Looking at the qualities that make a great nurse.

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“Great nurses, regardless of whether they work in clinical practice, education, administration, research or other areas, all possess three qualities or essences. These are:

Passion: Their passion for excellence in all they do can be seen and felt by others.
Pride: They take immense pride in being a nurse and in honoring the heritage and legacy of a caring profession.
Presence: Great nurses communicate with — and from — a profound depth and quality of presence. They are committed to ‘being with’ and ‘being there’ with patients and clients.”
—Professor Susan Sweat Gunby


What qualities make a great nurse? Well you will probably hear a wide and diverse range of responses to that question.

When you look through the literature for some sort of guidance you see a lot of stuff about knowledge and emotional intelligence, of being a problem solver, and a critical thinker.

And then there is the ‘C’ word. As one nurse manager wrote:

“Great nurses are born, not made. They have an innate gift of unconditional compassion and a relentless determination to alleviate suffering.”

I guess there might be some truth in all these things. Perhaps not.

Thinking about my own experiences as a nurse of 30 years, and with a few (albeit brief) experiences on the receiving end of the nursing profession here is my own list.
Its not based on research or evidence….it is based on observation:


Im not talking about being engaged with patients here, although that is part of it. I am talking about being engaged with the very act of being a nurse.

Nurses who stand out are awake to the power and responsibility of their profession and celebrate this rather than shy away from it or attempt to wield it for personal promotion.

Some nurses never really completely turn up for the shift. Others are in a real hurry to be somewhere else. But you always notice the nurses who are truly amongst it all.


Only a nurse or someone who works alongside a nurse will understand the toughness that is required. And unless there is an ability to respond to the unique stressors that each shift throws up, a great nurse will not be great for long.

The great nurse will have their unique personal reservoir that they can tap into during tough times. Or a strong social support system to tourniquet their hearts when bleeding out.

They know when to hang on. They know when to let go.


Great nurses may be smart. They may be academically astute. But they will always be competent.

In actuality some of the best nurses I have ever worked with are not natural leaders. They are not high achievers. They are not intellectual Everest’s. They are not in positions of authority. They are not often acknowledged by their organisations.

But they are solid clinicians. They are advocates for their patients. And when the shit hits the fan, you absolutely want them at your shoulder.


Hmmm. Let see.
Some great nurses are totally leaders. On the occasions that the gears of great nurse and strong leader do sync…lean in and hang on.

However many of the great nurses I have worked have more a quiet confidence. In some respects they may even come across a little under-confident. They may tend to underestimate their worth within organisational structures. They don’t talk themselves up much. They are not particularly interested in self promotion, probably because they recognise that nursing is by its very nature is more about other than self.  (This is both its real source of power and its greatest Achilles heel. But I digress…).

But when you watch them at work. There is a quiet confidence in their every move. They make the rest of us look good by proxy.


Great nurses always seem happy in their work. Well perhaps not always….but often.
Good shift, bad shift they seem comfortable in their skin and able to lift the morale of those around them.
As someone who tends to get all serious and frowny about 45 seconds into most shifts I envy them.


Finally, great nurses will do what needs to be done for their patients. Even when it gets all difficult and even when it involves conflict with peers and colleagues. But it is done with assertiveness. From a place of quiet confidence and professional stability.


Which patients admitted for pneumonia need MRSA coverage?

Let's be honest, our decisions to cover MRSA among patients admitted to the hospital with pneumonia are haphazard. It's not our fault. The guidelines are contradictory. For example, the MRSA guidelines by the Infectious Disease Society of America recommend coverage for everyone admitted to the ICU with pneumonia. However, pneumonia guidelines by the same society recommend coverage only for patients with specific risk factors. Fortunately, new evidence and diagnostic tools may allow us to properly treat MRSA, without drowning the entire hospital in vancomycin.

EMCrit by Josh Farkas.

A Highly Gifted Juice

Author: Danielle Miller, MD (EM Resident Physician, PGY-2, NUEM) // Edited by: Colin McCloskey, MD // Expert Commentary: Brian Sellers, MD

Citation: [Peer-Reviewed, Web Publication] Miller D, McCloskey C (2016, July 19). A Highly Gifted Juice: Opening Pressure In Idiopathic Intracranial Hypertension [NUEM Blog. Expert Commentary by Sellers B]. Retrieved from http://www.nuemblog.com/blog/highly-gifted-juice/

An Evidence Based Approach To Opening Pressure in CSF Analysis and its Role in Idiopathic Intracranial Hypertension 


A 27 year-old obese female with a past medical history of migraines presents with the worst headache of her life. A non-contrast head CT shows no mass and no blood. A lumbar puncture (LP) is performed to rule out SAH and to measure opening pressures. The intial opening pressure is 44 with a closing pressure of 21. The CSF is negative for blood. A diagnosis of idiopathic intracranial hypertension (IIH) is suspected.

The History Of The Lumbar Puncture

Cerebrospinal fluid was originally identified by Swedish mystic Emanuel Swedenborg in 1736, who described the fluid as a “spirituous lymph’ and “highly gifted juice.” [1]  

The first LP was performed in the late 19th century by Heinrich Iraneus Quincke and Walter Essex Wynterin. At that time, the mortality rate of the procedure was high as a result of being performed on sick patients and involvinga large incision with a scalpel down to the spinal cord [2]. As early as the 20th century, scientists started to measure opening pressures [3]. 

Does positioning matter?

Yes, the patient must be lying in lateral decubitus to essentially zero the manometer.  The head should be in line with the right atrium, which should be in line with the spinal needle. Technically, the legs should be extended to minimize falsely elevated values. Opening pressures in the seated position are elevated by approximately 25 cm H20 [3]. 

Seriously, leg extension?

Studies suggest that hip flexion may increase CSF opening pressure by increasing intra-abdominal pressure [5].   A study in 1991 found that a flexed position increased opening pressures by 6–8 cm H2O [6]. However, a more recent study in 2001, found differences of only 1–2 cm H2O [7]. 

Does BMI affect opening pressures?

Yes, there is a correlation between BMI and opening pressure, but the values are clinically insignificant, with ranges still remaining 10 cm H20 to 25 cm H20 [8].

  CSF opening pressure (cm CSF) according to four categories of body mass index (BMI). Boxes represent point estimates of median CSF opening pressure, and error bars represent 95% reference intervals. The area of each box is proportional to the sample size of each group [8].

CSF opening pressure (cm CSF) according to four categories of body mass index (BMI). Boxes represent point estimates of median CSF opening pressure, and error bars represent 95% reference intervals. The area of each box is proportional to the sample size of each group [8].


What Disease States Should I Worry About With A High Opening Pressure?

  1. Processes that block CSF reabsorption by the arachnoid granulations or increase/obstruct the venous outflow pathway:
    1. Idiopathic intracranial hypertension (IIH)
    2. Cerebral venous sinus thrombosis
    3. Intracranial or spinal mass  
    4. Scarring inflammation (sequelae of meningitis, SAH)
  2. Any process that increase venous pressures:
    1. Arteriovenous malformations
    2. Superior vena cava syndrome
    3. Elevated right heart pressures
  3. Miscellaneous causes:
    1. Hypervitaminosis A
    2. Addison’s Disease
    3. Hypoparathyroidism [9]  
    4. Medications (tetracyclines, nitrofurantoin, and nalidixic acid), amiodarone, cyclosporin, systemic and topical steroids, and the oral contraceptive pill [10] 

Do you need a high opening pressure to diagnose IIH?

Yes and no, IIH is diagnosed with the Dandy criteria:

  • Signs & symptoms of increased intracranial pressure such as headache, visual changes, tinnitus, or papilledema
  • No other neurologic deficits or evidence of impaired consciousness
  • Elevated intracranial pressure with normal CSF analysis.
  • A neuroimaging study that shows no etiology for intracranial hypertension
  • No other cause of intracranial hypertension apparent [4] 

However, if a patient does not have an elevated opening pressure, the patient can still have IIH, given that intracranial pressure (ICP) fluctuates throughout the day. 

Why is opening pressure high in IIH?

The true pathophysiology is unknown. Recent studies have suggested that cerebral venous outflow abnormalities lead to elevated intracranial venous pressures, which leads to increased ICP, and thus higher opening pressures.  Causes of outflow abnormalities include venous stenosis or venous hypertension. However, none of the studies can determine if the venous abnormalities are the cause of IIH or merely secondary to the disease process itself [11]. 

So will the LP that was just performed in the ED on the patient with suspected IIH really alleviate the patient’s headache?

Maybe. Use of LP in symptom management is controversial.  CSF returns to pre-tap levels in approximately 82 minutes. Thus, the LP has a short-lived effect on symptom management [11,12]. 

What are treatment options for patients with IIH that present to the ED with headache?

Acetazolamide (Diamox) 250-500 mg BID is recommended and works by decreasing CSF flow. However, because the medication’s effect does not occur until 99.5% of choroid plexus carbonic anhydrase is inhibited, in the acute setting, this may not provide immediate relief [13]. 

Furosemide (Lasix) can also treat IIH.  Lasix alleviates the headache through diuresis and reducing sodium transport into the brain, thus reducing ICP. Outpatient management generally begins at 20 mg BID dosing [14]. 

What are the practice patterns for obtaining an opening pressure in the ED?

There is no data on ED practioners’ frequency of obtaining opening pressure as a part of the LP procedure.

Case Conclusion

The patient is admitted to neurology for MRI to exclude secondary causes of increased intracranial pressure. MRI is negative.  She returns home with neurology follow-up for likely diagnosis of idiopathic intracranial hypertension. 

Take Home Points

  • Lumbar puncture should be performed in the lateral decubitus position to properly obtain an accurate opening pressure if there is concerned for increased ICP. Leg extension may provide a more accurate reading however this is at the expense of increasing procedural difficulty and is not advised currently with the available data.

  • An opening pressure in adults > 25 cm H20 is abnormal and a broad differential diagnosis should be considered before the diagnosis of idiopathic intracranial hypertension is made.

  • The use of CSF removal for symptomatic control of IIH is controversial and may not be necessary in the emergency department setting. Starting medications such as acetazolamide and furosemide for IIH should be done in consultation with neurology once other causes of increased ICP have been ruled out. 

Expert Commentary

Great post.  

In emergency medicine practice, most cases of IIH (pseudotumor cerebri) are diagnosed as described in this case – incidentally.  The emergent need for LP is quite rare, focusing on time sensitive conditions (meningitis, subarachnoid hemorrhage).  The literature regarding the emergent need for LP to rule out IIH is somewhat unclear.  For example, I once had a primary care provider send a patient to the ED for “an emergent diagnostic LP to rule out pseudotumor.”  His patient presented as an outpatient with blurred vision, a new gradual onset headache, and had recently started an anti-acne medication containing Vitamin A (OCP’s, Vitamin A, tetracycline, and thyroid disorders can all cause IIH).  The data/reasoning behind sending this patient to the ER for an emergent LP is murky at best.  Could the primary care provider simply have dilated the eyes and look for papilledema?  Used an ultrasound if he did not trust his exam?  Referred the patient urgently to IR or neurology?  Many will opt to simply refer the patient to the ED.

One study shows that patients who experience worsening visual field defects despite medical therapy, or have the presence of visual acuity loss attributed to papilledema, do have improvement in vision following surgical therapy (optic nerve sheath fenestration, shunting, venous sinus stenting) [16].

Therefore, it seems reasonable that a patient at high risk for IIH who has new visual acuity or field deficits should receive an urgent or emergent LP in combination with an evaluation for papilledema (dilation or ultrasound) in order to properly expedite further care.  The time frame within which this needs to occur (urgent vs emergent) is not currently clear.  For my personal practice in the community, if your pre-test probability for IIH is high, and your vision is worsening, you will usually get an LP, unless I can arrange for close specialist re-evaluation within 24 hours. 

Brian Sellers, MD
Department of Emergency Medicine
Northwestern Medicine Lake Forest Hospital

Other Posts You May Enjoy


  1. Pickover, Clifford. The Medical Book: 250 Milestones in the History of Medicine. New York: Sterling Publishing, 2012. Print.

  2. Pearce JM. Walter Essex Wynter, Quincke, and lumbar puncture. J Neurol Neurosurg Psychiatry. 1994;57(2):179.

  3. Lee SC1, Lueck CJ. Cerebrospinal fluid pressure in adults. J Neuroophthalmol. 2014 Sep;34(3):278-83. 

  4. Lee, Andrew and Michael Wall.  Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis. Uptodate.  17 June 2015.

  5. Corbett JJ, Mehta MP. Cerebrospinal fluid pressure in normal obese subjects and patients with pseudotumour cerebri. Neurology. 1983;33:1386–1388.

  6. Watanabe S, Yamaguchi H, Ishizawa Y. Level of spinal anesthesia can be predicted by the cerebrospinal fluid pressure difference between flull-flexed and non-full-flexed lateral position. Anesth Analg. 1991;73:391–393.

  7. Abbrescia KL, Brabson TA, Dalsey WC, Kelly JJ, Kaplan JL, Young TM, Jenkins D, Chu J, Emery MS; Lumbar Puncture Study Group. The effect of lower-extremity position on cerebrospinal fluid pressures. Acad Emerg Med. 2001;8:8–12.

  8. Whiteley W1, Al-Shahi R, Warlow CP, Zeidler M, Lueck CJ.  CSF opening pressure: reference interval and the effect of body mass index.  Neurology. 2006 Nov 14;67(9):1690-1.

  9. Wall, Micaheal.  Idiopathic Intracranial Hypertension.  Neurol Clin. 2010 Aug; 28(3): 593–617.

  10. Sharma, Dushyant, et al. "Addison's disease presenting with idiopathic intracranial hypertension in 24-year-old woman: a case report." Journal of medical case reports 4.1 (2010): 60.

  11. Wakerley, B. R., M. H. Tan, and E. Y. Ting. "Idiopathic intracranial hypertension." Cephalalgia.  35 (2015), pp. 248–261.

  12. Johnston I, Paterson A. Benign intracranial hypertension. II. CSF pressure and circulation. Brain. 1974;97:301–312.

  13. McCarthy KD, Reed DJ. The effect of acetazolamide and furosemide on CSF production and choroid plexus carbonic anhydrase activity. J Pharmacol Exp Ther. 1974;189:194–201.  

  14. Pollay M, Fullenwider C, Roberts PA, Stevens FA. Effect of mannitol and furosemide on blood-brain osmotic gradient and intracranial pressure. J Neurosurg. 1983;59:945–950.

  15. Image The Library at Welcome Collection: Bucretius, Daniel Ed. De humani corporis fabrica libri decem. Tabulis XCIIX. aeri incisisexornatiopus posthumum. Imprint Francofurti Impensis & Caelo Matthaei Meriani, 1632. http://catalogue.wellcomelibrary.org/record=b1217708.

  16. Br J Ophthalmol. 2014 Oct;98(10):1360-3. Epub 2014 May 12.  

Revision Tips for the MRCEM A/FRCEM Primary

MRCEM Part A-2I recently battled my way through the final ever MRCEM Part A exam. The exam has since had a facelift and is now called the ‘FRCEM Primary’.

The format of the exam is changing from a true-false format to a single best answer MCQ. For more information on the new exam, check out the ‘FRCEM Primary Information Pack’. The curriculum will not change – it remains a Basic Sciences slugfest.

I have written a handful of blogs which cover some of curriculum.

Here are my thoughts on how to prepare best for the exam.

Give yourself at least 3 months

Make no mistake – the exam is very tough. Over 50% of candidates failed the last sitting (June 2016).

Unless you are freakishly good at cramming you will need to set aside at least 3 months to prepare.

Use the Curriculum

Leafing through the RCEM Basic Sciences Curriculum (embedded below) in its entirety is a frightening process at first – it’s bloody massive. However, it’s crucial that you acquaint yourself with the document from day 1 of your revision, and avoid straying from it. It is now your bible. 

It’s very representative of the exam content – an opinion shared by everyone I’ve spoken to that’s taken the exam. Hearteningly, you’ll find it’s easy to read, and it’s written in sufficient detail to double up as a textbook for certain topics. It’s a fantastic revision guide.

It can be very easy to find yourself stuck in a rabbit hole (so to speak) if you don’t know how much detail to learn – especially when wading through the vast anatomy content. Most recommended textbooks (e.g. Clinical Anatomy by Harold Ellis) describe far more detail than is required for the exam, which makes the curriculum essential as it very clearly explains what you don’t need to know.

I printed out a copy of the curriculum and constantly referred to it as I went through each topic. You’d be crazy not to do the same.

Familiarise yourself with the question style

This is tricky for me to comment on as the exam format has changed.

With the true/false question style it was very easy to get tripped up by subtleties in the wording of the question. Therefore, reading the questions extremely carefully (i.e. avoiding skimming) was essential. For example:

The rotator cuff consists of supraspinatus, infraspinatus, subscapularis and teres major – true or false?

The answer is false (teres minor is a rotator cuff muscle, not teres major). You can see how easy it would be to get fooled into putting true, especially if rushed.

In my opinion, the new exam format might make the right answer stand out more clearly as it will be written out for you in plain site (albeit mixed in with four wrong answers), instead of hiding behind a awkwardly worded riddle. Dare I say it… the exam will become a little easier?

Having said that, I’d imagine it’ll be the same crafty people writing the new exam, so the same rule applies – read the questions carefully. There’s bound to be a few curveballs flying your way.

Prioritise Anatomy and Physiology

Below is a table outlining the distribution of questions in the FRCEM Primary. This is a table taken directly from the new exam information pack:

AnatomyUpper limb
Lower limb
Head and Neck
Central Nervous System
Cranial Nerve Lesions
PhysiologyBasic celluar physiology
Respiratory physiology
Cardiovascular physiology
Gastrointestinal physiology
Renal physiology
Endocrine physiology
PharmacologyGastrointestinal pharmacology
Cardiovascular system
Respiratory system
Central Nervous System
Endocrine system
Fluids and electrolytes
Muscoskeletal system
Immunological products and vaccines
MicrobiologyPrinciples of microbiology
Pathogen groups
PathologyInflammatory responses
Immune responses
Wound healing
Evidence Based MedicineStatistics
Study methodology
Principles of critical appraisal

Focus the bulk of your revision on anatomy and physiology – as can be seen above they make up the lions share of the content.

Tip: Upper and lower limb anatomy are always heavily represented in the exam. The advice I was given by multiple educators and veterans of the exam was to prioritise these topics. This was echoed by the faculty at the excellent Bromley Revision Course.

The smaller topics (microbiology/pathology/pathology/haematology) shouldn’t be ignored, but be disciplined with the amount of time you spend on them. Remember to constantly refer back to the curriculum to maximise your efficiency when revising these topics.

Spend 1-2 days towards the end of your revision focusing on statistics/EBM. It’s very different to the rest of the curriculum, and it will likely be completely new territory. Once learned, it sticks, and it’s guaranteed easy marks – which might push you over the threshold into a pass. It won’t take you long to cover it all, especially if you use these free videos supplied by Bromley (registration required).

Free Online Resources

I learn best via audio/video content. With that in mind, I went hunting for some online resources that covered the curriculum. Here is what I found:

Dr. Eric’s Strong Medicine – A phenomenal youtube channel resource covering a vast amount of the curriculum (though no anatomy). I couldn’t believe my luck when I stumbled across Dr. Eric. Check out the awesome intro video below featuring JD from Scrubs!

Armando Hasudungan – Beautiful videos that cover anatomy and physiology. Armando is an artist and medical educator in equal measure.

Handwritten tutorials – Again, videos that cover anatomy and physiology, ideal for the visual learner.

Khan Academy Medicine – More great videos for basic cellular physiology (there are thousands of videos, so search wisely).

All of the above I found by searching Youtube, and the list is by no means exhaustive, there is loads more stuff out there – a seemingly never-ending supply of awesome lectures/videos that are very applicable to the exam. There is so much content that it can almost be overwhelming. Just remember to keep referring to the curriculum to keep you on the straight and narrow.

TeachMeAnatomy.info is an amazing anatomy website. The content is excellently written text with great diagrams. It’s very digestible stuff, and the website is easy to navigate. This was my main resource for anatomy revision.


Having been an avid FOAMite for a few years now, the idea of reading a dusty old textbook repulses me (tongue firmly in cheek). However, the reality is that you will need to occasionally refer to textbooks for this exam because so much of the content is back-to-basics. You’re not going to hear EMCrit podcasting about the contents of the anatomical snuffbox any time soon.

My textbook recommendations:

Clinical Anatomy: Harold Ellis

Physiology at a Glance: Ward, Clarke and Linden

Revision Notes for MCEM Part A: Mark Harrison – I used this very sparingly, mainly as a last resort if I couldn’t find the content elsewhere. It’s pretty dry reading, but it’s mapped to the curriculum.

Question Banks

There are multiple great online question banks that all provide a similar service. I used two – passmcem.com and mrcemsuccess.com. Both are excellent, and give appropriately detailed explanations for the answers. Having re-visited both websites, they are yet to put up questions in the new format, but I’m sure that’s in the pipeline.

I also used ‘Get Through MCEM Part A: MCQs’ by Iain Beardsell (of St. Emlyn’s fame) et al. This is a paperback book full of true/false questions with fantastic explanations. The explanations are so useful it can almost be used as an exam-specific textbook. 

It is critical to take practice exams in their entirety the week before the exam, and then check the answers/explanations after completion. I did 10 full practice exams (via the online question banks), and it gave me the confidence that I was getting good enough marks even if I felt like I didn’t know a lot of the answers in the paper (you’ll be surprised how well you do), and it got me into ‘exam mode’. When I was sitting the exam for real and I hit a stretch of questions I wasn’t sure about, I knew not to press the panic button.

Consider a revision course

Bromley logoI threw money at the problem and went on a 2-day revision course put on by Bromley. It was pretty expensive, but worth every penny. As well as providing some excellent exam-focused teaching, you receive a great handout which covers a huge amount of the curriculum.

Arguably the best thing about attending a revision course, was that it made me realise very clearly just how tall the mountain was, and therefore gave me that all important kick-up-the-arse (or ‘exam fear’), with plenty of time to spare before the exam.

A revision course is certainly not essential, but if you’ve got a bit of extra locum-cash lying around, it’s definitely worth it.

A Cruel Mistress

There is no doubt that the MRCEM part A/FCEM Primary exam is brutal. You will not pass it unless you put the work in. I took the MRCP part 1 (a few years back now… prior to seeing the light of Emergency Medicine) and I believe that the MRCEM part A is tougher, mainly because the bulk of the basic science content is pretty abstract – minimally applicable to everyday practice in the ED. It’s stuff you probably last visited in years 1-3 at medical school!

Having said that, I’m told that the exam has become increasingly clinical since it’s 2003 inception (I dread to think what it used to be like), and perhaps the new format will lend itself to a more clinically relevant exam.

Never let that curriculum document out of your site, get creative with the online resources that you use, focus on high yield topics, and do loads of practice exams. You’ll be fine.

Anyone who has any additional resources they have found particularly useful I’d be very grateful if you’d post in the comments.

Good luck!


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