IOURNAL OF EMERGENCY NURSING/Letters

uncomfortable with this plan of action, that in itself would be enough to warrant compliance with the orig- inal disposition.

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Another example is that of a simple laceration for which the protocol indicates “emergency department now” for suturing and a tetanus toxoid update. In this case;after assessment for problems such as continued bleeding and deficits distal to the injury, if the triage was being done by a practice that had a physician avail- able to suture the wound, a downgrade from “emer- gency department now” to “office now” would be appro- priate if the patient had immediate access to an office practice capable of doing a “now” laceration repair.

As far as “deviating from protocol” on a whim- NO! ! ! To downgrade, a sound reason is required that is based on the patient assessment and good nursing judgment. My concern is that some persons might view protocols as “artificial intelligence” and overlook the role that nursing judgment plays in patient triage and management. If we are not exercising judgment, then why is the task being done by an RN?-Car01 Dare Rutenberg, RN, MNSc, CEN, Hot Springs, Ark; E-mail: CRlIiage@aol. corn

More on international emergency nursing Dear Editor:

I hope I am not too late to respond to the guest editorial by Susan Budassi Sheehy in the December issue (1999;25:439-40). In Nepal, where I am working, we are accustomed to journals arriving late and are grateful if they arrive at all!

If Susan would like a real trip down memory lane, she is more than welcome to visit our emergency de- partment at Patan Hospital here in Kathmandu. Al- though medical care keeps up relatively well with ad- vances in the West, nursing care, for reasons of economics, struggles to do so. As a result, yes, we still use rubber rectal tubes, glass thermometers, glass sy- ringes, and sundry other instruments that must be cleaned, sterilized, and reused, including oxygen masks and tubing, suture needles, and blades. Med- ications still often come in glass ampules, and I fre- quently experience glass shards in my hands from opening an ampule of 50% dextrose in a hurry. Unfor- tunately, we do not have a bedpan sterilizer in our de- partment for our few bedpans. At hospitals in poor countries such as Nepal, where the costs of running the hospital are paid mostly by patients from poor families, we try to keep expenses down to a minimum and offer charity when we can. Thus disposable items, while convenient, are often too expensive for us to even consider using, and a lot of nursing time (a cheaper commodity in a country where labor costs are low) is taken up with cleaning reusable items.

I echo the sentiments expressed by Kate Reeves on the Letters page of the same issue with regard to the article from Spain on “Voluntary Ingestion of Organophosphate Insecticide by a Young Farmer.” Suicide in such a manner is common here also. Like- wise, regarding the leading causes of death shown in Susan’s editorial, the leading causes of death in Nepal unfortunately reflect the 1899 column rather than the 1999 column (although I was surprised that I did not see maternal death through childbirth). Let’s have more articles from other countries-there is a whole world out there, and not all places have reached the 21st century yet.-Gaynor Sheahan, RN, Certificate in Emergency Nursing, Emergency Department, Patan Hospital, Kathmandu, Nepal

More on successful use of LET for wound repair Dear Editor:

I am an RN employed at the pediatric emergency department at Yale-New Haven Hospital. In August 1999, I conducted a quality improvement observation- al assessment of LET application for children between the ages of 5 and 10 years. During the month, LET was applied to the lacerations of 8 boys and 10 girls.

Our LET application procedure was similar to the one described in “Tips on Avoiding Lidocaine Infiltra- tion for Simple Wound Repairs and Using LET Effec- tively in the Emergency Department: One Pediatric Nurse’s Experience” (2000;26:40-l), differing only with the addition of methylcelluose to create a gelati- nous compound.

Overall, we used complete analgesia for chin, scalp, and bridge-of-nose lacerations, while abdomi- nal wounds and hand, knee, and foot lacerations re- quired infiltration with lidocaine. The Faces Pain Scale’ was used to assess comfort at the triage desk, 30 minutes after the LET was applied, and after the procedure. Ninety-five percent of the children went home happy after suturing (even those requiring some lidocaine infiltration after LET application). I used this as an opportunity to educate others on ap- plication and procedure and set up an evaluation data sheet to collect information.

We use LET in caring for the patients in our pediatric emergency department and like the re- sults-Deborah Gallagher, RN, CN fl, Pediatric Emer- gency Department, Yale-New Haven Hospital

Reference

1. Wong DL, Wilson D, Whaley LF. Whaley & Wong’s nurs- ing care of infants and children. 5th ed. St Louis: Mosby; 1995.

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