Portraits of a Nurse and the #MeToo movement by Joan Viscardi RN, BSN CEO/CNO

In preparation for Nurses Week, I had so many thoughts come to mind. Who becomes a nurse? What does the public think about us as a profession? How are we portrayed? 

I began by searching images of nursing and while I did chuckle at some, I remain horrified at others. It is no wonder that there was a nursing shortage.  And, it is no wonder it took so long for the #MeToo movement to arrive.

Screen Shot 2018-05-07 at 11.19.49 AM.png

From the ads, it appeared that “all” that was needed to be a nurse was, well… to be a young lady, attractive, “Barbie” like, and white.  It was a profession that would find you a handsome doctor or even patient to marry. 

I can still hear my own mother, back in the 70’s saying to me, “Why don’t you become a nurse, you might marry a nice rich doctor.”  Or, “you could travel to exotic places and learn something.”

In the male-dominated field of medicine, in the 70’s and 80’s, being a proper young lady meant you were quiet, respectful, and often submissive.  I learned that at home and in my training.  Few empowered me to rise above the ole image of a nurse bending over backwards for the physician or patient.  From physicians’ inappropriate comments and propositions to the whispers and exposure of male patients, I had to learn to navigate that territory on my own.  But, looking at hundreds of images, it is easy to understand how that idea was portrayed.


But, it was an ad done in 2004 by Skechers that really stunned me. It was only 14 years ago. In many regions of the country and world, the height of the nursing shortage.  Hard to imagine why an image of a nurse would be needed to sell sneakers. Isn’t a sexy Christina Aguilera enough?  I guess not.


Well, times are changing.  I can only answer these questions for myself. I became a nurse to give of myself; my heart, my soul, my spirit and my intelligence, Yes, intelligence, something missing from each of these ads.  To those still wondering, I did not want to become a physician.  But more than that, I did not go into nursing to serve the physician. I went into it and remain true to serving the patient.  I hope the nurses that I mentor and work with agree that it is a profession of independence and collaboration.  It is a give and take.  I hope those that those considering it as a profession see it as it should be seen.

Thank you to all the nurses, nursing educators, and nursing organizations who promote the profession for equal opportunity. Thank you for abandoning the portrayal of the nurse as a specific race or gender. To all nurses in practice now, I encourage you to be a mentor, to share your experiences.  Empower those around you.  Raise awareness of our specialty and our significant impact on the patient and the health care industry.  Portray the right image. 

To VR’s nurses, be who you are- it is why we honor you this week and thank you. 

Authorjames viscardi

"Kids and Medication - What can we do?"

I am so happy you asked that question. This has always been something at the forefront of my mind and the reason I worked with the experts at VR so hard to create the NRxCM® program. However, more recently with the addition of my cutie pie grandson I cannot help but think what the average home environment is like.  Medications not only impact the user they can be dangerous to the children around them.  We can do many things to reduce the risk of medications/narcotics/opioids getting into the hands of our children and teens.

Let's first talk about the types of medications. Starting with one you may not find dangerous-Acetaminophen. According to the Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC - "Acetaminophen is the most common pharmaceutical involved in calls to poison control centers about infants."  That is Tylenol folks.  Where do you store it?

That is followed by opioids as the most common drug involved in Emergency Department visits. Statistics show 35% of child deaths are from prescription medication (Bond, 2012). According to one study, the most common medications involved in deaths in children 10 and younger were codeine (54%); oxycodone or brand name Oxycontin (32%) and methadone (15.5%) (St. Joseph Heritage Group, 2017).  With that comes an ever-growing danger of a child's exposure to synthetic opioids such as fentanyl and carfentanil which can cause death with as little as "a few grains" (Martin, 2017). That affects everyone.  As children grow older and become teens, they often seek out a parent's prescription to get high or to assist in depression and suicide.  Look at this alarming statistic - "in 2012, 10.17 per 100,000 teenagers were hospitalized for opioid poisoning" (Martin 2017).  Do you know someone on these medications? 

Medications are not the only form for children to consume these. Everyday child snacks are now being laced with dangerous substances. A 9-year-old girl came to school with what looked like typical gummy candies, but were edibles laced with THC, one of the psychoactive chemicals found in cannabis. With medical marijuana now permitted in 29 states, and recreational marijuana legal in an additional eight, many public health officials have voiced concerns about children accidentally ingesting edibles, particularly those packaged as kid-friendly treats such as candy, brownies and cookies (Ducharme, 2018).  Anyone you know? 

So, what can we do?

-Lock them up - keep in a locked cabinet that requires a key.

-Ensure that bottles have child proof caps.

-Did I say, lock them up?

-Teach your children about medication safety.

-If you or your family members or friends are prescribed opioids, talk to the healthcare

 prescriber about alternatives and weaning ability. 

-Dispose of the unused medication properly. Do not keep "leftover" pills in your cabinet. Talk to your pharmacist about this.

What can doctors do?

-Find alternatives

-Send patients home from the hospital with a non-steroidal anti-inflammatory medication, where indicated.

-If absolutely necessary, prescribe in limited quantity and reevaluate necessity frequently.

-Have a conversation. Know their patients' family and home situation and risks of child exposure.  Discuss a caretaker's role in keeping medications locked in a safe place and away from children and teens.

What can government do?

The National Institute on Drug Abuse says it best (https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-federal-government-doing-to-combat-opioid-abuse-epidemic)

- Keep the public informed and aware of this epidemic

- "Provide primary prevention thru educational initiatives in schools and communities"

-"Support the continued use of prescription drug monitoring programs"

-Implement "overdose education and naloxone distribution programs to issue naloxone directly to opioid users and potential bystanders"

- Provide "aggressive law enforcement efforts to address doctor shopping and pill mills"

-Continue research on "abuse-deterrent formulations for opioid analgesics"

Recently, the FDA announced that it would take a stronger stance on labeling changes to cough and cold medicines which contain opioids such as codeine and hydrocodone for children less than 18 years of age.  This new labeling will notify the consumer that these medications are to be used only in adult’s ages 18 years and older.  Boxes will now contain a warning for all uses that will highlight the risks of misuse, abuse, addiction, overdose and death as well as the respiratory impact that can result of exposure. Bravo FDA! 

Protect our children - they deserve it!



Bond GR, Woodward RW, Ho M. The growing impact of pediatric pharmaceutical poisoning. J

Pediatr. 2012;160:265-270.

Ducharme, Jamie. A 9 Year-Old Accidentally Shared her Grandpa’s Marijuana Gummies with

her Fifth-Grade Class. Time. Retrieved January 29, 2018, from http://time.com/5114582/thc-edibles-new-mexico/

Martin, K. (2017, July 24). US Growing danger of children overdosing from opioids. Retrieved

September 29, 2017, from https://www.wsws.org/en/articles/2017/07/24/opio-j24.html

St. Joseph Heritage Medical Group. (2017, February 27). Kids' OD Risk Rises When Opioids

Left Out at Home. Retrieved September 29, 2017, from https://www.sjhmg.org/health-  library/article/?CT=6&C=719792

Authorjames viscardi

"Food for thought by Dr. Tony:"


The easiest way to decrease a patient's opioid usage may be to not begin at all. The utilization of non-opioid analgesia early in the course of therapy can be a valuable tool in reducing opioid use and abuse, if the prescriber can be convinced of the non-superiority of their analgesia. A tough road, I know.

Three JAMA articles are food for thought.

1. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients with Chronic Back Pain or

   Hip or Knee Osteoarthritis Pain (March 6, 2018)

Direct Link: https://jamanetwork.com/journals/jama/article-abstract/2673971


2. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity

   Pain in the Emergency Department (November 7, 2017)

Direct Link:



3. No significant difference in pain relief for opioids vs. non-opioid analgesics for treating arm or leg pain.   

   (November 7, 2017)

Direct Link: https://media.jamanetwork.com/news-item/no-significant-difference-pain-relief-opioids-vs-non-opioid-analgesics-treating-arm-leg-pain/

Source: The JAMA Network Journals


Executive commentary:

Anthony Mladinov, RPh., Pharm.D.

Director of Pharmacy Compliance


AuthorAnne Lackner

The Workers Compensation Board (WCB) has established new guidelines in establishing scheduled loss of use (SLU) cases. If the first medical evaluation of SLU occurs on or after January 1st, 2018, the question of the SLU will be evaluated under the 2018 SLU Guidelines. If at least one SLU examination was conducted before January 1st, 2018, the Board will determine the claimant’s degree of permanent disability using the 2012 Guidelines. The Loss of Wage Earning Capacity is not changing and the schedule loss of use number of weeks per body part has not changed. The new guidelines have changed through 6 sections. The first section: Objectives, describes the body parts, systems, or extremity, and its use. The second section: Methods, describes when the exam should take place and requires the examiner to use range of motion (ROM), and to consider contralateral body parts. The third section: Range of Motion, describes the “normal” range of motion. The fourth section: Calculating Loss of Use, provides the formula for reaching an impairment percentage. The fifth section: Special Considerations, emphasizes the essential bonus points and enumerated values for SLU. The sixth section: Amputation, describes when to consider a limb or body part amputated. The SLU is awarded if it meets all six sections. There are also non-schedule awards in which certain body parts will be subject to classification in which the claimant can show joint inflammation, x-ray evidence of progressive and severe degenerative arthritis, and no improvement after all modalities of care have been exhausted. For more details and specifics on SLU award, refer to the Worker’s Compensation Guidelines for Determining Impairment, First Edition, November 22, 2017.


AuthorAnne Lackner

By Anthony Mladinov, RPh., Pharm.D. - Director of Pharmacy Compliance

Tuesday, August 8th, 2017

                  The Miami Herald recently reported that 10 year old Alton Banks collapsed on June 23 and subsequently died, due to what preliminary toxicology reports indicate was the presence of fentanyl in his system. My initial exposure to this story was as a very brief news blurb that I placed in the basket with most of the terrible stories the media supplies.  But, when a person I consider astute and insightful (and the CEO) says there could be a message brought forth from this tragedy I investigated further.  My initial thought was that the child came into contact with an inadvertently discarded or lost fentanyl patch. The patch is the most common means of legitimately obtaining fentanyl as an outpatient. Additionally, the victim had been at a public pool, on a hot day. Perhaps if the child had found a patch, placed it on his hot skin, the accelerated release might have been a deadly factor. But no, depending on the news source, the fentanyl may have been mixed with heroin and another opioid. The neighborhood was near locations where the detritus of illicit drug use was clearly visible. The Miami Police have created a video advising and instructing parents and caregivers how to protect and warn your children from potentially deadly exposure to illicit drugs.   

                   So I must proceed on the basis that this tragedy was something that I, along with my fellow healthcare professionals could not have prevented. There is a good chance the fentanyl that killed Alton Banks was never part of the typical health care process that legitimately provides narcotics to the patients that need them. The fentanyl could have been manufactured in an illegal lab. What could I do to prevent this tragedy?  Nothing. Right?

            Wrong. Very wrong. I have seen the numbers that suggest that illicit drug use, from sources other than diverted drugs from legitimate health care scenarios, is on the rise…….perhaps because the regulations, restrictions, and monitoring of the legitimate use of narcotics has been significantly intensified. That seems to be a problem for the law enforcement agencies of this country. But the healthcare professional’s vigilance is in the foundation of all efforts in decreasing the illicit use of drugs. A legitimate drug diverted can be the stepping stone to years of drug abuse. Patients incorrectly monitored may provide the means to divert unlimited amounts of powerful opioids. Improper therapy may create a drug abuser out of a patient that had no nefarious intents.           

            For years, I have been a critic of therapies that have denied adequate pain relief. Reluctant use of narcotics due to the impediments of regulatory requirements, ignorance, and fear of abuse, have no place in correct protocols for pain management. However, these impediments can be overcome with professional effort, vigilance, and compassion.

          From my experience working in a poison control center, I am sorry to say there will be more stories such as Alton Banks in the news. Injury or death may come from fentanyl, antihistamines, vitamins, OTC analgesics or a houseplant. We must all do our part. Parents, be vigilant. Physicians, be vigilant. Pharmacists, be vigilant. Nurses, be vigilant.

  Anthony Mladinov, RPh., Pharm.D

Anthony Mladinov, RPh., Pharm.D


AuthorAnne Lackner

For the Viscardi Resources family Case Management is a collaborative process defined by respect for people and a relentless pursuit of efficiency.  Every interaction that takes place at our company - whether it's between colleagues or with a patient - is informed by these two ideas. Beyond human interaction, the creation, deployment and refinement of services takes place in an environment where a free exchange of ideas is encouraged and no area of improvement is too small to be taken seriously.  We are a company made up of people: people caring for people, people helping people, people bringing efficiency to a system.

Our growth over the past four years, following our strategic expansion initiative, has been astronomical.  I attribute a large part of this success to the fact that we've been guided by these principles of respect for people and a relentless pursuit of efficiency.  Collaborative Case Management lies at the heart of everything we do.  It's easy to look at Case Management, particularly in the workers' compensation industry, as a static entity.  Does a claim meet one of the pre-defined thresholds for the deployment of Case Management services? Yes, then put a nurse on it. End of conversation.  

At Viscardi Resources that doesn't constitute the beginning or the end of anything.  We acknowledge the fact that each patient has the potential to follow myriad treatment trajectories and aim to steer them down the best path from as close to the time of injury as possible.  Our Case Management teams do this by following specific protocols developed and refined in-house by the most capable specialists in the industry. In addition, research, development and refinement are done in a collaborative environment, with teams leveraging technology to maximize effectiveness at every stage.  The outcome is a set of highly efficient systems and novel solutions for the workers' compensation industry's toughest challenges.  

The outcomes provide proof that our method works: for starters, injured workers getting back on the job faster than the national standard and adjusters handling claims more effectively than they ever imagined possible. 

John Viscardi- Executive Vice President of Viscardi Resources

Authorjohn viscardi

Congratulations to the Nurses' Health Study on their 40th year and a big thank you to all those nurses who continue to participate in this project.  Your dedication and mine has contributed to the massive knowledge obtained in the area of chronic health and has influenced much in the field of public health.  Well done and thank you!   For more on this topic, click here.

Authorjohn viscardi

This year during National Case Management week, we honor all those involved in the collaborative process of improving people's lives.  It takes a village. 

Authorjohn viscardi



Each year, more Americans die from drug overdoses than in traffic accidents, and more than three out of five of these deaths involve an opioid. Since 1999, the number of overdose deaths involving opioids, including prescription opioid pain relievers, heroin, and fentanyl, has nearly quadrupled. Many people who die from an overdose struggle with an opioid use disorder...

Authorjohn viscardi

A new study by the Workers Comp Research Institute observed a noticeable reduction in the amount of opioids prescribed per claim in a majority of the 25 states investigated.  

The 25 States in the study are Arkansas, California, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New York, North Carolina, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Wisconsin. 

Click Here for the Abstract, Executive Summary and to order the study. 

Authorjohn viscardi