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Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.
Saturday, November 07, 2015


In the first part of my career, I did ambulance work, before there was ACLS, and certainly no pain medicine. We had only first aid, oxygen, and CPR to offer. Even as a Paramedic, in the early days, there was no analgesia, sedative (except for seizures), or anesthetic, to provide. One was alone with an Ill or injured patient in the back of an ambulance throughout bumpy trips. Thoughtful driving might minimize the bumps but not eliminate all of them. One had to engage with the patient and talk them (and listen to them) into not noticing whatever else was going on.


In my opinion, hypnosis is a little-understood but potentially valuable technique for the emergency department. In essence, it is a means of establishing rapport and conveying ideas, understandings, and possibilities, which might be useful for the patient. The patient isn't actually "asleep" as is so often thought, but is a willing participant who interacts knowingly for the benefits to be obtained.


In a sense, whenever a nurse or mother soothes a child, or analgesia is given with the suggestion of its benefit ("verbal endorphin enhancement"), or a patient is led by suggested imaginings ("guided imagery") to gain further benefit, then the principles of hypnosis have been used regardless of how it is called or the methods used. In truth, a so-called "trance" state does not need to exist for useful work to be done.


What is useful is for the practitioner to be able to establish a rapport, and to express what the patient might wish to use in a form that is meaningful from the patient's own needs, perceptions, and desires. "Why, yes, that's what we try to do with any patient!" ─Yes, of course, you do; that is good care and practice.


What is valuable is that training in hypnotherapy provides us with a way of making such a consistent practice of expressing things in a manner consistent with the patient's needs and desires so that it we use it effectively all the time. Why is this important? Remember that it is impossible to shout at a person to "Relax!" and have him do so. Everything must come from within. Redirection must create what is desired. If the patient is distracted, we suggest a focus. If the patient is focused elsewhere, we provide a distraction. Literally, focus is distraction; and, distraction is focus.


When a patient is in crisis, the world contracts to primal needs and perceptions seeking a control of self and immediate surroundings. This can make him spontaneously receptive to useful suggestion, and he will cling to it as a drowning man will cling to a floating object. This reinforcement helps him redraw his area of control; each slight physical improvement noted to him will reinforce his belief in his survival. When a patient is so adrift, give me a clinician who will lean in and talk directly to his ear with suggestions, encouragement, anticipatory guidance through what will come, and talks him through to confidence and success!


Is this hypnosis? Where's the swinging watch or spiral disc? Why is there no droning of "You are getting slee-e-e-py!"? Isn't this just good care? Yes; it is taking advantage of spontaneous natural receptivity to exchange meanings, understandings, and feelings. Yes; it is good care. And, it's using a hypnotherapeutic means to gain benefit for the patient. Studying hypnotherapy helps us make better use of these skills.


Why isn't hypnosis used more in emergency departments? I think that it's a number of things.

  • The ED is a bright, noisy, distracting, barely controlled environment with many interruptions. This is difficult to modify.
  • There is a common perception that hypnosis is a rare skill unsuited to the ED, and a feeling of wanting reliable scientific means to achieve effects. "There's no time for hypnosis. Propofol is my hypnosis."
  • No one wants to look weird, or to be using "alternative medicine" methods of dubious reliability. It seems odd to suggest hypnosis; so, in effect, we do what parts of it that we can, and call it something else as a euphemism.
  • It's difficult to have a cohesive team approach. Everyone works different shifts and may have different "styles" of practice; consultants may not be in on the scheme. It's not uncommon for a colleague to pipe up "Hey, you're making me sleepy!"
  • Calling in a "Child Life Specialist" may, in fact, be the only time that we admit we need non-pharmaceutical distraction, suggestion, and focus, to aid in the procedure. And, we don't even realize it as such.
  • When we say to a colleague, "Say, you did a great job in talking that patient down!" … we are saying that "You did a nice job in establishing rapport and communicating ideas, possibilities, and understandings."


Well, then, what to do?

  • Find a continuing education course in hypnotherapy.
  • Read any of the books by or about Milton H. Erickson, M.D. (an amazing and gifted American psychiatrist who pioneered modern methods of hypnosis); such books are often in medical or academic libraries, many are online with digital samples.
  • Contact your psychiatry service or Child Life for local suggestions.
  • Remember that your interactions with the patient needn't be a ritual or simulation of a "stage hypnosis" presentation. All that is necessary is to recognize when rapport is occurring, enhance it when possible, and frame the desired responses in terms that would be perceived and framed by the patient's own needs.
  • With patients in crisis (e.g., respiratory failure, awake intubation, etc.), a team clinician with these skills should engage the patient continuously, mouth to ear, until the patient is comfortable and stable.  



*Iserson, K. V. (2014). An hypnotic suggestion: review of hypnosis for clinical emergency care. The Journal of emergency medicine, 46(4), 588-596. PMID: 24472351


*"New Definition: Hypnosis". Society of Psychological Hypnosis Division 30 – American Psychological Association as cited in Wikipedia.


*Deltito, J. A. (1984). Hypnosis in the treatment of acute pain in the emergency department setting. Postgraduate medical journal, 60(702), 263-266. PMCID: PMC2417820.


Anbar, R. D. (2002). Hypnosis in pediatrics: applications at a pediatric pulmonary center. BMC pediatrics, 2(1), 11. [PDF]


*Bierman, S. F. (1989). Hypnosis in the emergency department. The American journal of emergency medicine, 7(2), 238-242. PMID: 2920089.


Hopayian, K. (1984). A brief technique of hypnoanasthesia for children in a casualty department. Anaesthesia, 39(11), 1139-1141. PMID: 6507833.


O'Donnell, J., Maurice, S., & Beattie, T. (2002). Emergency analgesia in the paediatric population. Part III Non-pharmacological measures of pain relief and anxiolysis. Emergency medicine journal: EMJ, 19(3), 195. [PDF] PMID: 11971825.


Ehrlich, Steven D., NMD. Hypnotherapy.  University of Maryland Medical Center. Medical Reference Guide, Complementary and Alternative Medicine Guide. Last reviewed on 9/19/2013.


Wobst, A. H. (2007). Hypnosis and surgery: past, present, and future. Anesthesia & Analgesia, 104(5), 1199-1208. [PDF]


Marmer, M. J. (1956). The role of hypnosis in anesthesiology. Journal of the American Medical Association, 162(5), 441-443.


Stewart, J. H. (2005, April). Hypnosis in contemporary medicine. In Mayo Clinic Proceedings (Vol. 80, No. 4, pp. 511-524). Elsevier. [PDF]

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

Friday, October 02, 2015

All the world’s a stage,
And all the men and women merely players;
They have their exits and their entrances,
And one man in his time plays many parts,
His acts being seven ages. At first the infant,
Mewling and puking in the nurse’s arms;
And then the whining schoolboy, with his satchel
And shining morning face, creeping like snail
Unwillingly to school. And then the lover,
Sighing like furnace, with a woeful ballad
Made to his mistress’ eyebrow. Then a soldier,
Full of strange oaths, and bearded like the pard,
Jealous in honor, sudden and quick in quarrel,
Seeking the bubble reputation
Even in the cannon’s mouth. And then the justice,
In fair round belly with good capon lined,
With eyes severe and beard of formal cut,
Full of wise saws and modern instances;
And so he plays his part. The sixth age shifts
Into the lean and slippered pantaloon,
With spectacles on nose and pouch on side;
His youthful hose, well saved, a world too wide
For his shrunk shank; and his big manly voice,
Turning again toward childish treble, pipes
And whistles in his sound. Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.

William Shakespeare’s
As You Like It Act II, Scene vii.


Recently, a nurse [Leonard] wrote of her father’s illness and learning to cope with changing roles and attaining empowerment as a nurse-advocate in her father’s care. It has been reposted widely.


Her story speaks to many of us as we ourselves age and retire; face the aging and end of life problems of our parents; reevaluate our roles as “good child” and and a “good subordinate” healthcare worker; and be able to speak up as needed. Her story has the advantage of having time to evolve and is still ongoing.


A large number of “older” nurses are now retiring, or withdrawing in hours of work, or from bedside care. I call this part of a “Broken-Down Baby Boomer Syndrome.” We are old, and if our parents still live, they are very old. The formerly up-and-coming younger professionals are hitting midlife stride but are developing their own aches and pains as their parents, no longer young, retire or become older and sicker. The youngest professionals are working, playing, starting families, and struggling with a completely different economy. Those second jobs will take a toll on their physique and psyche. More nurses yet will need to be recruited and educated to replace those leaving and to serve a population that will be 25% geriatric.


It is very off-putting to have one’s soundly reasoned professional advice to a parent be ignored, dismissed, or thought to be insulting the parent’s competence. One is the whippersnapper child, presumptuous, and even “planning to put me in an old-folks home.” Other divisive influences might exploit such contretemps to gain a foothold of control and misuse the trust that is given.


When the parent gives excuses, rationalizations, or even confabulates explanations, one really wants to believe those, and hardly think to question and investigate whether such is so. “Trust, but verify.”


With the parent’s provider, one might be thought to be only the “driver” for the appointment and not a natural ally with a common patient. (What, challenge my judgement?) When there are multiple specialist providers that can be too many blind men examining the fabled elephant and having different findings; polypharmacy is often a result. The unifying thoughts of the gate-keeping primary provider may be ignored by the elder who may respect the specialist more.


When there are different perceptions as to medical needs, one must try to depersonalize the family relationship briefly to ask oneself “If this were my patient, what would be the right thing to do?” As you owe a patient the kindness that you would show a parent, so must you also owe your parent the same professional advice that you would give your patient. Explaining and exploring the proposed action as the most reasonable step to return to status ante quo may be the most helpful approach.


Some degree of cooperation and shared understanding by the parent is required, as Powers of Attorney for Health Care Decisions are valid only during the incapacity of the parent and there is often a long and debatable period as to how much relative capacity actually exists in legal terms. A General Power of Attorney would be needed to manage finances and property. —Mom or Dad may seem to close relatives to be neglectful of responsibilities or “not doing well” yet still may have sufficient faculties to pass an interview to determine capacity (in the legal sense) and be bluffing their way along. Subtle signs may be noticed only by family but the law requires “hard” signs of grave disability to understand or manage affairs and plan for meeting basic needs.


If one can achieve some agreements beforehand to any serious illnesses, some problems can be forestalled. Be aware of friends and confidants who might be a willing ally. On touchy matters, such as a mental status evaluation, circumspection in supporting the recommendations of care agencies may be needed lest one be thought too ardent in changing status.


I learned from my mother that one must plan ahead for infirmities and old age just as much as planning for the events of today. There are no easy answers or predictable solutions for all possibilities, but trust and planning help.


Leonard, Julie, BSN, RN. “From our readers: When your parent is the patient.” American Nurse Today website. American Nurses Association (ANA), August 2015 Vol. 10 No. 8.




Tom Trimble, RN CEN


All opinions are solely those of the author.

Readers must verify validity to their own practice.




Monday, September 14, 2015



Preface: In January 2015, this blog provided resources for Emergencies of the Third Trimester, however, we did not separately discuss airway management in third trimester pregnancy.


What:   When a third-trimester pregnant woman is stopped in your ED, one cannot help having concern for things that might go wrong. She’s there because your hospital is under-resourced, has injury or illness not thought related to gravidity, is too “sick” to make it to OB Labor/Delivery, or you’re trying to get OR to open. In rural Critical Access Hospitals, or austere conditions, you may be all that is available.

While one first thinks of problems with the pregnancy or the fetus, the woman may be there for reasons that may impact her life or that of her child: e.g., a motor vehicle collision may inflict injuries; especially as the seat belt may not have been worn due to poor fit (riding above the pelvis) or discomfort over the gravid uterus, thus she may have been at greater risk than other passengers. The greatest risk to the child is the risk to the mother.


Why:  Why did Rapid Sequence Induction by anaesthetists develop? Because of the grave concerns of airway management, difficult airway, and aspiration common to third-trimester pregnancy. 

Present obstetric anesthesia practice fosters awake delivery ± regional anesthesia whenever possible to avoid intubation; but when intubation is clearly needed, it is best performed with aspiration precautions, RSI, and a cuffed tube.

When difficulty occurs, second generation supraglottic airways may be used for rescue, especially one that favors conduit intubation through the SGA; concurrent ventilation with a bronchoscopy swivel adapter during fiberoptic guidance is ideal.


When: The patient needs airway control for resuscitation of mother or child, emergent surgery for maternal or fetal indications; block cannot be effected or would be unsafe. The concept of post-mortem caesarian delivery is being supplanted by ante-mortem resuscitative uterine extraction to save both mother and child.


What’s different about late-gravidity airways? – What to do about it?

  1. Increasing maternal weight, even morbid obesity, impairs stomach-emptying, and a diaphragm raised by baby’s presence, thus each partuitent is essentially a “full-stomach” patient. Further, there may also have been recurring esophageal reflux irritating the vocal cords.

  2. These reasons also decrease functional reserve capacity (FVC) of the lungs, and inhibit diaphragmatic excursion, especially if supine: patients can desaturate very quickly. Use the NODESAT technique. Monitor oximetry and capnography.

  3. The weight of the fetus upon the aorta and IVC, especially when supine, embarrasses return circulation, contributes to shock, and O2 delivery to the fetus may be sluggish. If the patient cannot be managed with a leftward tilt of the body and bolstered there, then Manual Displacement of the Gravid Uterus (leftward) is mandatory.

  4. Due to weight gain and fluid retention, tissues of the upper airway may be edematous, engorged, and friable, impairing laryngoscopy and intubation, also making manual upper airway manipulations and BVM ventilation more difficult. Obesity/Morbid Obesity increases the risks. Be prepared with a bougie or ventilating introducer such as the Frova Catheter, and with smaller-than-expected endotracheal tubes.

  5. As above, especially in short-necked women and obesity, the chest contours may be raised, and breasts enlarged, to the extent that your customary laryngoscope handle may not fit between the airway and the chest wall.

    –“Ramp” the patient to a 30° angle with the “ear hole” level with the manubrium/sternum, and face parallel to the ceiling. This helps all of the above, improves visualization of the glottis, improves FRC, improves oxygenation/ventilation, and minimizes regurgitation/aspiration.

    –Use a short or stubby handle, if available. If not, then de-mount the blade; insert in mouth sideways; rotate to correct A-P orientation; remount handle.

    –If you have difficulty visualizing your approach to the glottis while in the ramped position, consider:

    A) Using a footstool or standing on the end of the gurney to attain a superior altitude.

    B) Having an assistant who is facing “do the heavy lifting” taking over the laryngoscope handle while you look and direct.

    C) Lowering the bed, but not the head of the bed, and facing the patient yourself (or kneeling/straddling alongside on the bed surface), use your right hand to hold the inverted laryngoscope (like an Ice-Axe or Tomahawk) to perform laryngoscopy and manipulate the tube with your left hand.

    –A videolaryngoscope may be of great assistance.

    –If you foresee great difficulty, be fully set-up with a second-generation supraglottic airway (ideally, able to be a conduit for an endotracheal tube) and cricothyrotomy kit ready to go.

    –Don’t remain fixated on intubation. Oxygenation is primary. Ventilation is next. Neither requires an endotracheal tube. Call for help before, or upon first difficulty, not afterwards. More damage to the airway occurs with each attempt. Successful simplicity trumps a precarious triumph over adversity that results in a damaged airway or mother or child.



Kodali, B. S., Chandrasekhar, S., Bulich, L. N., Topulos, G. P., & Datta, S. (2008). Airway Changes during Labor and Delivery. Anesthesiology, 108(3), 357-362. [Free]


Isono, S. (2008). Mallampati classification, an estimate of upper airway anatomical balance, can change rapidly during labor. Anesthesiology, 108(3), 347. [Free]


Mrinalini Balki, M.B.B.S., M.D., Mary Ellen Cooke, M.D., F.R.C.P.C., Susan Dunington, M.A., R.R.T., F.C.S.R.T., Aliya Salman, M.D., F.R.C.P.C., Eric Goldszmidt, M.D., F.R.C.P.C.; Unanticipated Difficult Airway in Obstetric Patients: Development of a New Algorithm for Formative Assessment in High-fidelity Simulation. Anesthesiology 2012;117(4):883-897.

Figure 1. Algorithm for unanticipated difficult airway in obstetric patients. Ibid.


Munnur, U., de Boisblanc, B., & Suresh, M. S. (2005). Airway problems in pregnancy. Critical care medicine, 33(10), S259-S268


Geoff Jara-Almonte, MD and Hilary Fairbrother, MD  // Editor: Alex Koyfman, MD Resuscitation of the Pregnant Trauma Patient – Pearls and Pitfalls 2/6/2015


Cabrera, Daniel, M.D. A new mindset: from perimortem cesarean to resuscitative hysterotomy. EMBlog Mayo Clinic. Tue, Aug 25, 2015.


Weingart, Scott, MD. Use of the bougie for intubation.  YouTube. 6/2010.

Llobell, Francisca, MD PhD. Frova intubating catheter+ Jet rescue in mannequin. YouTube. May 24, 2014. 

Weingart, S. D., & Levitan, R. M. (2012). Preoxygenation and prevention of desaturation during emergency airway management. Annals of emergency medicine, 59(3), 165-175. [PDF]

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




Wednesday, August 19, 2015



It is a curious thing that people often think that we must have a special interest in medical shows on television or in movies, and should prefer to watch them, or that we will give expert commentary upon the depictions.


There is a difference, too, between actors as medical people, and medical people as actors. Yes, medical people sometimes play themselves, suckered in by the excitement of Hollywood, but are subject to the director's coaching which can compromise reality for the sake of visual and dramatic appearance or timing.


My absolute pet peeve, with ~95% prevalence, is backwards insertion of a stethoscope into the ears. It is usually the first clue of an actor rather than a medical person. I am countered with "Well, maybe some people wear them that way!" "No. They don't work that way."


Time is compressed, sped up, and some actions omitted or implied to maintain dramatic pacing. The classic example is the admission by actors of ER in TV Guide that a shot would begin with their gloves already on, snapping the cuff while coming through the door to imply being just put on. {You don't open a door with sterile gloves, do you?} It was also confessed that the clipboard was a reminder as to the pronunciation of medical words. A correct BVM bagging rate is never seen, as the 60 bpm rate is necessary for the visual pacing.


Other implied actions include oxygen administration (a staple of soap operas, where a cannula is in place regardless of putative pathology) usually to merely suggest severe illness: it is especially incongruous for a non-rebreather mask to be worn without oxygen flow [flat bag, no exhalation to mist the mask and be cleared by gas flow] {Now, that's just going too cheap in production values.}.


Twice in my career, I've spoken to patients soothingly during CPR so proficiently performed that spontaneous movements and sentient responses could be discerned and apparently calmed; ─a quite remarkable thing. I have never found it necessary to stop CPR to beat my patient and curse them, yelling for them to come back! Regardless, the successful resuscitation rate is admirable (and as yet, impossible) although the technique is terrible. Survival is so assured that

Tom Cruise and Daniel Craig can plan on electrically cheating death.


Nor, did I ever load a corpse into the ambulance and drive away with red lights and siren on. For me, patients have not woken clear-headed from non-survivable blunt trauma. And I am amazed at the number of heroes with a knock-out punch or baseball bat,  that avoid epidural bleeds, closed brain injury, or spinal trauma.


No doubt, you may have seen the "Ambu-slap" when the patient is loaded and a cop helps with a goodbye double-slap to the door to let the crew know that they can leave now. I've never been part of an ambulance crew that closes the loading doors on the patient and both of the crew get in front seats leaving the patient alone! Sometimes, as in Mother, Jugs and Speed, someone attends the patient without meaningful treatment, and the patient dies. Often, a cop rides in the back to get a confession, or a significant other is there for the patient's last words. Seat belts are omitted and frequently any treatment. Combining these activities/inactivity saves a good deal of screen time.


Soap opera hospitals' ICUs seem to always be a "nice" room with an unused ventilator or IV pumps in the room; with a small monitor nearby with NSR at an unvarying rate regardless of emotions. In fact, Dr. House's hospital seems to have no nurses at all unless he needs to be told a message. He also seems to be able to perform any imaging, intervention, or procedure regardless of which specialty actually owns it. Angry patients who pull out their own IV never bleed from the hole just unplugged.


Stated dosages are often vague, e.g., the scientific sounding "Give him 3 c.c.'s." Drug names may be obscured for safety's sake (Let's hope.).


Injections are given with the needle "to the hilt." Never more so than in the infamous over-the-head resuscitative intra-cardiac injection in Pulp Fiction. The Rock also features intra-cardiac injection. Generally, drugs are shown to have immediate effect (dramatic pacing) regardless of drug or route (IM). When I was young, abductees in black and white movies would be overcome with "rag & bottle" Chloroform (and no attention to the airway), now, it's often a stab injection to the neck (gives me the willies), and especially in the case of Dexter using unbelievable amounts of Etorphine/M99.


This attention to detail can have interesting consequences. I was completely silent while walking out of (in my opinion) the insane and execrable Flatliners. My wife commented to me, "You know, I didn't see the name of a Medical Advisor in the credits." I could only grit my teeth and say "That's probably because no one was willing to put their name on it!" As the tagline of the movie said, "Some lines shouldn't be crossed."


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



Wednesday, July 29, 2015

Norman E. McSwain, MD FACS

Norman E. McSwain, Jr., MD FACS, Trauma Surgeon, Pioneering EMS Educator ,and Advocate for PreHospital Care Systems; dies at 78 years of age on July 28, 2015, in New Orleans, Louisiana, following an intracerebral hemorrhage on July 20th, 2015.



The Journal of Advanced Emergency Nursing mourns his death, but honors and celebrates the legacy of his lifetime of devotion to victims of trauma. We commend his life of service and teaching as an inspiration to be remembered and continued by others.


Dr. Norman McSwain

Additional information about Dr McSwain's life and work can be found at:





James Jude, MD


James Jude, MD, early Pioneer in Cardiac Resuscitation, developer of External Chest Compressions, and "father of modern cardiopulmonary resuscitation" dies at age 87, on July 28, 2015, "of complications from a rare Parkinson’s disease-related ailment.

Dr James Jude demonstrating chest compressions

Journal of Advanced Emergency Nursing mourns the death of Dr James Jude, but celebrations the life and his accomplishments. His work has restored the life of many who had "hearts too good to die," given hope to others at times of crisis, and helped teach us to persevere when caring for the apparently dead.



Additional information about Dr Jude's life and work can be found at:



About the Author

Tom Trimble
Tom Trimble, RN CEN is the Online Editor of AENJ.