirty bomb can have on society. During the Gulf War, only 22% of emergency room admissions had physical injuries actually related to the blast following Scud missile attacks. Another 22% of treated soldiers had unnecessarily used their atropine-injectors thinking they had been exposed to nerve gas, while 51% of the admissions were of people who could not cope with the anxiety and panic associated with these missile attacks (Salter, 2001).

With the release of radiation, even with the small amounts found in dirty bombs, the psychological impact can be expected to be much greater. The general population believes that radiation can kill and cause severe harm. Following the 1986 Chernobyl nuclear power plant accident, citizens across the world feared the movement of radioactive fallout into their living environments. Many refused to go outdoors unless it was absolutely necessary and ate only canned foods. Some living in nearby countries even committed suicide to prevent what they felt would be a horrible radiation-induced death (Salter, 2001).

Widespread alarm and psychological disturbances also occurred in 1979 with the nuclear accident at Three Mile Island. Even though there were no injuries or deaths, and those who were exposed had minimal levels of radiation, the psychological impact was very real. Psychosomatic complaints were common, and many fled the region in fear. Even some medical personnel reportedly left the area to prevent themselves from having to treat possible radiation-exposure casualties (Salter, 2001).

Documentation

Meticulous documentation for forensic and long-term followup must be maintained during mass casualty events surrounding an explosion by a dirty bomb. Civil litigation against responsible parties can be expected, and accurate medical documentation is critical in identifying pathologies and radiation exposure. Even though documentation is extremely difficult during the chaos of initial management, time must be devoted to documentation as soon as possible (Wightman & Gladish, 2001).

Implications for Medical-Surgical Nursing

Nurses on a medical-surgical unit who encounter patients with blast injuries from a dirty bomb explosion should understand that there is no danger of radiation exposure for them. Nursing management for these patients would include the same care needed for patients with the particular injuries they have sustained, regardless of the cause of the injury. For example, patients with pulmonary contusions from primary blast injuries, patients with limb amputations from secondary or tertiary blast injuries, and patients with burns from secondary fires with miscellaneous blast injuries require the appropriate nursing care regardless of the cause of the injuries. However, when the cause of the injuries is a dirty bomb explosion from a terrorist attack, patients experience special psychological needs. Further, all patients with a history of injuries sustained from a dirty bomb explosion have an increased risk of developing cancer, cataracts, and dermatitis, as well as decreased fertility. Medical-surgical nurses should be aware of these delayed health effects when planning care for patients who have been victims of a dirty bomb explosion. Military nurses can provide some assistance in this and other practice areas as America protects itself from terrorism.

Note: The opinions expressed in this article are those of the authors and do not necessarily reflect the views of the Department of Army or the U.S. Department of Defense.

References

Argyros, G.J. (1997). Management of primary blast injury. Toxicology, 121(1), 105-115.

Centers for Disease Control (CDC). (2003). Explosions and blast injuries, A primer for clinicians. Retrieved June 16, 2003, from http://www.cdc.gov/masstrauma/ preparedness/primer.pdf

City of New York Department and Mental Hygiene, The. (2003). Information on radiological emergency response. Retrieved June 16, 2003, from http://www.nyc.gov/health

Covey, D.C. (2002). Blast and fragment injuries of the musculoskeletal system. The Journal of Bone and Joint Surgery, 84-A(7), 1221-1234.

Department of the Army, the Navy, and the Air Force and the Commandant, Marine Corps. (2001). Army field manual 402.283, treatment of nuclear and radiological casualties. Retrieved June 16, 2003 from http://www.globalsecurity.org/ wmd/library/policy/army/fm/4-02-283/fm4-02-283.pdf

Harris, T. (2002). How dirty bombs work. Retrieved October 24, 2002, from http://www.howstuffworks.com/dirtybomb.htm

Karon, T. (2002). The "dirty bomb" scenario. Retrieved October 24, 2002, from http://www.time.com/time/nation/article/0,8599,182637,00.html

Kobyakov, D., & Florquin, N. (2002). Dirty bomb threat awakens dormant disarmament conference. Monterey Institute of International Studies. Retrieved October 24, 2002, from http:// cns.miis.edu/pubs/week/020826.htm

Lavonas, E. (2001). Blast injuries. Retrieved November 9, 2002, from http:// www.emedicine.com/emerg/topic63.htm

Oak Ridge Associated Universities. (2000). Managing radiation emergencies. Retrieved October 16, 2002, from http://www.orau.gov/reacts/care.htm

Marx, J., & Hockberger, R. (2002). In R. Walls & R. Hockberger (Eds.), Rosen's emergency medicine: Concepts and clinical practice (p. 2633). St. Louis: Mosby.

Mettler, F.A., Jr., & Voelz, G.L. (2002). Major radiation exposure--what to expect and how to respond. New England Journal of Medicine, 346(20), 1554-1561.

Salter, C.A. (2001). Psychological effects of nuclear and radiological warfare. Military Medicine, 166(12 Suppl), 17-18.

Skorga, P., Persell, D.J., Arangie, P., Gilbert-Palmer, D., Winters, R., Stokes, E.N., & Young, C. (2003). Caring for victims of nuclear and radiological terrorism. Nurse Practitioner, 28(2), 24-41.

Stein, M., & Hirshberg, A. (1999). Medical consequences of terrorism. The conventional weapon threat. Surgical Clinics of North America, 79(6), 15371552.

United States Army, Center for Health Promotion and Preventative Medicine. (2000). The medical NBC battlebook.

Warrick, J. (2002, Sunday, November 17). Fears of Soviet-era radioactive cesium spark search. Arkansas Democrat Gazette, 13.

Wightman, J.M., & Gladish, S.L. (2001). Explosions and blast injuries. Annals of Emergency Medicine, 37(6), 664-678.

Statement of Ownership Management and Circulation (required by 39 U.S.C. 3685)

Date of filing--November 6, 2003. MEDSURG Nursing (ISSN 1092-0811) is published bimonthly at East Holly Avenue/Box 56, Pitman, Gloucester County, NJ 08071-0056, with headquarters or business offices of the publisher at East Holly Avenue/Box 56, Pitman, Gloucester County, NJ 08071-0056. The name and address of the publisher is Anthony J. Jannetti, East Holly Avenue/Box 56, Pitman, Gloucester County, NJ 08071-0056. The editor is Dottie Roberts, East Holly Avenue/Box 56, Pitman, Gloucester County, NJ 08071-0056. Managing editor is Kenneth J. Thomas, East Holly Avenue/Box 56, Pitman, Gloucester County, NJ 08071-0056. Owner of the publication is Jannetti Publications, Inc., East Holly Avenue/Box 56, Pitman, Gloucester County, NJ 08071-0056. There are no bondholders, mortgagees, or security holders.

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Access to genomic healthcare: the role of the nurse.

The following is an excerpt from the ISONG position statement "Access to Genomic Healthcare: The Role of the Nurse." The position statement was approved by the ISONG Board on September 9, 2003.

It is the position of ISONG that professional nurses will:

* Recognize and acknowledge the role of genomics as an integral component in the promotion of the public's health and well-being.

* Advocate and promote the right of the individual or family to voluntarily choose or to not choose to seek genomic healthcare services.

* Evaluate and support legislation that provides protection from health insurance and employment discrimination at the state and federal levels.

* Identify and seek solutions to the elimination of barriers to accessing genetic healthcare.

* Advocate equal access to genomic healthcare.

* Implement continuing higher genetic education programs in genetics for nurses to improve and maintain their genetic science knowledge base.

* Establish and evaluate practice settings for provision of genetic counseling, genetic education, or other genetic healthcare services to meet the needs of the patient population.

* Integrate into clinical practice genetic research findings that promote the health and well being of individuals and families.

* Participate in strategic planning that creates partnerships for the delivery of genomic healthcare within and between the public and private sectors.

* Conductor participate in research studies that attempt to describe and explain the interactions of genetic susceptibility and environmental factors.

* Educate the public about genetic healthcare and genetic healthcare services using school-based and community-based educational programs.

* Participate in and endorse the need for evidence-based research by nurses.

References

American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Kansas City, MO: Author.

Baker, T. (1998). Genetics and public health: Need for information, integration and infrastructure. Genomics and Disease Prevention, Centers for Disease Prevention. Retrieved from www.cdc.gov/genomics/infor/reports/program/baker.html

Guttmacher, A.E., & Collins, F.S. (2002). Genomic medicine: A primer. New England Journal of Medicine, 347, 1512-1520.

Institute of Medicine. (1988). The future of public health. Washington, DC: National Academy Press.

International Council of Nurses. (2000). The ICN code of ethics for nurses. Geneva, Switzerland: Author.

International Society of Nurses in Genetics. (1998). Statement on the scope and standards of genetics clinical nursing practice. Washington, DC: American Nurses Publishing.

International Society of Nurses in Genetics. (2003, Winter). Position statement: Genetic counseling for vulnerable populations: The role of nursing. International Society of Nurses in Genetics Newsletter, 14(1), insert.

International Society of Nurses in Genetics. (2002, Winter). Position statement: Privacy and confidentiality of genetic information: The role of the nurse. International Society of Nurses in Genetics Newsletter, 13(1), insert.

International Society of Nurses in Genetics, Inc. (2000, Winter). Position statement: Informed decision-making and consent: The role of nursing. International Society of Nurses in Genetics Newsletter, 11(3), 7-8.

Jane, L.F., & Michele, L.P. (2000). Access to genetic services in the United States: A challenge to genetics in public health. In Genetics and public health in the 21st century: Using genetic information to improve health and prevent disease. New York: Oxford University Press.

Robert C. McIlvaine Circulation Manager

Denise Willis, MNSc, APN, is a Family Nurse Practitioner, John L. McClellan Memorial Veterans Hospital, Little Rock, AK, and a Captain in the Nurse Corps, Army Reserve, 5th Brigade (Health Services), 95th Division.

Elizabeth Ann Coleman, PhD, RNP, AOCN, is a Professor in the Colleges of Nursing and Medicine, University of Arkansas for Medical Sciences, Little Rock, AK, and a retired Colonel in the Nurse Corps, Army Reserve.
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Title Annotation:Best Practice
Author:Willis, Denise; Coleman, Elizabeth Ann
Publication:MedSurg Nursing
Date:Dec 1, 2003
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