The focus of this chapter is culture and developing nursing care that is culturally sensitive and culturally safe. To many nurses in Australian culture, the idea of concealing the truth seems improper. Truthfulness underpins our practices of informed consent and also forms the basis of clear communication and trust in the nurse–patient relationship. However, in different cultures there is a common expectation that patients will not be told of certain diagnoses, and that the burden of knowledge and decision-making is delegated to family members. Placing a very high value on truthfulness and the right to know assumes a desire to know the truth on the part of the patient and the community. Not all people or communities hold this desire. In such cases, imposing Western values would be paternalistic, overbearing and disempowering, and would therefore constitute culturally insensitive care. The presence of different cultures in our community brings about social diversity and requires culturally sensitive and culturally safe care from nurses and midwives.

The focus of this chapter is the moral aspects of the nurse–patient relationship. Rights and obligations are like two sides of the same coin. A legal right comes with a corresponding obligation, or duty. A right is a legal entitlement to do something, and an obligation is the constraint upon individuals’ behaviour that comes with that entitlement. However, the nurse–patient relationship involves more than legalities. As discussed in Chapter 1, interpersonal relationships involve moral values, such as respect, beneficence and compassion.

In this Chapter we will focus more on what law is in general, and on some of the basic philosophical and legal principles that make up the Australian legal system. Accordingly, this Chapter will briefly introduce the main features of the Australian legal system, including: the different parts or ‘arms’ of the Government; the sources of law; and some key features of different branches of law relevant to nursing. A basic knowledge of the legal system is fundamental to understanding the law as it applies to nursing practice. Indeed, the very first principle of the Code of conduct for nurses requires that ‘Nurses respect and adhere to their professional obligations under the National Law, and abide by relevant laws’ (Nursing and Midwifery Board of Australia, 2018). This Chapter will look at this aspect of the role of law in nursing through a discussion of a nurse’s ‘scope of practice’.

Facial trauma is a common presentation in the Emergency Department. As the face is vital to both physical appearance and the ability to eat, speak, and perform other important functions, proper management of patients presenting with facial trauma is critical. Initial treatment must focus on life-threatening injuries, but careful attention to long-term function and cosmesis must also be considered. Any patient presenting with facial trauma must also be evaluated for other traumatic injuries, as more than 50% of these patients will have injuries in multiple systems.1 As with any trauma patient, ATLS guidelines should be followed, and the initial evaluation of injuries should begin with management of the airway, breathing, and circulation.

Head trauma is a significant cause of death around the world, especially in patients 1–45 years old.1–5 Close to 80% of patients are managed in the emergency department (ED).1.2 Head injury not only causes initial primary injury, but it is associated with several secondary injuries.1–5

Abdominal trauma is a significant cause of morbidity and mortality in the United States, with abdominal injuries occurring in approximately 1% of all trauma patients.1 However, abdominal trauma accounts for over 20% of all trauma-related deaths.2 Abdominal and flank trauma may result in direct injury to a number of important structures, including the liver, spleen, kidneys, diaphragm, pancreas, and intestines. Unfortunately, the diagnosis may be challenging, as patients often present with multiple other injuries and may not be able to provide a reliable history or examination.3

Hemorrhage is a leading cause of death in trauma, following head injury. Shock is defined by inadequate tissue perfusion with hemodynamic instability and organ dysfunction.1–10 In trauma, the most common cause of shock is due to acute hemorrhage. Advanced Trauma Life Support (ATLS) describes four classes of hemorrhage,1 but these are not relevant to real world practice, due to different injury types (blunt vs. penetrating), age (due to blunted physiologic responses in the elderly), comorbidities, and medication use (beta blockade reduces the chance of tachycardia in response to decreased blood pressure).6–14 Bradycardia may also be seen in hemorrhage, due to several causes including vagal stimulation and failure to mount a tachycardic response.13,14

Cardiac trauma is a critical injury, with penetrating cardiothoracic injury accounting for up to a third of traumatic deaths.1–4 These injuries often involve the heart or great vessels and include traumatic insertion of a foreign body, including invasive iatrogenic injury.1–8 Blunt cardiac trauma occurs in a wide range of patients, with 8–71% of patients with cardiothoracic trauma demonstrating signs of cardiac injury.1,2,8 Blunt cardiac injury encompasses all types of injury associated with blunt thoracic trauma to the heart.8–13 Up to 20% of deaths from motor vehicle collisions (MVCs) are due to this type of injury. Patients with thoracic great vessel injury due to penetrating injury have a high mortality rate (over 90% die at the scene),14,15 and blunt injury to the thoracic vessels is commonly due to motor vehicle accident.12,13,16,17 These injuries can result in chest, upper abdominal, back, arm/shoulder, or lower neck pain, as well as hemodynamic instability, nausea/vomiting, and shortness of breath.

Trauma accounts for nearly half of all deaths of pregnant women.1 Pregnant women have distinct physiologic and anatomic characteristics which complicate their management following major trauma. Furthermore, the presence of a fetus means there are effectively two patients, both of whom require evaluation and potentially treatment. The priority in resuscitation of pregnant trauma patients is maternal stabilization.2

Peripheral vascular injury (PVI) is a major concern in the Emergency Department (ED). According to the CDC, there were 33,594 mortalities related to firearms in 2014.1 There were 803,007 cases of aggravated assault that occurred in 2016. Nearly 24% of these (190,000) were performed with firearms and 16% (120,000) with cutting instruments.2 Inevitably, many of these result in damage to the vasculature, leading to blood loss and presentation to the ED. While some forms of injury are immediately life threatening and require emergent intervention, some present asymptomatically, which can lead to delayed or missed diagnoses. Emergency physicians should be well versed in the diagnosis, management, and disposition of these patients. This chapter will focus on the management of penetrating extremity trauma with vascular injury.

Usually results from high-energy mechanisms (i.e. high speed MVC), but low-energy mechanisms (falls) are possible in elderly patients as well.1

In the United States alone, burns are responsible for 450,000 emergency department visits, 45,000 hospitalizations, and 3,500 deaths every year.1 Roughly half of those hospital admissions are to specialized regional burn centers.2 In 2009, there were 128 regional burn centers in 43 states, and 40% of admissions were due to fire or flame burns, while another 30% were due to scald injuries. The majority of scald injuries occur in children under the age of 5 years.3,4 Therefore, understanding the management of the burn patient is essential to all emergency physicians. Not only do burns cause local damage to the affected site, but large burns can also result in fluid and electrolyte abnormalities, metabolic acidosis, inflammatory response, and even myocardial dysfunction in severe cases.5

Injury of the cervical spine occurs most commonly due to high impact blunt trauma.1–3 It is the most commonly injured portion of the spine as it is not as well protected as the lower thoracic and lumbar spine. The most commonly injured vertebrae are C2 and C5–7, and injuries are more common in males than females.1,2,4

Chest trauma is present in almost two thirds of all trauma patients, varying in severity from a simple rib fracture to penetrating injury to the heart.1 Blunt chest trauma accounts for 90% of cases, where less than 10% require surgical intervention.1 Understanding chest trauma mechanism is key to the approach when evaluating and managing an individual with potential chest trauma.

Procedural sedation and analgesia (PSA) is a core competency for emergency physicians (EP) that is commonly practiced.1–4 PSA entails suppressing a patient’s level of consciousness with sedative or dissociative agents to alleviate pain, anxiety, and suffering to enhance medical procedure performance and patient experience (Table 22.1).1,5

Pelvic fractures are serious injuries, accounting for 20% of deaths due to trauma.1 Most high energy pelvic fractures are due to motor vehicle accidents, including motorcycles, and falls from a significant height. Since these injuries can have major effects on hemodynamics, especially in the setting of multi-trauma, time is of the essence, with focus on early diagnosis and management.

Airway management is of paramount importance in trauma resuscitations; in fact, virtually all management algorithms begin with the assessment and protection of the airway. Trauma airways are often compromised and among the most difficult to manage due to hemodynamic instability from multi-organ dysfunction, cervical trauma, or direct trauma to airway structures.