Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.

Monday, March 27, 2017

​Clinical Tips # 200 {'Double-Century' Edition} – Helping Those with Hearing Loss, appearing Monday, March 27th, 2017 to April 3rd, 2017, brings back the "Ten Commandments the Hearing Impaired Wish You Knew" previously listed in this blog in "Ten Commandments for Emergency Professionals; a compendium."

This has particular significance and importance for us as emergency professional for several reasons:

  1. Our business is helping patients who are unselected and undifferentiated. We take all comers. Some have hearing problems also. We must be able to communicate effectively.

  2. Hearing problems may develop insidiously; the patient, perhaps with some denial, may not yet have realized how hard of hearing he has become. We may notice behaviors that indicate difficulty in hearing. In fact, we may not have admitted as much to ourselves that our hearing 'isn't what it was.'

  3. Office practices may be open forty hours weekly. We're open 168/168. Patients may come to us with a sudden decrement in hearing, or in caring for a work-related condition, we can counsel them as to the potential worsening of their present hearing.

  4. We are bombarded with noise in our own work environment. Alarms; tools; falling objects; screams and shouts; PA systems; radios; doors; computers; on it goes. Rarely is there a calm and noiseless time. (There, I wrote it without saying the dreaded "Q word.") This contributes to the totality of risk factors in our lives from genetic or familial causes to percussive sounds with high intensity.
  5. We may be able to suggest less ototoxic drug choices to lower the risk of impaired hearing or tinnitus.
  6. If we are able to counsel and intervene effectively with the patient who hasn't yet admitted to hearing loss, we can restore a sense of joy to their world and their social interactions that can ease the progression to stress, depression, learning and memory difficulties, social isolation/withdrawal, and dementia.

In my family, my brother and I had so many elders who had severe hearing loss that we took for granted that this lot would befall us also. We learned early to speak slowly, clearly, with sharpened articulation, in a normal or slightly louder voice, in good light while facing the person with whom we were talking. The dictum "Children should be seen and not heard" and other maxims of old-fashioned "polite conversation" helped ensure that only one person spoke at a time.

My brother had many ear infections, including an emergency meryngotomy while papoosed in a sheet on his own bed. His hearing deficiency was such that, as a contributory factor, he deliberately chose for his life's work, an industry known for its noise levels and the number of deaf men who worked in it so that he would not be disadvantaged. It was probably a decade in the future before sound safety muffs would be provided to the men.

Hearing loss is not always inevitable. The earlier diagnosis and assessment by otologists and audiologists can lead to better protective measures, treatments, or hearing instruments that minimize disability. (Yes, I know that 'disability' is a word that is charged with much baggage of political correctness.)

In my case, increasing tinnitus was not something that might go away {it didn't}, but a sign of increased hearing loss. As my hearing worsened, I worried that I might miss an essential clue at Triage, or that I would not be able to hear a patient's last words; such worry is a burden. It became a factor as I chose how best to carry on. If you, or someone else, is having hearing difficulty, take an audiometry test to determine how things stand. It's quick, easy, and can start one on  the road to improved hearing and participation in life.

Hearing loss is common and usually noticed by others first, be the advocate who encourages testing and treatment.

 

Sincerely,
 
Tom Trimble, RN
 
All opinions are solely those of the author.
Readers must verify validity to their own practice.

 


Sunday, February 19, 2017

"Time, the subtle thief of youth … "
John Milton. Sonnet 7: How soon hath Time, the subtle thief of youth

 

There's a subtle, but significant, problem with the work that we do. It's largely invisible to our families. Visiting us at work and watching our labor is seldom possible and violates patient privacy. "Nobody knows the trouble I see."

It is hard for them to understand what it is like, why we are tired, or the stress involved. Many stressors are mental or emotional, not just tasks, but intellectual turmoil in sorting patients, being inclusive and accurate when making lists of differential diagnoses, the self-questioning and self-doubt of 'what am I missing here?" or "why didn't I see that earlier?" Wondering if one is seeing the patient's inner needs or hidden agenda. Reacting to outbursts or abusive behavior. "Is this case one where I am going to see a lawyer's letter or law suit?"

Having a "Take Your Daughter To Work Day" conveys little, and necessarily is as sanitized beyond recognition as the silly 'medical' and 'emergency' dramas on television. Other occupations, such as military, police, and fire, have come to grips with the reality of Post-Traumatic Stress Disorder in their field, but I think that Emergency Nursing doesn't yet accept the cumulative nature of the stresses in our field.

My own career includes both prehospital and in-hospital care. Stressors occur in both, but in different ways. The 'shop culture' in each is to a greater or lesser degree, one of tough self-reliance, and 'these things don't bother me." Available support is probably greater within a hospital than outside, where the environment is more isolating and 'John Wayne' cultural issues are prevalent. And there are cases that we will never mention; sparing them, but taking the weight of our experiences totally upon ourselves. If this seems unreal, recall those nurses you've known who decided emergency nursing 'wasn't for them' and wanted to move to 'something else' or even leave nursing. Were we always clear upon what really bothered them?

Some cases never involve the hospital and are selected out as only living persons or those with potential viability are ever transported, thus there is no exposure for hospital staff to the greatest carnage. Decapitations, incinerations, the decomposed, —the person struck by a locomotive who is now only a three-foot square pile of rags, do not need a hospital for care. The slashed throat, whose spilled warm blood gives rise to visible vapors in the cool night air of a two A.M. bar-closing; if 'medical care would be unavailing' the body is left for the homicide investigation.

A woman, now suddenly a widow, watched her husband fall in the bathroom, proving the statistic that one-third of first heart attacks is a sudden cardiac death; his head having gone through the shower door glass lies in the same position with jagged shards surrounding his head and neck, must now have to learn that his body shall remain that way until the police and coroner's deputies arrive for the investigation. How great must be her shock.

I recall a shift in emotional content for myself while attempting resuscitation of a one-month old infant (who appeared more dead than stated); the care-giver thinking that it "had only been 10 minutes." Pulmonary compliance was so poor that I gave up the BVM to instead give oxygen -enriched mouth-to-mouth resuscitation. Tears welled up while doing so as I thought of my own toddlers. The infant's Mom and Dad weren't present as they had gone away for the weekend to a gambling resort. Was there already some post-partum depression at work in that family? How would things be to find they no longer had a child?

The public think that our stress would be due to such lurid cases as these, and that "Man, you must see some really weird S**t."  Certainly, such things happen less often than is imagined by them. More often, I think, greater psychic wear and tear occurs from repetitive lower stress matters analogous to the growth of a cave or the Grand Canyon by continuous flow of water. Almost a 'Death by a Thousand Cuts.' One fellow left our department to work in Post Anesthesia Care because, "I just want to be able to sit down." Hearing an endless litany of patients' woes takes a toll.

Some have called this "Compassion Fatigue." I don't think that there's a fatigue in giving compassion; I think that it is endlessly drawing from a well of one's own reserves to the point of exhaustion, and the sore muscles, bad feet, bad back, and bad bladder sacrificed in endless giving to those in need. Need always exceeds resources, doesn't it?

I do belief that staff should be able to negotiate for the sort of shifts that they wish. However, it seems to me that the prevalent twelve-hour shift pattern has seduced many into long term problems for short term gain. It is an enticing thought to work 'fewer' days; but the semblance of more time for oneself can turn into extra shifts for a new house. Remember, too, that the institution saves considerable money with fewer shifts to staff, despite awkward shift plans to avoid penalties in overtime compensation and taxation that incur when staff work more than forty hours weekly. It is not necessarily to our advantage to accept such terms.

Especially in urban areas, economics mean multiple incomes for housing, longer commutes to affordable homes, yet staff are not consistently relieved for breaks, stay late to finish charting or work, and are cautioned to avoid dangerous 'micro-sleeps' while commuting when fatigued. Staff meetings are seldom scheduled for night shift but where managers can fit them in to their daily round of meetings during what would otherwise be a sleeping period for the night worker.  

Long hours and working extra are part of the 'American Way.' Yet, there is increased physical wear and tear, and increased psychic wear and tear may well occur with extended hours, increased fatigue, and decreased rest or decompression. Our resilience is worn down.

I know too, that having to work 'eight days a week' kept me from spending the time that I would have liked to have with my children, and sharing tasks and responsibilities with my wife. That time spent at home was out-of-sync with normal hours of the real world, and often taken up with essential sleep before the next shift.

As time passed, jobs and wages changed, and things improved, but were never normal. Especially, when social, civic, and child-rearing responsibilities, due to odd hours and mandatory every other weekend shifts and holiday requests, required a fixed date for planning three months in advance; a form of 'unobtanium.' How can one's work (and its meaning) be seen in context by family? If an older child should be able to visit and observe during one's night shift, that child will likely fall asleep. They don't see it.

Now that our children are grown and have Life and families apart, I feel a great regret that I missed their childhoods. Yes, I made time for Scouts and other activities. But always with a necessary eye on the clock and calendar for return to work; indeed, once, nearly two months went by, without a single night at home or day off. That was too much.

The American people have forgotten the struggle of Labor to achieve "Eight hours for Work, Eight hours for rest, Eight hours for what we will." Spending six days a week or more in mines or fields to pay off the Company Store, seems incomprehensible toil, yet it is a forgotten tale. Now, we are drawn into stolen hours by longer commutes and traffic delays, more than one income necessary to have a decent place to live, and the hours of overscheduling children and ourselves: stolen from the eight hours for rest and eight hours for what we will.

It's been said that 'Nursing works on Guilt"; perhaps due to its background in orders of nunnery. Scheduling and vacation or holiday requests are countered with tinges of guilt and compulsion to 'make it fair.' It certainly is insufficiently flexible and the burden is on oneself to 'find your own replacement.' Also, "I requested it off and couldn't get a replacement, now I can't call in sick even though I am sick.'

How then do we recover our equanimity? How do we reduce stress? I'm not sure. There are many conventional and familiar suggestions, each with some potential merit, but any list is surely incomplete nor particularized to an individual's own needs. I am increasingly sure, however, that many would find better balance in "Eight hours for Work, Eight hours for rest, Eight hours for what we will."

 

              Sincerely,
 
              Tom Trimble, RN
 
              All opinions are solely those of the author.
              Readers must verify validity to their own practice.

 


Monday, January 9, 2017

     California has been preparing for, and enduring, an exceptionally intense, 'once-in-ten-years', storm (Level 4; not previously seen in the area); –the product of an "atmospheric river" of moisture from the Pacific dumping as much as 12 inches of rain in two days. Those who ascribe to the Boy Scout Motto of 'Be Prepared' filled sandbags, moved goods to higher floors, checked flashlights and radios, filled up gas tanks (gasoline can pump if there's no electricity), and readied themselves to evacuate, or were barred from where they live or public places to which they might have gone.

      Probably, not all efforts were as complete as they should have been. Seldom used lanterns were found with corrosion and dead batteries.  Stock up food and batteries, but forget serious foul-weather gear? Was the car actually packed for evacuation? Was a place to stay planned? Were wallets and important papers sealed against an accidental dunking?

      Medical emergency personnel prepare well for their work: preplanning, checking equipment, reserve supplies, drills to varied scenarios. We should, but don't always (if we're like most people), apply those same skills to our home; our bastion of feeling safe. Often, it seems monumental to make considerable preparation. Certainly, it is if done all at once, or under the compulsion of immediate necessity. "We just grabbed what we could. It all happened so fast!" Taken in smaller bites, incrementally, in stages; it's not so bad or expensive. We can do better planning if the flood level isn't coming in our door.

     Firstly, do you have a communications and family reunion plan. Successful contact will ease everyone's mind. Remember that telephone circuits may be overloaded or destroyed. Think of alternatives, Inexpensive family radios or citizens band may be helpful if distances are short and clear, but may be crowded. Text may get through, as it needs less bandwidth and time. Call distant relatives who may be able to relay for you. If all are at home, action is easier; when the family is scattered, or under the authority of the school's emergency plans (please reread), it may be harder to reunite, or if the first meeting-place is at risk --what is the alternate choice?

     One of the most important steps to take is redundant documentation: identity; money, credit, finances, ownership, documents. Some can be saved on your cellular phone, cloud storage, in pdfs on your encrypted flash drive; each adult and responsible child should have such a flash drive, in case of separation. Have recent family photos for identification by authorities or for posters.  Deeds, mortgages, insurance policies, wills, may be sitting in a safe deposit box. Is there a family cemetery plot; do you have a copy of that paperwork?. If a tornado or earthquake destroys your bank, what then? The bank won't reimburse you on the alleged value of things they never see, and which is at your own risk.

     Trying to recover or replace missing documents is tedious and difficult. A lawyer's office in your town may suffer from the same calamity. Having photocopies or pdfs is invaluable. Remember to include a copy of your Internet password manager. Make photocopies of both sides of your credit cards, so that you can call for replacements, and emergency funds.

      Interior photos and videos should be uploaded to the cloud server, in addition to precious family photos, as they can greatly ease making insurance claims.

      You hope that your healthcare system has copies of your records, but will they be delayed while restoring the system? Think of yourself or loved ones as if they were inbound critical patients to your facility, what information would you want to have in the transfer packet?

      Suppose that you must relocate to a faraway place, as happened with Hurricane Katrina. Do you have copies of school and team physicals, and immunization records, as well as a short-term supply of medications and prescriptions, optical prescriptions? Transcripts and school records would be useful for reintroducing your children, or yourself, back into a new school. Copies of your professional documentation may help you start a new job sooner. Do you have a durable waterproof box for that cellular phone? It, and your computers and devices, are backed up to a cloud server, right? When did you last run a backup?

      Mandatory Evacuation in 1 - 2 hours? Have you planned what you will take in addition to 'must take'? Don't overestimate what to take, where it will fit, how heavy it is to carry, who's fit to carry it. Have you practiced it? (You would do drills at work.) Keep the essential clothes hanging on the rod with the hooks the same way; they can be lifted off and dropped into a plastic storage tub, and go! Don't forget necessary 'security blankets' or dolls. A few favorite treats can refresh exhausted children's psyches.

      Sure, take your GPS; but do you have maps in case there's no signal or the batteries are down? Maps, compass, and flashlights may help get you out of where there's no lights, and signs are washed away. If you're lost or trapped for an extended interval, do you have a known plan with your extended family, that you'll conserve the phone battery by turning on and calling for 5 minutes on every even hour? This helps authorities check for pings if there are working towers. You might need to seek higher ground to get your signal out and may need adequate footwear and clothing to be able to do that. Having signals to flash or wave or prevent others from hitting your car in the ditch, can be helpful if there are overflights or search parties. Plan for extra batteries, and extra devices. Plan for no batteries left; even use a loud police whistle.

      Sometimes, threats from Nature go past our imaginings to life-altering personal risk and regional devastation. Storms, blizzards, monsoon, tornados, typhoons, heatwaves or extreme cold. Flash floods in deserts, or watersheds and alluvial areas. Earthquakes, tsunamis, and volcanism on the Pacific Rim's Ring of Fire, and may occur elsewhere. Secondary hazards may include: loss of power; loss of roadways and transportation; avalanches, rockfalls, and mudslides; tree-falls and downed electrical wires; disruption of 'Just in time' planned deliveries of food and supplies to markets. Just as for many families, homelessness or bankruptcy is only a few failed paychecks away, a few days of hunger and despair can produce looting and lawlessness. Knowledge is power. Know your community's enemy by learning about the most likely problems and known post-event organization for your area.

     If family members are in the Scouting movement, they may be more expert on some of these matters than you, and should be involved in the planning, as they will be trained and responsible stepping up to help. There are several, reasonably-priced, Boy Scout Merit Badge Pamphlets and Handbooks that are incredibly useful, and ideal for family sharing and training. With almost 200 topics, there may well be others to meet your needs. As a Merit Badge Counselor for these and others, I am confident in recommending them to you as you begin your study and preparations.

Safety  Fire Safety     First Aid   Traffic Safety   Emergency Preparedness

Wilderness Survival     Search and Rescue

 

     Sincerely,

     Tom Trimble, RN CEN 

     All opinions are solely those of the author.
     Readers must verify validity to their own practice.

 


Thursday, November 24, 2016

      I am very thankful for the modern tools and techniques which we now have. I am thankful for having a career of wonderful care at supportive institutions. I am thankful for the family that I have been able to raise and sustain.

 

What I wish that I had then, that we have now …

 

  1. POCUS. While Point of Care Ultrasound has made limited entry in prehospital care, largely with physician-led services and some Advanced Paramedics; it has largely been as a proof of concept rather than everyday care. It is training and resource-intensive for prehospital care and indicated treatment may not be feasible, especially in austere environments and economies. Yet, clearly in good hands it delivers real-time anatomic, physiologic, and pathological information that can be life-saving; it has been revolutionary; once having it, one never wishes to regress. Its dissemination in poorer countries might be a better first-step than having one CT or MR scanner.

  2. 911. At the beginning of my career, making an emergency call involved finding a working wired telephone; either knowing and dialing a 7-digit number for each needed service in that jurisdiction, or calling the Operator; explaining the need (if one spoke the national language), or calling a bilingual family member to place the call, —his would sometimes be first to the doctor, then the emergency service; which was connected by telephones or telegraphic alarm systems with their dispatchers. Adding these delays, response times, and in a vertical city -reaching the patient's level meant that there were only two primary rhythms: Asystole, and Sinus (A. Fib, if elderly). There were no coordinated multiple-agency responses.

  3. Really-good 2nd Generation Supraglottic Airways, & Video Laryngoscopy. How great it would have been to have these modalities! In the seventies, there were oral airways; plastic, if you were lucky; metal wire, if you weren't. In the mid-seventies, we began using nasopharyngeal airways. (This was pretty esoteric.)

    We were even more exotic, with 15 mm endotracheal tube connectors fitted in ours. This allowed us to bypass mask facial fit problems by using the nose. If doing what was called "the one-man-band resurrection shuffle" [single person CPR in the back of a moving ambulance], this worked very well, as the bag would stay hanging there on the patient's face. At the ventilation break, without changing kneeling or sitting position, move the hands over for a head-tilt chin-lift that sealed the lips and squeezed the open nostril shut for quick inflations, then resume compressions. Absence of teeth was no problem.

    There was no field endotracheal intubation. Not even an "Esophageal Airway." {By the time we were allowed to do that, we were able to go directly to the Esophageal Gastric Tube Airway. Years later, ETI was finally allowed, but only in extremis with unconscious patients; RSI is still not allowed. There was no protocol for cricothyrotomy: had the need for it occurred, do you follow the rules? If you do one, you might either be a successful hero, or the unlucky schmuck who used to work here. Airways were a highly contentious and polarizing issue: directors and doctors with no field experience; medics with much field experience and no authority to do things already studied; "status-quo politics" remained the order of the day.

    Had we had a good Gen 2 SGA, we might have avoided some aspiration problems, better ventilation in difficult circumstances, and "conduit intubation" might have been the next step. Video Laryngoscopy might have lessened concerns about laryngoscopic intubation, or been a back-up for the difficult intubation.

  4. Pulse Oximetry & End-Tidal Capnography. Wow. How useful these would have been to let us know how well the patient was oxygenating and ventilating! These indices would have reinforced the clinical decision progress and avoided bad outcomes from unsuccessful estimates. So much more than just a BP cuff and a rhythm monitor.

  5. Disposable BVMs (one at every bedside). Yes, there's a crash cart —at the end of the ward's hallway from me. Meanwhile, the patient has just returned from a scan and had a seizure in front of you because his brain is speckled with contrast; post-ictus, he's apneic despite airway measures, and now one must give mouth-to-mouth because there's no bag at the bedside … see what I mean?

  6. Intraosseous Infusion. Not as often resorted to promptly, as it should be. An elderly lady in cardiogenic shock (BP 60/40) with no veins, I was lucky to get a 24-gauge PIV into the back of her wrist. It was all she had.

  7. GPS, Mobile Data Terminals, and Cell Phones. There were times that units were delayed or lost on calls, relying upon local knowledge and paper maps. In foggy or white-out conditions, one might not even see the curbs or intersections, and be dazzled by the flashing lights. Confusion might arise from similar or sound-alike names, the same name on a street, avenue, drive, or court.

    The isolation from having only two-way limited range radio, and no alternate means unless a pay telephone could be found, is not well-understood now. Once, while taking a patient to the hospital, Dispatch radioed us to call ASAP (radio rules didn't allow explanation). By the time that we delivered the patient and called, the five-minute radio-station contest call-back window had elapsed, and I did not win the brand-new car for which they had called my name. This was a sad blow for a poor young medic and family-man whose cars were very old and no money to spare.

All of The Editors, The Publisher, and Staff of Advanced Emergency Nursing Journal wish you a very happy time of thanksgiving and holiday celebration.

            Sincerely,

                        Tom Trimble, RN
                        All opinions are solely those of the author.
                        Readers must verify validity to their own practice.


Monday, October 31, 2016

Recurring clinical situations and personal interactions may need an astutely apt phrase or bon mot. It's good to have a mental library of successful phrases to use again. 

For example, instructions for the peak flow meter can be confusing. Most people try to "blow-blow-blow" as if for birthday candles. Say that the needle is "like a highway patrol speedometer –it flies up to your fastest speed and stays there" may get a laugh and a better performance. 

  • Sharing one's own allergy problems, "I feel like my Life is attached to my nose!" shows sympathy and empathy.

  • The acute-on-chronic respiratory distress is eased in hearing "You know, ordinary people don't realize what a privilege it is to draw an easy breath." {Let me help position you to breathe with less work, and get you some treatments to help."} {"What do you need most, right now, to help you feel better?"}

  • The person straining with back pain will understand "there's an old song with the line 'Every little movement has a meaning all its own!"  While the reference is not the same, the emphasis on movement is relevant to the present reality.

  • A silly pun such as "needing a good understanding" highlights the importance of a good footing.

  • Novices with crutches tend to look at the floor and their feet which makes them off-balance. Remind them that in diving "the body follows the head; --if you look at the floor, you'll end up on the floor."

  • Persons dwelling on their symptoms, or if you're cautioning about a potential side-effect can be told: "But, you don't have to pay any attention to that and don't need to remember it … 'these are not the droids that you're looking for'" will remind them of Star Wars and that your 'Jedi Mind-Trick' is fun and that they may safely not remember.

  • If more emphasis is needed, or you wish to enhance amnesia as wakening from sedation occurs, say again they don't need to remember, then add "just forget to remember, and remember to forget "  This creates a psychological double-bind that loops itself creating confused 'forgettery'.

  • When doing a shoulder pull-down to see C-7 on x-ray, decrease the muscle tension with visualization of walking through the airport carrying heavy bags (no wheels) and you're staying tall to carry them but your arms are stretching l-o-n-g-e-r … "

  • Not sure which way the differentiation will go? Politely stall with "We'll know more when certain tests have been done." This also helps induce buy-in to the plan by the patient and family.

  • Those anxious prognosis questions can be given assurance as my surgeon grandfather did with "you're doing as well as can be expected considering the circumstances." This non-committal phrase can be fine-tuned with different tone and affect to either be encouraging or cautionary.

  • "How am I doing, Doc?" can get a hearty rejoinder "Why, you're doing the best that you possibly can!considering). "And, I expect that with a little more rest and medicine, you'll be feeling better yet." "How soon, I wonder, do you think you'll be able to feel that way?" " I imagine that you'll want it to be soon." This puts into play the powerful forces of expectation of a positive outcome.

  • Have some simple accurate descriptions of pathophysiology and therapy. E.g., "The heart isn't pumping out all the blood that it receives, so it backs up like traffic at the toll gate, so the liquid part is oozing out into the lungs." "No, it's not really a 'blood-thinner' like paint thinner, it just slows down the clotting a little bit so that it's less likely to sludge up in tight spaces." 

  • You and the patient are working with different mental lists during history-taking and review of systems. Avoid important omissions or kept secrets and anxieties, with a kind and trustworthy: "Tell me, now, anything that you haven't yet told me." If you've established a good rapport, and a yes-series or positive responses, then you will likely get some useful replies.

  • Every good clinician will develop, over time, a personal 'patter' or internalized ready answers, ready questions, and ready assurances appropriate to many situations. You, too, should definitely do so. 

The key is to be warm, engaging, cognizant of present difficulties yet optimistic and good-natured as to outcome and how to get there. If it comes from the heart, it will be received and felt in the heart.

                Sincerely,
 
               Tom Trimble, RN
 
               All opinions are solely those of the author.
               Readers must verify validity to their own practice.