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



Friday, July 10, 2015


You are fortunate to have a “q***t” shift with some slack time that could be put to good use and some fun.


How versatile are your airway skills? Oh, sure, you can handle any supine situations! Gather everyone. Pull out the manikins (or use a volunteer; BVM only) and run some awkward codes!


Most airway management is done with the patient supine and on a table. Most training is likewise done with the patient on a table. Patients in their moment of crisis may not be in such a position! They may be entrapped; have limited access; may be midway in an operating position that can’t be changed; may need to be sitting due to pulmonary edema, morbid obesity, aspiration prevention or for awake intubation.


Try these situations.

  • A “chunky” kid has been sedated for a complicated wound repair, but soft-tissue upper airway obstruction (needs tonsillectomy, too) ensues. Snot drops down from the back of his nose irritating the glottis, and the stridor of partial laryngospasm is heard.

    Yell for help! Do an excellent Triple Airway Maneuver. Add gentle rotation of the neck seeking better airway opening. Add Larson’s Maneuver of painful pressure at the “laryngospasm notch” to break the spasm. Add CPAP with an anesthesia bag, or a BVM with PEEP valve.

    If all improves, turn patient on side to increase diameter of airway, continue respiratory support, and allow to waken. If laryngospasm continues, use succinylcholine by any route: IV; Intralingual; IO; IM. Continue support; intubate.

  • Your patient is on his side and, inopportunely, is either too difficult or not ready to be turned. Practice Bag-Valve-Mask ventilation in the lateral position. Insert OPAs, NPAs, supraglottic airway, deliver an ET tube through the SGA. Practice DL/VL and intubation laterally.

  • The patient is prone (after c-spine clearance) to repair his occipital laceration. He is not easily turned with the help available. Practice BVM assist, and insertion of airways (OPA, NPA, SGA, ETT via SGA, DL/VL & ETT, digital. You will be working from underneath.

  • Good on you, if you already “ramp” morbidly obese patients with the ear-canal-to-level-of-sternal-notch. Now imagine a very large and heavy head, very “jowl-ly” facies, and “no-neck.”  Try a very-ramped or sitting position. Lower the entire bed, or stand on a stool to gain a vantage point above the patient’s mouth, facing him,  insert your laryngoscope or videolaryngoscope upside-down with your right hand. Pull down and forward to visualize the glottis. Deliver the tube with your left hand.

    This is called by several names: Inverse intubation; Ice-Axe or Icepick intubation; Tomahawk Intubation, Face to Face Intubation, or Aussie Intubation. You are using gravity and better mechanics to manipulate the scope and jaw rather than fatiguing yourself. Variation: Assume an entrapped sitting patient. Try intubating digitally, +|- bougie. Try inserting a supraglottic airway; then deliver an endotracheal tube through your SGA.

    A form of awake (or ketamine-dissociated) intubation can be done in this way with adequate topicalization of local anesthetic.

  • Intubate your patient on the floor where he lies. Try different positions to see what works best for you. Inverse intubation while straddling the patient or alongside. Prone on your elbows behind the patient’s vertex. Right and left lateral positions (you lying on your side, behind the head). Sitting behind the head (if cervical injury excluded, the head might be supported on your calf.) Try positions with a rescue collar on the manikin or Manual In-Line Stabilization being held.

    Do this with a patient who has slumped and fallen supine with his head in the corner of the bathroom (airway support and BVM assist; place collar, place scoop or spine board and "extricate" patient to an exam room.

  • Importantly, you should practice airway support and BVM facing the patient "from the south" (facing cephalad). You may be assisting an airway manager (who's in the vertex position) who needs extra jaw thrust or lift. The proceduralist may be repairing a head laceration on a child who becomes too sleepy and needs some mask support. A problem may occur in the CT or MRI scanner. There may be a cluster of people at the patient's head, in a room too small, and you are the one who can see the see-saw of thoracoabdominal dysynchrony of breathing and tracheal tug of a now-obstructed airway. Reach up to the patient with the mask and apply inverted control. When all is OK, complete the procedure with the support of the mask and /or any needed airway devices.

    For infants and small children, I stand facing the patient from either side towards the head. My hand reaches under the jaw, lifting it and tilting the head with my thumb and ring (4th) fingers, while my index/pointer (2nd) and middle (3rd) fingers hold the mask in place (correctly fitted, with the mouth open). A pad should be under the thorax to maintain the neutrality of the neck and provide space for the large occiput.

    Someone is intubating the supine patient from the vertex (perhaps, even on a table, as usual) and perhaps petite or fatiguing is struggling to get sufficient visualization by direct laryngoscopy. Practice providing assistance with a two-handed jaw thrust, or “skyhook” a jaw lift by raising it with thumb and first finger as the hook. Larson’s maneuver (painfully distracting the condyles of the mandible) can be provided if there is laryngospasm.

Useful Take-Away Tipsu:


ü      A lateral position favors widening of the upper airway in obesity, and obstructive sleep apnea; and may assist in drainage of regurgitation or vomitus.

ü      Rotating the neck, with positive pressure ventilation may help break a partial laryngospasm. If cannot be ventilated (ball-valve obstruction of the glottis by the positive pressure; then NMB paralysis MUST be done.

ü      A semi-sitting, sitting, or Reverse Trendelenburg's Position, takes weight of abdominal viscera off the diaphragm; improves Functional Reserve Capacity; minimizes risk of aspiration; dependency of upper airway soft tissue improves available airway space; improves visualization of the glottis; and lessens the work of laryngoscopy.

ü      A prone position does not guarantee a safe patent airway. It limits respiratory excursion by the weight of the body, and by any viscera pressing against the diaphragm. Bolsters can provide room for the chest and abdomen to be free. SGAs and some methods of intubation can be placed in the prone position.

ü      Due to a large occiput, infants and small children need pads under the shoulders and torso to prevent flexion of the head/chin upon the neck and airway obstruction thereby.

ü      Patients being rescued from awkward positions need airway control where they lie, rather than delaying until post-extrication.

ü      With foresight, plan for your alternatives based upon what you have now, until the patient can be brought safely to conventional resuscitation room settings. Be wary of any patient with limited access, and watchful for any airway or respiratory compromise.


Your self-assigned goal is be prepared by forethought and practice to deal with any awkward circumstance. Your team is prepared, and camaraderie is shared. Flexibility of mind and skill bodes well.




Wiget, Urs & Torres, Eric. {Before} 19 May 01. Trucs et ficelles du métier:

Intubation extra-hospitalière : Intubation inverse, technique dite de «l’intubation au piolet {Defunct} Archived at <>.  Google Translation.


Smally, A. J., Dufel, S., Beckham, J., & Cortes, V. (2002). Inverse intubation: potential for complications. Journal of Trauma and Acute Care Surgery, 52(5), 1005-1007.


Weinberg, G. L. (2000). A versatile alternative to standard laryngoscopy. Anesthesiology, 93(1), 309.


Gürtner, I., Kanz, K. G., Lackner, C., & Schweiberer, L. (1993). Inverse intubation beim polytrauma: indikation, technik, erfahrungen. Intensivmedizin und Notfallmedizin, 30, 426-7.


Tesler, J., Rucker, J., Sommer, D., Vesely, A., McClusky, S., Koetter, K. P., ... & Petroianu, G. A. (2003). Rescuer position for tracheal intubation on the ground. Resuscitation, 56(1), 83-89.


Michael F. Murphy, MD, Fred Ellinger Jr., NREMT (2008) . A Tight Squeeze Airway management for the limited-access patient. December 2008 JEMS Vol. 33 No. 12


Larson, P. C. (1998). Laryngospasm-the best treatment. The Journal of the American Society of Anesthesiologists, 89(5), 1293-1294.


Nickson, Chris. Laryngospasm - Life in the Fast Lane Medical Blog. 2015.


“zmorgan morgan” Laryngospasm. [Video] Oct 30, 2012.

[43” nice video of breathing effort against obstruction of laryngospasm; lists consequences.]


Amato, Anthony. Pediatric Laryngospasm. [Video] Sep 15, 2014.


Larson Maneuver. NEJM Video. Mar 27, 2014.


Huitink, Johannes, MD PhD.  The one second intubation technique. [Video] Feb 11, 2014.

[Face to Face SGA Conduit ET Intubation, with video ETT]


High, Kevin. Digital Intubation. Vanderbilt University Emergency Medicine.

Estis, Gad. Digital Intubation. [Video]

[Note the angled ETT to rotate tube into glottis without obstructing visual path.]


Alenazty, Faisal. Face to Face Orotracheal Intubation. [Video] Sep 15, 2013.


Alternate Jaw Thrust. [Video]
[One version of inverted jaw thrust facing cephalad]


Podder, S., Dutta, A., Yaddanapudi, S., & Chari, P. (2001). Challenges in paediatric mask holding; the ‘claw hand’technique. Anaesthesia, 56(7), 697-699.

Lee, Daniel E., MD PhD - UCSDTraumaBurn. Pediatric Airway Management. {Pediatric Airway: brief intro for trauma providers} [Video] May 21, 2012.
[Time=33’11” Presentation]

EMS World. Paragon Medical Education group. Advanced Airway Management Techniques. [Video] Nov 19, 2013.
[Time=21’29” Laryngoscopy & Intubation didactic in Cadaver Lab, covering technique, problems, tips, direct or video laryngoscopy with bougie, etc.]

“Dr Gallagher’s Neighborhood” Lesson 3 - Mask Ventilation: MICU Fellows Airway Course. [Video] Dec 19, 2012.
[Review of sound BVM use, torso tilt, neck rotation, adjuncts, ergonomics.]


Chrimes, Nicholas. Face Mask Ventilation by Chrimes at SMACC Gold. [Video] Jan 28, 2015.
[Dr Chrimes demonstrates & compares BVM vs. Anesthesia Bag; two-hand vs. two-thumbs mask hold; leak & obstruction; OPA & NPA]

The Case for Teaching Face-to-Face (Tomahawk, Ice-Pick or Inverse) Intubation. [Poster Presentation by and based upon the article:
Venezia, D., Wackett, A., Remedios, A., & Tarsia, V. (2012).
Comparison of sitting face-to-face intubation (two-person technique) with standard oral-tracheal intubation in novices: a mannequin study. The Journal of emergency medicine, 43(6), 1188-1195.

Pap, R. (2013). A comparison of airway devices for the simulated entrapped patient (Doctoral dissertation).




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

Tuesday, June 16, 2015

During annual fit-testing for masks as Personal Protective Equipment, mine was a foregone determination. As one who wears eyeglasses and a full beard, I was to wear “the Hood.” That is to say, I would need a “Positive Air Pressure Respirator” [Powered Air-Purifying Respirator] or “PAPR.” The acronym is pronounced “papper” as if it were a word.


Ordinary hospital practice would be for admission orders to specify Isolation Cart, to ensure that the ward would have one delivered and restocked daily until no longer needed. This is not a feasible practice in the Emergency Department which must deal immediately with an undifferentiated patient. We stock a large quantity of masks, face shields, goggles, gowns, and other supplies ready for instant use. Ahh, but, PAPRs, no (except in the Disaster Closet, for Disaster Triage and Decontamination teams; but those had the filter cartridges for toxins and vapors). Delivery time estimated <2 hours.


An arrangement was made to issue me a PAPR to keep in the department for immediate use. They are costly, too. It would be kept in an anteroom of an Isolation Room (the only one with a private bathroom for the patient) which had cabinetry and sink, and an electric outlet to operate the battery charger. I was to store, charge, retrieve, and order resupply for it. It consists of a nylon web belt to hold the battery pack, motor, and a HEPA filter assembly; large bore tubing, and a demi-hood that enclosed the face and crown of the head swith the connecting tubing down the back.


I always worried how patients might be affected by my technological appearance and whether they would be frightened or feel that we must think they had Ebola virus. I likened myself to resemble the mysterious federal agents with HAZMAT gear (whom I think of as “the Science Police”) from the movie “E.T.the Extra-Terrestrial.” Fortunately, it did not seem to be a problem. I would explain that “this is just the mask that I am required to wear” (because of the beard, if need be). As with the movie, it stayed “P.G.”


If exciting in a movie, it is not exciting to actually work in one.

  • The hood is made of Tyvek and a plastic sheet (like a page protector).
  • The tubing tugs on it so that it feels awkwardly as if it will slip. (I was issued the “regular” size which was tight and uncomfortable; Large was better, but a little loose.
  • It rattles and makes brushing sounds as one moves.
  • The plastic was not optical quality, so it is difficult to read, write, examine, view monitors, read syringes, etc. Viewing angles are limited. Looking down is awkward. Normal exchange of facial gestures or lip-reading inhibits communication. For protection during shipping, the plastic is closely covered with paper sewn into the seam; this is awkward to remove quickly when starting a new hood. The plastic can be scratched with wear.
  • It works by making a generous air-flow of filtered air into the hood to make an over-pressure barrier-cushion of air against entry of pathogens; noise is necessarily involved. As it was not a full hood or caped, a stethoscope could be used, but one must tune out extraneous sounds. The air flow can be cooling on a warm day, but warmth increases and safety decreases as the battery fades. (Spare charged battery is essential.)
  • When leaving briefly, pulling off the hood requires it to be draped over the shoulder or carried (mindful of any fomite contamination that could be spread). The battery pack and filter unit are noticeably heavy and clumsy to don or remove.
  • Access to personal tools and supplies on your person will be limited by gloves, PAPR-hood, and any cover garments, be sure that whatever you will need is either supplied within the room or brought in via carry-all or tote with you. Minimize non-essentials.
  • As with any high-risk hazardous or infectious environment situation, try to arrange dedicated work-time with someone covering your other patients, and be prepared to stay the duration without having to leave for the bathroom, in order that your work can be accomplished in each visit without having to break isolation.
  • Although, compared with other staff, I would have the most experience in working in a hood, working in the HAZMAT disaster gear would not be feasible (for me) as only “average” sizes are stocked by the hospital. This is a different issue, but you may wish to explore your expected duties and what PPE equipment will be provided you from the disaster supplies.

Using a PAPR gave me the satisfaction of knowing that I had the best splash and respiratory protection to deal with nearly all foreseeable patients, notwithstanding the qualms that I had for emotional reactions by patient and family.


Organizationally, I had the advocacy of my manager to help make arrangements, and I assumed responsibility for care, maintenance, and resupply of the device and its accessories.


If you may need to use a PAPR, I hope that my experiences will be useful to you.


Wikipedia article: Surgical Mask

Wikipedia article: Personal Protective Equipment


Wikipedia article: Powered air-purifying respirators


Wikipedia article: Hazmat Suit



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



Wednesday, May 27, 2015

            An ambulance pulls up, in haste, to the Receiving door of the Emergency Department with a last squeal of the siren. The ED staff open the doors for them, wondering “Why didn’t they call first?”, but welcoming nonetheless. As the stretcher rolls in, the patient sits up suddenly with an AK-47. His attendants reach under the blanket for their AK-47s. and all start shooting the hospital staff. Moments later, a large rental van, heavily laden, crashes through the walls and windows of the waiting room. The driver and the ambulance terrorists suddenly run for a safer vantage point away from the building, which now suddenly explodes, with horrendous noise and flying debris, collapsing and melting into rubble that was formerly the home of the critical care wing, operating rooms, blood bank, radiology department, and power plant ,of what had been the majestic edifice of a modern metropolitan medical center.


            Two ordinary looking guys in large coveralls, using a pallet-lift dolly with a large cardboard box with the brand of a well-known office machine manufacturer, roll the device deep into the lobby past the complaining security guard to the bank of elevators. “No, no, Doctor Jones ordered it himself, and said that if it wasn’t here and running by 10:30 this morning, there would be hell to pay!” Other men, with ski masks and weapons, who have seized the entrances, now fire shots into the ceiling, and yell, “You are ALL prisoners and hostages of The Revolution! If our comrades are not freed, and we are not paid, everything will be blown up!


            That’s not the way that it’s supposed to be. We’re here to help everyone. Is this a bad movie, going on? Scenes such as these are entirely possible. North America’s hospitals have only focused on terrorism as external events: deploring crimes such as 9/11, Boston Marathon bombing, or Oklahoma City; trying to train for Anthrax letters; doing triage exercises and decontamination drills, but hoping not to be overwhelmed by 4,000 patients in sixty minutes as in the Tokyo Subway Sarin release. Little attention has been given to the Hospital as the target of terror. Other issues in hospital security have been dealing with assaultive behavior of patients; workplace violence; active killer scenarios. Many of these real concerns are treated by employees as ho-hum annual review training like fire extinguishers.


            In Israel, ambulances have been stolen and used for transporting arms and men. Attacks have occurred upon hospitals in other countries, notably Yemen. The large scale coordinated attacks such as in Mumbai, could be directed at hospitals here. Why? The purpose of Terrorism is terror. Attacking a hospital hits at everyone’s heartstrings, and shows that the regime cannot defend its most essential infrastructure.


            The physical security of many hospitals is poor. Vast buildings and campuses with multiple entrances, many staff coming and going, often in shifts, all of whom feel entitled to use a personal side-entrance, perhaps not even wearing one’s badge. “I belong here.” Or, “don’t you know who I am? As most workers are female, little physical resistance is likely. Last year, a municipal public hospital with a law-enforcement agency for security did not find a missing patient, presumed walk-away, despite searches did not find the dead body of the patient in a stairwell for two weeks! [Dolan, LA Times]


Administrators often insist that the hospital be a “weapons-free” zone (as if there was any protection in that), that guards are often unarmed –perhaps with just a radio and a flashlight, and often wearing a “friendly” blazer rather than a uniform of obvious authority. Security departments are often understaffed, unfit, underweight, and undertrained for extreme emergencies; or overweight, over-aged, over-worked, unfit, or if real police officers –are working over-time as a side job. In contentious situations, they are often expected to only “observe and report.” If there is uncertainty or controversy, they are often expected to defer to those “wearing white” or wearing suits and be controlled by the business administrators of the hospital.


Long corridors, large lobbies, small offices, persons preoccupied with other matters and oblivious to potential danger, all funnel potential victims into a “target-rich environment.” If mere criminality was the only matter, there’s some cash, personal electronics, appliances, and business machines; if not merely criminal, and well-studied beforehand, there are to be had radioactive materials, drugs, toxins, chemicals, and many who would pay a ransom for the loved ones within.  Chiefly, there are victims: innocent, defenseless, vulnerable, victims in a place of presumed public safety. The only limit is the size of the attacking force, its ruthlessness, and the end to which it will go (e.g., very large bomb) or to sacrifice itself. The Hostage Negotiator won’t get far with an ideologically committed group that accepts martyrdom. Counter-attack would be difficult in the extreme, with so many interior spaces and hostages (Remember the Moscow Theater raid by Spetsnaz).


–If we continue with business as usual, and “security guards” that primarily greet visitors, “shake doors,” or deescalate drunks who disturb the peace, we are remiss.

–If we expect to call for help from agencies with Hollywood’s black SUVs and sunglasses, or SWAT units, they will be too late for the worst harm will have been done in the first fifteen minutes (Oklahoma City).

–Thereafter, “siege warfare” conditions prevail, and no one does very well with that, as in Mumbai, Waco, etc.

―What must be done needs doing beforehand, and at the moment of need, must be done, essentially, with the resources at hand.


Fortunately, such incidents, although conceptually feasible, have not occurred in North America; but the potential is real. A hospital building or campus with its weakness to raid and invasion is difficult for a small group to hold, and must, like an Alamo, inevitably fall to besiegers. The process can result in considerable calamity and mischief.


We hear “have a Happy Memorial Day weekend” suggesting fun and festivities, or pleasant recreation. The holiday was proposed for the decoration of graves of The Civil War Dead and sober reflection upon the sacrifices of our military. Now, we should use it also for the thoughtful and proactive prevention and protection from terrorism upon our populace.


Dolan, Maura. Family of patient found dead in hospital stairwell to sue S.F.
Los Angeles Times, March 5, 2014.


Shipton, Paul. (5 June 2014) Terrorist attacks on hospitals 1982-2013 (June). A Public Display of Terrorism and other Suspicious Activity. Bomb Incidents/Explosives/ Hoax Devices - Last 30 days


U.S. Department of Homeland Security. (September, 2014)
Spotting Terrorism Trends: The Global Terrorism Database.


Israel Ministry of Foreign Affairs. (28 July 2014)
Hamas uses hospitals and ambulances for military-terrorist purposes.


Ernst, Matthew. (2013) Terrorism : Are U.S. Hospitals in the Crosshairs? website.

Belz, Kate, & Anderson, Kendi. (November 12th, 2014}
Hospital insecurity: Guards without guns worry Erlanger staff.
{Chattanooga, Tennessee}

Schoenfisch, Ashley, Ph.D., et al, Duke University Medical Center (2014) for International Healthcare Security and Safety Foundation.

Weapons Use Among Hospital Security Personnel.


Corbin, Dave. (05.03.2015 - 08:17 PM)
Mitigating the Terrorist Threat Against Hospitals- 4 Strategies.


Ganor, Prof. Boaz, & Wernli, Dr. Miri Halperin. (15/01/2015).
The Paris Attack and the Terrorist Threat to Hospitals.
International Institute for Counter-Terrorism.


Ganor, Prof. Boaz, & Wernli, Dr. Miri Halperin. (27/10/2013).
Terrorist Attacks against Hospitals Case Studies.
International Institute for Counter-Terrorism. editorial staff. (Updated: January 1, 2006).
Responding to a Terrorist Attack: Hospital Emergency Rooms.
Council on Foreign Relations.


Dworkin, Ronald W., M.D., Ph.D. (10/30/2002).
Preparing Hospitals, Doctors, and Nurses for a Terrorist Attack.
Hudson Institute White Paper.


California Hospital Association. (2011) Emergency Preparedness. Preparing Hospitals for Disaster. What Boston Hospitals Learned from Israel. Key advances in trauma medicine from terror attacks. Sourced from:

Sales, Ben, JTA. (4/22/2011) What Boston Hospitals Learned from Israel.


Mohammed, A. B., Mann, H. A., Nawabi, D. H., Goodier, D. W., & Ang, S. C. (2006). Impact of London's terrorist attacks on a major trauma center in London. Prehospital and disaster medicine, 21(05), 340-344. PDF


Office of the Assistant Secretary For Public Affairs. U.S. Department of Health and Human Services. (September 2005)

Terrorism and Other Public Health Emergencies Reference Guide for Media.
USDHHS Public Health Emergency website for more current and general information]
Sourced from:
California Hospital Association. Emergency Preparedness. Preparing Hospitals for Disaster.


Overseas Security Advisory Council. (2008) Mumbai Combined Arms Operation November 26-28, 2008. Sourced from: California Hospital Association. Emergency Preparedness. Preparing Hospitals for Disaster. Terrorism.


Vernon, August. (No Date, possibly 9/1/2011)
Mumbai Large Scale Attacks. Situational Awareness Considerations for Public Safety.


Federal Emergency Management Agency. (July, 2002)
Managing the Emergency Consequences of Terrorist Incidents. Interim Planning Guide for State and Local Governments.


U.S. Department of Labor. Occupational Safety and Health Administration. (No Date) [Some links for the Emergency Department of Hospitals including Terrorism.]


Unbound Medline links on Terrorism


No Author. (July 28, 2012) British hospitals present easy terrorist target for CBRNE attacks warns former Athens Olympic security chief.
Government and Public Sector Journal


International Association for Healthcare Security and Safety website.
Search results for keyword: Terrorism.


Rogers, Mark C., Esq. The Rogers Law Firm. Boston, Mass. [No Date]
The Liability Risk of Hospitals as a Target of Terrorism [PPT]


Tom Trimble, RN CEN
All opinions are solely those of the author.



About the Author

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