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



Wednesday, April 29, 2015

“Time will rust the sharpest sword … ”
Sir Walter Scott. Harold the Dauntless, Canto I, st. 4 (1817).]

―No, No, Sir Walter. It’s not “Time” that rusts the sword; it’s Oxygen!


We tend to think of oxygen as a benign and positive life-sustaining force. It is good. It is goodness, itself, so to speak. To perceive a change in saturation, or signs of hypoxia, is (as in Star Wars) to “feel a disturbance in The Force.


In television dramas, it is customary to see nasal prongs (or a non-rebreather mask –often without any gas filling the bag) as a banal and necessary prop to indicate the patient is “serious” even if the seeming clinical circumstances are no indication for the treatment.


Yet, ongoing research indicates that excessive oxygen is damaging rather than helpful. Hyperoxia may increase cellular death from free radicals as exposed ischemic and injured cells during reperfusion progress to apoptosis. Perhaps, then, we should be thinking not only of “oxygenation” but also of “oxidation” as in the rusted sword mentioned above.


It will be interesting to see what changes may come from ILCOR this year. Every five years, a conference determines the current state of the art for resuscitation recommendations. Ongoing research supports moderating inspired oxygen concentrations in critical illness and injury.


In 2010, the AHA recommendation for pediatrics was: ”Hyperoxia can be toxic, particularly to the preterm infant. For babies born at term, it is best to begin resuscitation with room air rather than 100% oxygen. Any supplementary oxygen administered should be regulated by blending oxygen and air, using oximetry to guide titration okf the blend delivered.”

The 2010 AHA recommendations for adults were:

  • “Although 100% oxygen may have been used during initial resuscitation, providers should titrate inspired oxygen to the lowest level required to achieve an arterial oxygen saturation of ≥94%, so as to avoid potential oxygen toxicity.”
  • “The optimal Fio2 during the immediate period after cardiac arrest is still debated. The beneficial effect of high Fio2 on systemic oxygen delivery should be balanced with the deleterious effect of generating oxygen-derived free radicals during the reperfusion phase.”
  • “Once the circulation is restored, monitor systemic arterial oxyhemoglobin saturation. It may be reasonable, when the appropriate equipment is available, to titrate oxygen administration to maintain the arterial oxyhemoglobin saturation ≥94%. Provided appropriate equipment is available, once ROSC is achieved, adjust the Fio2 to the minimum concentration needed to achieve arterial oxyhemoglobin saturation ≥94%, with the goal of avoiding hyperoxia while ensuring adequate oxygen delivery. Since an arterial oxyhemoglobin saturation of 100% may correspond to a Pao2 anywhere between 80 and 500 mm Hg, in general it is appropriate to wean Fio2 when saturation is 100%, provided the oxyhemoglobin saturation can be maintained ≥94% (Class I, LOE C).”


In an older article, Downs effectively argues that there are six causes of arterial hypoxemia, and that for only one is oxygen a treatment specific to the pathology, but since we can improve the numbers, so to speak, in all cases we are really treating the numbers rather than finding the specific cause and giving a pathology specific treatment. E.g., oxygen is frequently given when a patient may become hypoxic due to hypoventilation from sedation, anesthesia, and analgesia, yet the specific treatment is to improve the ventilation whereas the oxygen masks the monitoring (SPO2) that would have given earlier detection of hypoventilation (as the hypoxia is then detected). Niesters, Mahajan, et al, found that respiratory depression from an opioid was worsened under oxygen with lower minute volume and respiratory rate than when tested with room air, (in addition to masking of the SPO2).


Roberts, JR. (2013). InFocus: Think Twice Before Routinely Administering Oxygen. Emergency Medicine News: November 2013 - Volume 35 - Issue 11 - p 12–13. doi: 10.1097/01.EEM.0000437839.37882.dd 


Stuntz, Bob. Turn the Oxygen DOWN! The Emergency Medicine Resident Blog. January 22, 2013  


Shiang-Hu, Ang. (2013). Oxygen is harmful –You just didn’t know it. Emergence Phenomena blog.


Elmer, J., Scutella, M., Pullalarevu, R., Wang, B., Vaghasia, N., Trzeciak, S., ... & Dezfulian, C. (2015). The association between hyperoxia and patient outcomes after cardiac arrest: analysis of a high-resolution database. Intensive care medicine, 41(1), 49-57.

cited in: Pourmand, A. (2014). Oxygen, Good or bad! Emergency Medical Education blog. Dec. 20, 2014.


Wang, C. H., Chang, W. T., Huang, C. H., Tsai, M. S., Yu, P. H., Wang, A. Y., ... & Chen, W. J. (2014). The effect of hyperoxia on survival following adult cardiac arrest: a systematic review and meta-analysis of observational studies. Resuscitation, 85(9), 1142-1148.


Eastwood, G. M., Young, P. J., & Bellomo, R. (2014). The impact of oxygen and carbon dioxide management on outcome after cardiac arrest. Current opinion in critical care, 20(3), 266-272.


Resuscitation of asphyxiated newborn infants with room air or oxygen: an international controlled trial: the Resair 2 study.

Saugstad, O. D., Rootwelt, T., & Aalen, O. (1998). Resuscitation of asphyxiated newborn infants with room air or oxygen: an international controlled trial: the Resair 2 study. Pediatrics, 102(1), e1-e1.


Cornet, A. D., Kooter, A. J., Peters, M. J., & Smulders, Y. M. (2013). The potential harm of oxygen therapy in medical emergencies. Critical Care, 17(2), 313.  [abstract | pdf]


O'Driscoll, B. R., Howard, L. S., & Davison, A. G. (2008). BTS guideline for emergency oxygen use in adult patients. Thorax  2008;63:vi1-vi68   doi:10.1136/thx.2008.102947


Downs, J. B. (2003). Has oxygen administration delayed appropriate respiratory care? Fallacies regarding oxygen therapy. Respiratory care, 48(6), 611-620.


Niesters, M., Mahajan, R. P., Aarts, L., & Dahan, A. (2013). High-inspired oxygen concentration further impairs opioid-induced respiratory depression. British journal of anaesthesia, aes494.


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


Friday, March 27, 2015

This Blog episode concerns aspects of the concept of using the nose to obtain an airway or to ventilate emergency patients; it does not deal comprehensively with all aspects thereof that a specialist might do. Overlapping categories include the nasal natural airway; expiratory airway obstruction in sleep and resuscitation; Mouth to Nose resuscitation; airway adjuncts that traverse the nasal passage; intubation via the nasal route whether “blind” (auditory, tactile), visualized by laryngoscope or other optical/video/endoscopic device.



My first professional ambulance call was for three victims of Carbon Monoxide poisoning. A couple came home from an evening out and inadvertently left the car’s engine running in the garage below. Before the romantic portion could begin, the cat became ill. While attempting to call a veterinarian, the woman became headachy, dizzy, nauseous, and passed out. The man, too, was overcome. Fortunately, the upstairs landlords returned home, heard, and turned off the running engine, tried to telephone them, then unlocked and entered the flat and opened windows. They found the man breathing, but the woman was not. Mouth to mouth artificial respiration was given to the woman while help was called. The victims was awake and talking upon our arrival. The woman's elderly rescuer said “I couldn’t get her mouth open. What should I have done?” I replied that “You could either blow through the nose, or blow between the teeth.” Her rejoinder was “I didn’t think to blow through the nose, but, boy, did I blow between the teeth!


The nose in Early Modern Expired Air Resuscitation:

Early teaching in expired-air resuscitation was three-fold. Mouth to mouth for larger children, adolescents, and adults; mouth to nose if a good seal could not be obtained, or if the rescuer could not abide oral contact; and mouth to mouth and nose for infants and small children. Subsequently, the teaching was simplified and mouth to nose deemphasized and faded away.


Few people now remember that a strong early proposal in the move for expired air resuscitation was Mouth to Nose. (James O. Elam, MD, and associates, per Peter Safar, MD.) Advantages included: a good seal by a rescuer with a small mouth and a victim with a large mouth; excellent patency of the upper airway using head tilt and chin lift to tension the pharyngeal dilating muscles of the neck; gastric insufflation was less likely with the nasal cavities moderating the force of the airflow. It lost out, I think, to a slightly greater “eww!” factor than oral (which still suffers from the too-personal-contact-reluctance of the lay rescuer, as in “hands only CPR”), and to the more euphonious persuasion of “Mouth to Mouth” and “Kiss of Life.”


At that time, too, it was felt that the cause, or  —at least, the major focus of investigation, of Upper Airway Obstruction was the tongue. This followed on the oft-held old notion of the victim “swallowing his tongue,” and of early “rag and bottle anaesthetists” manipulating the head and neck or using “tongue-pulling forceps” to obtain an airway or stimulate respiration. Safar & Escarraga, inter alia, did studies of Mouth to Mouth and found that combinations of lifting the neck, tilting the head, and lifting the chin were necessary for any form of artificial respiration. They also proved that only expired air resuscitation guaranteed sufficient inflation volumes; that exhaled air was a suitable resuscitating gas; and that the operator would have continuous feedback from each breath.


Their focus was on developing a refined technique suitable for mass usage by the military who funded them and by the lay public. With each test of group instruction, simplifications would be made to streamline to what was practical by the public and most easily remembered. Therefore, early Mouth to Mouth training would include saggital views of the airway or articulated models demonstrating the lifting of the tongue.


In fact, of methods not using an adjunct, they had found that moth to nose gave consistently higher volumes, with ~no gastric insufflation, however, sometimes the public (but not professional) would flex the neck, and mandibular advancement was not a skill easily learned or remembered. [Ruben, Elam, Ruben, & Greene] A small incidence of palatal obstruction was found, but would be obviated by an open mouth with the oral method. Mouth to mouth, as they taught it, gave more than adequate volumes; using maximal head tilt with chin lift was more than 90% effective in opening the airway; was easier to teach and remember; and although gastric insufflation was not uncommon (all positive pressure methods produced some), it was felt that the dilatation was manageable with manual decompression of the stomach and possible cleaning of the airway. For unity of concept and presentation, it was decided to emphasize mouth to mouth for lay and all non-specialist professional rescuers.


Expiratory Airway Obstruction:

I wrote about “The ‘Poof’ Sign” in Clinical Tips # 44. In earlier studies, expiratory airway obstruction was estimated to be 1-4% occurrence, and was little written of. Much of anesthesiology technique was passed on by the apprenticeship of residency. Now, there is an enlarging body of data from modern writings and from study of Obstructive Sleep Apnea. Increased prevalence may, in part, be due to the larger habitus and aging of our population than in the leaner population of the 1950s and ‘60s. In the convenience samples then, expiratory airway obstruction was found in . . . the older, more obese, patients. Surprise.


Now, we know that airway obstruction is most often palatal, or multilevel, and may include retrolingual, and hypopharyngeal. It is the vibration of the palate which gives common snoring its characteristic sound.


Expiratory airway obstruction may well have been frequently misdiagnosed as it can produce breath-stacking and ball-valve obstruction that impedes any airflow with mask ventilation if neither a nasal nor an oral airway is used and the lips have closed under the mask. It would seem as if air couldn’t go in, but it was because the air already given couldn’t get out (and the chest and stomach were maximally expanded).


The desperate mask-ventilator would clasp the mask all the tighter, until it was removed, lips were parted and an oral airway inserted. Once an exhaust route is provided, expiratory airway obstruction cannot occur.


The nose in basic resuscitation:

In an ambulance service for which I worked as a Paramedic at a time when although trained in intubation, it was not yet permitted; our principle device was a nasopharyngeal airway with an oversized 15mm endotracheal tube connector. It did not fail us, whether the patient was large faced and bull-necked, or cachectic and edentulous. With head tilt, chin lift, and lip/nostril closure, we could quickly ventilate with a bag that remained in place while doing single-person CPR. This “Modified Nasal Trumpet” [Beattie], {of which more to come in another blog}, was already “an old anesthesia trick,” although not yet published.


Modern recommendations for difficult mask ventilation are to use three airways: two NPAs and one OPA, and of course, good positioning and excellent mask technique using two hands when available. This fits with experience, and does much to lift the palate, and separate lips, teeth, tongue, and pharynx with maximal airway flow characteristics. (NPA X2 = >cross section area than single OETT. OPA added prevents lips->pharynx obstruction; together, the three may ~seal upper airway.)


Avoidance and detection of Expiratory Airway Obstruction:

  • Beware of lip closure under the facemask: open the patient’s lips; keep them separated with an oral airway, if tolerated; use an NPA.
  • Avoid downward pressure that flexes the neck. OPAs/NPAs can occlude against tissue (reposition), or obstruct with vomitus (clean, replace).
  • Beware of smaller volumes exhaled than insufflated; watch for breath-stacking. Maintain maximum Triple Airway Maneuver throughout the entire respiratory cycle. Watch for hyperinflation of chest, without expiratory fall. Look for gastric distention. Note loss of CO2 tracing on the capnograph or color-change failure on a litmus paper type CO2 detector. [Buffington]
  • If expiratory obstruction occurs, open circuit and provide exhaust; if need be, assist exhalation with bilateral thoracic squeeze. Resume with OPA/NPA, SGA or ETT.
  • Capnography (waveform)/capnometry at first opportunity and throughout the ventilatory support. Be alert to changes in waveform. This, I hold, is Gold Standard performance. [Buffington]

NTI largely supplanted by RSI:

Current resuscitation practice focuses on the oral route for airway management and intubation. It’s the bigger hole with a view, and more room to manipulate. Rapid Sequence Induction has made it easier to use without “gassing the patient down by mask” (inhalation anesthesia) or fighting trismus. Experientially, I have had open-cone ether induction: RSI is easier for the patient to undergo, as unconsciousness is achieved in seconds.


Another reason that NTI is less often used than formerly is that in the 1980s and 1990s it was a mainstay for intubation of the person at risk for cervical spine injury wearing a cervical collar. Some would even do primary cricothyrotomy or tracheotomy. Subsequent research and experience shows that while some cervical spine movement occurs with direct laryngoscopy, it appears that with Manual Inline Stabilization, the anterior portion of the rescue collar could be loosened and direct laryngoscopy carefully done without clinically significant injury. A prepared RSI seems safe. Consider fiberoptic intubation, but this may be difficult after trauma. [Hung & Murphy]


First intubation for anesthetic:

It is no longer necessary, as it was for the first endotracheal anesthesia by Macewen in 1878, to teach an awake patient in several sessions to tolerate crawling the tube down through the mouth digitally while Macewen’s finger lifted the epiglottis to pass the tube. [Brandt]


In 1913, direct laryngoscopic intubation became better known from the work of Chevalier Jackson and by Henry H. Janeway.  A heyday for nasotracheal intubation would come with work by Sir Ivan Magill and others treating the WWI soldiers with needed maxillofacial reconstruction. Doing so avoided the oral surgical field while providing an airway for long surgeries and intubation could be done at a lighter plane of anesthesia. He became so adept that frequently he would ask someone to turn around for something only in that moment to intubate the patient before the person turned back. Indeed, many authors hold that NTI can be done blindly only in a spontaneously breathing patient (with the sound of air flow to guide the tube), yet it was not uncommon for him to intubate apneic patients.


Issues; Pro:

  • Blind nasotracheal intubation can be done without instruments. Just bring a tube.
  • The curved tube easily follows the path to the trachea.
  • Skilled intubators can achieve a +/- 90% success rate.
  • Avoids injured oral tissues, teeth, and surgical field.
  • Useful with cervical ankylosing spondylitis, etc.
  • Allows preservation of spontaneous breathing.
  • When secured, is very protected and unlikely to move.
  • May be done in upright or awkward positions.

Issues; Con:

  • The tube will be smaller than can be passed per oris.
  • Rough passage may cause epistaxis, false passage through mucosa, or shear off a turbinate. (Gentleness, smaller tube, rotation, vasoconstricting decongestant, lubrication, will aid in prevention.)
  • Coagulopathy requires careful consideration; relative contraindication.
  • Sinusitis can occur in long intubation. Cover with antibiotic.
  • Many authors feel NTI is absolutely or relatively contraindicated with potential basilar skull fractures; there is also opinion arguing that airway protection trumps the extreme rarity of this complication. [Marlow, TJ;  Rosen, CL; Walls, RM]

Aids to glottal entry of the endotracheal tube:

If tube doesn’t enter glottis easily:

―if patient is capable, have him take large inhalation to open cords;
―partially inflate cuff to elevate tip
―downward manipulation of the Thyroid Cartilage to provide a better angle of entry;
―use a “trigger tube” (e.g., Mallinckrodt Endotrol to shorten radius, or a directional stylet;
―direct laryngoscopy and advance tube with Magill’s Forceps;
―use an optical/video stylet/flexible bronchoscope to steer the tube  and visualize tube entry.)


Why use the nose?

We’ve heard, or been through, tales of early EM when BNTI was the fall-back for awkward intubations before EM could claim credentialing for RSI. So, why should we bother thinking of it, or develop any skill in it?


Paralysis doesn’t open every oral cavity. Consider: small mouth; perioral scarring;  TMJ problems; retrognathic jaw;  maxillofacial injury; sharp, irregular, rotten dentition; cancer of mouth or throat; Ludwig’s Angina; Angioedema; Cervical Ankylosing Spondylitis; laryngoscope failure.

Do you know how many mm of interdental opening you need for your direct or video laryngoscope, or your “rescue” LMA/SGA?


Narrow oral space:

Incidentally, in our shop, when we began to buy capital budget difficult airway equipment, our first choice was the Levitan FPS optical stylet to facilitate intubation with an opening no greater than the diameter of the endotracheal tube.


Passing behind the tongue:

The arcuate trajectory of the nasotracheal route gets behind the bulky tongue and naturally lines up with the glottis for passage. This aids in nasendoscopic inspection of the airway or using a flexible bronchoscope (whether traditional fiberoptic or video CMOS tip) to railroad the tube into the trachea. Sometimes, delivery of the tube behind the palate, base of tongue, and any associated pathology or masses is just easier this way.


When breathing should not be stopped:

There are also patients with dynamic airway obstructions in whom one should maintain spontaneous respiration and not ablate respiratory drive; whose waning catecholamines are preserving breath and life. [militarymd]


Induction and paralysis, sometimes even just topical anesthetic, may collapse the area.


Even the common advice “take a deep breath” can alter the pressure mechanics and collapse the area, when one should have cautioned “take slow careful breaths, as through a straw, and use the air; don’t go fast or hard.” Keeping spontaneous breathing keeps a bridge unburned. [militarymd]


Augmenting detection of airflow:

Nasal intubation is most often thought of when the patient is spontaneously breathing. It’s said of air-hungry desperate patients that they practically suck the tube in. The classic technique of ear to endotracheal tube and listening for greatest air flow is simplest, but vomit in the ear has happened.


One can pull off the tube of one’s stethoscope and insert that in the ETT instead. A whistle-cap, The Beck Airway Airflow Monitor (BAAM), on the tube can amplify breathing to the listener [Bruen]. Anesthesiologists have also used the respiratory stimulant Doxapram.


The Capnography Sensor can be attached to the ETT and the tube guided by “sniffing” the CO2. [Mentzelopoulos]


If respirations are shallow, one suggestion is to gently occlude lips and the contralateral nostril to divert full flow to the naris being intubated. [High]


Tips for Nasal Passage of Tubes:

  • Internal size of passage does not necessarily correlate with the external size of the nostril, patient’s little finger, or any other purported sign.
  • Ask patient which side has easier airflow. If in doubt, check forceful exalation through each.
  • Inspection, and tube entry, are eased by lifting and flattening the tip of the nose towards the top of the head.
  • If time permits, apply cocaine, phenylephrine or oxymetazoline to constrict the mucosa. Lidocaine sprays or nebulization can numb the passage. Both agents can be in the nebulizer.
  • The Right Nostril is usually attempted first, as for most of the population it is larger than the left. However, septal deviation or other problems may make it unusable. Airflow testing may help.
  • Usually, a 30 Fr | 7.5 mm NPA or ETT will pass easily and be adequate in average adults, but may be ± 0.5 mm. If there is swelling or encroachment, it may be necessary to go smaller: choose what will pass without injury.  

    A Timely smaller tube that passed easily is more valuable than a larger tube after the airway closes!
      There are CT images where the only open space is an inexpensive PVC tube that got there just in time.
    [Gerkin] Priceless.
  • Use a soft tube: latex, silicone, or PVC softened in warm water. Lubricate well. Using lidocaine jelly helps comfort. Squirting jelly into the chosen naris before passage insures that lubricant will be there when the tube arrives, rather than dragged off the tube as it pushes through. If time permits, dilatation with a smaller then a larger NPA may be possible.
  • Slide, and rotate gently as needed, any tube horizontally along the medio-inferior of the floor of the nose towards the occiput. Do not point upwards towards the vertex and cribiform plate, or laterally, thus shearing off the turbinates.
  • Gentle, steady, firm pressure pushes the tube through. If hung up within the nose, try rotating the bevel, once passing the block return to normal positioning.
  • Advance the tube (if an NPA) to a point just short of the glottis (~10 mm). If too long, it may impact the epiglottis into the glottis, or provoke laryngospasm. If too short, or migrates retrograde, may not provide sufficient airway behind the base of the tongue.
  • With NPAs, ensure there is a generous flange, or a safety-pin passed through it, (an oversize 15 mm endotracheal tube connector will also suffice while allowing direct connection to a BVM or ventilator) and secured to the face to prevent aspiration or retropulsion outwards by a wakening patient tonguing the tube.
  • Use capnography and pulse oximetry to assure awareness of patient status, failure of ventilation, or loss of airway throughout the period of care. Any patient requiring airway support should be continuously observed by a competent provider.

Technique for BNTI:

See Levitan-Emergency Physicians Monthly, Levitan-AirwayCam, High, below, as a start, then consult other textbooks, or local consultants.


NTI Assisted by Direct or Video/Optical Devices:

Standard techniques as for specific device.


Difficulty passing Arytenoid Cartilages during ETT delivery {not NTI specific}:
Ideally, use a non-bevel tip ETT, e.g., Parker/GlideScope, or the smooth silicone hemispherical tip ETT from FasTrach Intubating Laryngeal Mask Airway that avoid or glide over the cartilages without injury. If a beveled ETT, then rotate 90° to left to allow wedge shaped tip to center; if fails, rotate 90° again (total 180°) to move bevel fully left. Some have succeeded with slow full rotation (360°). Always be gentle!


Confirming endotracheal placement:

In addition to the usual required methods and documentation, remember that, most likely, your patient will still be breathing. Feel the airflow, see the mist, notice the lack of phonation, and auscultate the chest rise. How simple.



Brandt, L. (1987). The first reported oral intubation of the human trachea. Anesthesia & Analgesia, 66(11), 1198-1199.
**Account of the first intubation for a surgical anesthetic, rather than 18th century resuscitation.


McLachlan, G. (2008). Sir Ivan Magill KCVO, DSc, MB, BCh, BAO, FRCS, FFARCS (Hon), FFARCSI (Hon), DA,(1888-1986). The Ulster medical journal, 77(3), 146.

**Excellent single article summary of Magill’s life, inventions and career.


Marlow, T. J., Goltra, D. D., & Schabel, S. I. (1997). Intracranial placement of a nasotracheal tube after facial fracture: a rare complication. The Journal of emergency medicine, 15(2), 187-191.

**CT image illustration. Yes, we’ve all heard about it.


Rosen, C. L., Wolfe, R. E., Chew, S. E., Branney, S. W., & Roe, E. J. (1997). Blind nasotracheal intubation in the presence of facial trauma. The Journal of emergency medicine, 15(2), 141-145.
**Reviews relative risks of BNTI in facial trauma.


Walls, R. M. (1997). Blind nasotracheal intubation in the presence of facial trauma—Is it safe?. The Journal of emergency medicine, 15(2), 243-244.


Levitan, Richard M. Nasal Intubation. June 6, 2011. Emergency Physicians Monthly website.

**Nice short review of NTI.

Levitan, Richard M. website.


Ontario EMS Nasal Tracheal Intubation Video on the YouTube Channel of Ontario EMS.

Bruen, Charles  Nasotracheal Intubations with the BAAM Device ResusReview

**Brief review of the "whistle" device.


High, Kevin, Kevin High, RN, EMT, MPH, MHPE. (March, 2002) Emergency Care Essentials: 'Nasal Intubation Strategies'.

**Tips from author at Vanderbilt University LifeFlight, EM Faculty, and Trauma Resuscitation Mgr.


Cheryl Lynn Horton, MD, Calvin A. Brown III, MD, Ali S. Raja, MD, MBA, MPH

Trauma Airway Management J Emerg Med. 2014;46(6):814-820 on

**Example trauma case report requiring airway control; the decision process, algorithms, and alternatives, outcome.


Rogue Medic. 2011. Should EMS Use Nasotracheal Intubation?

**Argues for broad intubation skills for paramedics in a quality program, and that nasotracheal intubation, as per Ron Walls, MD, is not overly risky in facial trauma.


Jacobs, P., & Grabinsky, A. (2014). Advances in prehospital airway management. International Journal of Critical Illness and Injury Science, 4(1), 57–64. doi:10.4103/2229-5151.128014

**Broad review of the spectrum of current out-of-hospital airway management.


Deshmukh, S. R., Gadkari, C. P., Badwaik, G. M. & Bhure, A. R. (2014) EFFECT OF ENDOTRACHEAL TUBE CUFF INFLATION AND HEAD POSITION ON THE SUCCESS OF BLIND NASOTRACHEAL INTUBATION. International Journal of Current Research and Review, 6 (13), 24-30.

**Examines experimentally in surgery patients the effect of maneuvers to increase success in BNTI.


Barton, E. D., & Bair, A. E. (2008). Ludwig’s angina. The Journal of emergency medicine, 34(2), 163-169.

**Case review and discussion of airway management in Ludwig’s Angina.


Buffington, C. W., Wells, C. M., & Soose, R. J. (2012). Expiratory upper airway obstruction caused by the soft palate during bag-mask ventilation. Open Journal of Anesthesiology, 2012, 2, 38-43 doi:10.4236/ojanes.2012.22010 Published Online April 2012

**Significant major piece important for understanding. Highly recommended.


W. H. Rosenblatt and W. Sukhupragarn, “Airway Management,” In: P. G. Barash, B. F. Cullen, R. K. Stoelting, M. K. Cahalan and C. M. Stock, Eds., Clinical Anesthesia, Lippincott and Williams & Wilkins, New York, 2009, pp. 751-792.

**"One useful, albeit poorly characterized, maneuver that can aid in face mask ventilation is the expiratory chin drop. When positive pressure inspiration is successful, but is not followed by passive gas escape during expiration, allowing phasic head flexion and reducing chin/jaw lifting will often improve gas egress.”


Fortuna, Armando. <armando.fortuna@UOL.COM.BR> 2006 - "On blind nasal intubation" in ANESTHESIOLOGY Digest - 28 Jan 2006 (#2006-51) <ANESTHESIOLOGY@harpo.MED.YALE.EDU> Archived in Author's Collection
**Personal observation of Magill's work in 1962 recounted.


Jiang, Y., Bao, F. P., Liang, Y., Kimball, W. R., Liu, Y., & Zapol, W. M. (2011). Effectiveness of Breathing through Nasal and Oral Routes in Unconscious Apneic Adult Human Subjects. Anesthesiology, 115(1), 129.

**”Direct mouth ventilation delivered exclusively via the nose is significantly more effective than that delivered via the mouth in anesthetized, apneic adult subjects without muscle paralysis.”


Liang, Y., Kimball, W., Kacmarek, R., Zapol, W., & Jiang, Y. (2008). Nasal ventilation is more effective than combined oral-nasal ventilation during induction of general anesthesia in adult subjects. Anesthesiology-Hagerstown, 108(6), 998-1003.

**”Nasal mask ventilation was more effective than combined oral-nasal mask ventilation in apneic, nonparalyzed, adult subjects during induction of general anesthesia.” Suggests that it be considered.


Safar P, Escarraga LA, Chang F: Upper airway obstruction in the unconscious patient. J Appl Physiol 1959; 14:760-4
**Eighty anesthetized nonparalyzed patients in clinical and X-ray study. Airway loss in flexion, favors supine head/neck extension, oral airway; opposes prone position, expiratory obstruction may have contributed to partial obstruction when lips closed; one patient noted to have complete expiratory obstruction in optimal position.


Ruben HM, Elam JO, Ruben AM, Greene DG: Investigation of upper airway problems in resuscitation: 1. Studies of pharyngeal x-rays and performance by laymen. Anesthesiology 1961; 22:271-9
**Recounts investigations and developments, internationally, in expired air resuscitation teachings. A real case and simulations of “rigid victims” “emphasized the importance of the nasal route of inflation as an alternative to mouth-to-mouth techniques.”

** “In not a single case did the two-handed head-tilting fail to open the pharynx, and inflation through the nose revealed no limiting obstruction. When nasal respiratory obstruction was encountered exhalation through the mouth was always possible.”

** “Chin-lift, jaw-lift, and. head-tilt maneuvers all produce a satisfactory upper airway in flaccid subjects. The head-tilt method is preferable when the mouth-to-nose procedure is indicated, i.e., trismus, convulsions, and gastric distension.” “For the chance rescuer, the head-tilt method is  simpler, safer, more versatile, and less apt to aggravate complications involving gastric contents. Hyperextension of the patient’s head by one hand on the forehead and the other on the chin is recommended for both mouth-to-mouth and mouth-to-nose resuscitation by laymen.”


Kristensen, M. S. (2011). Ultrasonography in the management of the airway. Acta Anaesthesiologica Scandinavica, 55(10), 1155-1173.

**A useful reference for evaluating airway problems and tube placement.


Reber, A., Wetzel, S. G., Schnabel, K., Bongartz, G., & Frei, F. J. (1999). Effect of combined mouth closure and chin lift on upper airway dimensions during routine magnetic resonance imaging in pediatric patients sedated with propofol. Anesthesiology, 90(6), 1617-1623.

**Examines, under MRI, the effect of airway maneuvers during titrated propofol as for MRI exam or procedural sedation.


Safar, P., & Redding, J. (1958). The" tight jaw" in resuscitation. Anesthesiology, 20, 701-702. [N.B. The link is to correspondence edited by Stuart C. Cullen as "Current Comment" with the lead essay being "Orotracheal intubation in the Lateral Position." Scroll down for the Safar & Redding piece.
**This article lead to the conclusion, cited next, in which mouth to nose is disregarded.


SAFAR, P., AGUTO-ESCARRAGA, LOURDES., DRAWDY, L., McMAHON, M. C., NORRIS, A. H., & REDDING, J. (1959). The Resuscitation Dilemma*. Anesthesia & Analgesia, 38(5), 394-405.
**"Emphasis on the use of the nasal passageway because of the possibility of a "tight jaw" seemed unwarranted. [cite Safar, P. et al., op. cit.] The preferred mouth-to-mouth method (fig. 6) was effective also in the presence of a "tight jaw" and the nasal passage was found to be less patent than the oral passage."


Hillman, D. R., Walsh, J. H., Maddison, K. J., Platt, P. R., Kirkness, J. P., Noffsinger, W. J., & Eastwood, P. R. (2009). Evolution of changes in upper airway collapsibility during slow induction of anesthesia with propofol. Anesthesiology, 111(1), 63-71.

**Research results of airway changes while titrating propofol (similar to ED deep sedation).


Kempen, P. M., (2010). Airway collapse or closure via the soft palate as mechanism of obstruction in sedated patients?. Anesthesiology, 112(2), 496-497.

**Comment upon above article.


Hillman, D. R., Walsh, J., Maddison, K., Platt, P. R., Noffsinger, W. J., & Eastwood, P. R. (2010). Airway Collapse or Closure via the Soft Palate as Mechanism of Obstruction in Sedated Patients? Reply. Anesthesiology, 112(2), 497-497.

**Reply to Kempen’s comment.


Morikawa S, Safar P, DeCarlo J. 1961. INFLUENCE OF THE HEAD-JAW POSITION UPON UPPER AIRWAY PATENCY. Anesthesiology, Mar-Apr 1961.

**X-Ray study of pharyngeal patency for Mouth to Mouth found total expiratory obstruction without inspiratory obstruction in 7 of 68 patients despite maximal head tilt. Breath-stacking occurred until inspiration could no longer be done; opening the mouth relieved the obstruction. Attributed to soft palate obstruction. Oral inflations with obstruction were always correctable with jaw lift, improving head tilt, or OPA. Complete obstruction despite head tilt with lips closed occurred in 4 patients, of whom 3 were corrected with jaw displacement, and 1 required an OPA.


Hillman, D. R., Platt, P. R., & Eastwood, P. R. (2003). The upper airway during anaesthesia. British journal of anaesthesia, 91(1), 31-39.

**Excellent study and review of the physiology of the unconscious anesthetized patient (conditions similar to RSI in emergency patients).


Atul Malhotra, Yaqi Huang, Robert B. Fogel, Giora Pillar, Jill K. Edwards, Ron Kikinis, Stephen H. Loring, and David P. White "The Male Predisposition to Pharyngeal Collapse", American Journal of Respiratory and Critical Care Medicine, Vol. 166, No. 10 (2002), pp. 1388-1395. doi:  10.1164/rccm.2112072

**The authors found increased pharyngeal length and area, and larger soft palate area in men, which led to their conclusion (in part): "This study suggests that there are clearly definable differences in upper airway anatomy between men and women, with little to no difference in muscle activation/control. Furthermore, on the basis of computational modeling, we believe that the anatomic differences observed can significantly impact airway collapsibility and may, in part, explain the male predisposition to OSA."


Vroegop, A. V., Vanderveken, O. M., Boudewyns, A. N., Scholman, J., Saldien, V., Wouters, K., ... & Hamans, E. (2014). Druginduced sleep endoscopy in sleepdisordered breathing: Report on 1,249 cases. The Laryngoscope, 124(3), 797-802.

**Palatal collapse was seen most frequently (81%). Multilevel collapse was noted in 68.2% of all patients. The most frequently observed multilevel collapse pattern was a combination of palatal and tongue base collapse (25.5%). . . . The prevalence of complete collapse, multilevel collapse, and hypopharyngeal collapse increased with increasing severity of obstructive sleep apnea (OSA). Multilevel and complete collapse were more prevalent in obese patients and in those with more severe OSA. Both higher BMH and AHI values were associated with a higher probability of complete concentric palatal collapse.


Beattie, C. (2002). The modified nasal trumpet maneuver. Anesthesia & Analgesia, 94(2), 467-469.
**Describes the use of an NPA with added Murphy’s Eye and 15mm endotracheal tube connector as beneficial in several difficult airway situations.


“militarymd.” “The Student Doctor Network Forums: “Someone almost died” - Discussion in 'Anesthesiology' started by militarymd, Apr 25, 2006.
**Discussion of actual clinical case of dynamic airway obstruction and its implications. Do not miss. Instead of “big deep breaths”, it can be wise to urge slow smooth breaths.


Gillespie, N. A. (1950). Blind nasotracheal intubation. Anesthesia & Analgesia, 29(6), 217-222.

**This vintage piece included as by a classic and noted practitioner (English, then later at University of Wisconsin) for a view of the time and its memoir quality.


Mentzelopoulos, S. D., Augustatou, C. G., & Papageorgiou, E. P. (1998). Capnography-guided nasotracheal intubation of a patient with a difficult airway and unwanted respiratory depression. Anesthesia & Analgesia, 87(3), 734-736.


Gerkin, R., Sergent, K. C., Curry, S. C., Vance, M., Nielsen, D. R., & Kazan, A. (1987). Life-threatening airway obstruction from rattlesnake bite to the tongue. Annals of emergency medicine, 16(7), 813-816.
**Timely intubation: the PVC ETT was the only open space in an encroached airway for three days.


Hung, Orlando; Murphy, Michael F. Management of the difficult and failed airway. McGraw-Hill Medical, 2008. Section 14.4.14 and pp 212-219 passim.
**Nasal intubation reviewed and of risks in cervical spine injury.


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




Saturday, February 28, 2015

The February holidays have an interesting history and have undergone change. Washington’s Birthday is now most commonly called (in different spellings) “Presidents Day.” Lincoln’s Birthday, never a Federal holiday but widely celebrated on a State basis, now seems subsumed (even with all Presidents in many minds), in Presidents Day, while the Reverend Dr. Martin Luther King, Jr., is celebrated as the “other” holiday.


There are increasingly many writings upon the health of our Presidents either factual or speculative, and even in contention whether the office is inherently detrimental to wellness and longevity of its occupants. Difficulties abound as such matters were often secret, not observed by medically informed writers, and inability to examine the patient or perform an autopsy not done at the time.


George Washington

Washington’s robust constitution had endured a number of fevers, malaria, dysenteries, smallpox, “rheumatism,” dental problems, in his life. His care of others included being a “great vaccinator” to ward off smallpox. His fatal illness, probably supraglottitis, treated by methods of the day, included four blood-lettings to a total of 80 ounces (~35-40% of blood volume), purgatives, induced diaphoresis, and counter-irritant poultices (a blister of cantharides {Spanish Fly} to the neck, and wheat bran to the legs) to reduce the inflammation; a demulcent mixture nearly choked him. Dr. Elisha Dick (37 years old) objected to the bleedings (the first by the plantation’s blood-letter at Washington’s request prior to the physicians’ arrival, the sec{Spanish Fly}ond by the physicians upon arrival) but was overruled by the two elder physicians for the latter two, and his proposal for tracheotomy was likewise rejected. A fourth doctor didn’t arrive until the morning after the death but also knew tracheotomy, and in fact proposed revival of the corpse by rewarming, tracheotomy, and transfusion of lamb’s blood; Mrs. Washington did not agree.


Thomas Jefferson

In a controversial book, author Norm Ledgin argues that Jefferson’s many quirks and intensity are a pattern that he feels is most consistent with Asperger’s Autism or  a High-Functioning Autism. He gained this insight as the father of a son with Asperger’s.


Abraham Lincoln

Lincoln’s lankiness has been ascribed to Marfan’s Syndrome, but this is disputed. He suffered from depression and grief at the death of his son, Willie. His appearance greatly aged during the course of the Civil War. The mental problems of his wife, Mary Todd Lincoln, were a significant burden in his life. The first doctor to care for Lincoln at Ford’s Theater was Charles A. Leale, an army surgeon. Decompression of the brain by manual removal of wound clot features in the care.


James A. Garfield

The shooting of Garfield and his course over eighty days before his death greatly affected the nation and its emotions.  Ironically, Robert Todd Lincoln, son of President Lincoln, was present in the Garfield’s group at the shooting.  The medical care was predicated on an incorrect assessment of the internal trajectory of the bullet which wasn’t found or removed until autopsy. Alexander Graham Bell, inventor of the telephone, devised a metal detector to locate the bullet; its lack of success is thought due to interference of the metal bedsprings, as it was  later found functional; this would be an early attempt at diagnostic “imaging.” During the course, there was much infection, starvation to a weight loss of one hundred pounds, multiple organ failure, and rupture of an aneurysm to the splenic artery.


Grover Cleveland
In 1893, out of concern for any public reaction during a financial depression and fight over the monetary Gold Standard, Cleveland arranged for surgery to be done secretly while on a yacht off Long Island during a supposed vacation. This was done for a tumor of his palate, and involved partial removal of his maxilla; a second surgery placed a hard rubber dental prosthesis that restored the disfigurement and speech difficulty.


William Howard Taft

Taft is known for his morbid obesity, and hypertension. He often had daytime somnolence, even falling asleep on his feet. After leaving  the presidency, with diet and “physical culture,” he lost eighty pounds easing his obstructive sleep apnea, and moderating his blood pressure, thereby improving his alertness and work performance (he became Chief Justice of the Supreme Court); and extending his life span to 72 years.


Woodrow Wilson

Wilson suffered several strokes, and was isolated in the White House by his second wife, Edith, who allowed only herself and his physician to see him. This led to (inter alia) failure to ratify the League of Nations treaty, a paralysis of the executive branch and Cabinet, and accusations to this day that Edith “was running the government.” After five months, the public became aware and Wilson began to make appearances at Cabinet meetings. The Constitution did not provide who or how the determination of inability to serve was to proceed, and no one attempted it. This period, and several others of other Presidents, is considered to be a major reason for adoption of the Twenty-Fifth Amendment to the Constitution in 1967.


Calvin Coolidge

Often remembered for being taciturn, he had an effective career before as Massachusetts Governor. He succeeded to the Presidency upon Harding’s death by heart attack. He finished that term, and ran for a second term. His son, Calvin, Jr., died of sepsis from an infected blister on his foot resulting from a tennis game at the White House. Coolidge’s despondency and grief, blaming himself for being too involved in politics and inability to save his son, became life-altering major depression, losing all zest and feeling that the light had gone out of his life.


Franklin D. Roosevelt
The only President to be elected to a third and fourth term (which now is precluded by Constitutional Amendment), is well-known for his polio (the full extent of his paralysis being concealed from the public), Roosevelt had bad hypertension which progressed to cardiac disease and was worn-out during World War II, with noticeable periods of illness and decreased effectiveness at and subsequent to the Yalta Conference. He survived only four months into his fourth term, dying of a massive hemorrhagic stroke in Warm Springs, Georgia, where he would vacation and do physical therapy. This left Harry S. Truman to become President, complete the war; devise post-war demobilization, recovery; and deal with a Cold War of occupation, espionage, and Korean “Police Action.”


Dwight D. Eisenhower

Eisenhower “smoked like a furnace” at four packs a day during World War II, although he quit, cold turkey, at 56 years of age. September 23rd, 24th, and 25th of 1955, he experienced chest pains, resulting an anterolateral MI “the size of an olive.” He directed that the public be told everything; probably the first occurrence of such disclosure. The stock market panicked with a 6% drop in Dow Jones (~$14 Billion). His eventual death was due to Congestive Heart Failure, but he had endured “at least seven heart attacks, fourteen cardiac arrests;” ventricular aneurysm giving rise to his first stroke (subtherapeutic PT); COPD with O2 prn during his last three years of Presidency; Cholelitihiasis with sixteen stones at cholecystectomy; Crohn’s disease with SBO and ileotransverse anastomosis upon resection. (DuPont). He was among the first to receive DC defibrillation, and Bretyllium. He survived 14 years after his first MI. An adrenal pheochromocytoma was found on autopsy.


John F. Kennedy
Kennedy is now known to have Addison’s disease, diagnosed in 1947 but always kept secret, chronic back pain requiring many meds and several surgeries, hypothyroidism. He was at risk if there was a physical crisis, and two endocrine disorders suggest an autoimmune disorder. The impact of his polypharmacy on functional ability is debated.


This selection of presidential health and histories calls to mind the last words of Alexander the Great: “I am dying with the help of too many physicians.”


Clearly, modern medicine, had it existed at the time would have benefitted the victims. Additionally, there is the pervasive problem of multiple providers, disagreement, deference to the illustrious patient, a wish to be associated with the care of august persons, a tendency to secrecy, and less than adequate care than would be provided others.


While the absolute likelihood of being involved in such an incident is exceedingly small, it is always possible with travel and public appearances being an essential part of the Presidency.


As March is nearly here, remember: "The Ides of March is here." March 15 is the anniversary of the assassination of Julius Caesar. And, too, bear in mind the old injunction "Memento mori."




PBS NewsHour: Despite what you think, Presidents Day doesn't include Lincoln. February 16, 2014.


DuPont, Drew, MD, MSPH. "Illness in the White House: The Health of US Presidents" (no date) pdf of ppt from Internet source, not currently indexed.


Healthline Editorial Team [writers]; Kruick, George, MD MBA. [Editor]. Presidential Diseases. [2013]


A History of Death and Illness in the White House: U.S. Presidents' Disabilities (1993) C-Span interview of Robert E. Gilbert, author of The Mortal Presidency. Published on Jan 27, 2015.


PBS NewsHour” Dec. 14, 1799 The excruciating final hours of President George Washington. December 14, 2014.


PBS NewsHour: Bloodletting, blisters and the mystery of George Washington’s death. December 15, 2014.


George Washington Eyewitness Account of his Death © 2013.  Part of “Health and Medical History of President

George Washington.”


Vadakan, VV. (2002) The Asphyxiating and Exsanguinating Death of President George Washington. Permanente Journal. Spring 2004. Volume 8; Number 2.


Curfman, DR . The Medical History of the Father of our Country - General George Washington. The Order of the Founders and Patriots of America. ©2015. Articles


Schmidt, P. J. (2002). Transfuse George Washington!. Transfusion, 42(2), 275-277.


Ledgin, Norm. Diagnosing Jefferson: Evidence of a Condition that Guided His Beliefs, Behavior, and Personal Associations (2000  Future Horizons. ISBN-10: 1885477600


Leale, Charles A., MD.  Report of Dr. Charles A. Leale on Assassination, April 15, 1865. The Papers of Abraham Lincoln. .


“Is there a surgeon in the house?” Papers of Abraham Lincoln researcher discovers report of Dr. Charles A. Leale, first physician to reach Lincoln at Ford’s Theatre. June 5, 2012 News report and transcript of the manuscript “true copy” of Dr. Leale’s report of the assassination and medical care of President Lincoln. (above item; photographs of manuscript)


Sotos, John G. Taft and Pickwick; Sleep Apnea in the White House. Chest ®. September 2003. V.124 (3) 1133


 "The Death of President Franklin Roosevelt, 1945." EyeWitness to History, (2008).


Dallek, Matthew. (2012?) Franklin Delano Roosevelt—Four-Term President—and the Election of 1944.  The Gilder Lehrman Institute of American History.


Rogers, William Warren. “The Death of a President, April 12, 1945: An Account from Warm Springs” Reprinted from The Georgia Historical Quarterly, Vol. LXXV, No. 1, Summer 1991.


Heaton, L. D., Ravdin, I. S., Blades, B., & Whelan, T. J. (1964). President Eisenhower's Operation for Regional Enteritis A Footnote to History. Annals of surgery, 159(5), 661.


Wright, J. (2008). Cameos of Terror–Four US Presidents and a Senator. The Medscape Journal of Medicine, 10(7), 170.


PBS NewsHour. President Kennnedy’s Health Secrets. (Interview of a physician and an historian who had reviewed Kennedy’s health records at the Kennedy Library.) Transcript. November 18, 2002.


Dallek, Robert. “The Medical Ordeals of JFK. The Atlantic Monthly. December 2002. Article drawn from An Unfinished Life: John F. Kennedy, 1917-1963; Little Brown. Medical review by Jeffrey Kelman, MS MD. The above interview is with the authors and concerning this book.


Interviews: "Pulling Back the Curtain" (November 14, 2002) Interview in The Atlantic Monthly (Atlantic Unbound) concerning the development of the above article and book.


Groves, J. E., Dunderdale, B. A., & Stern, T. A. (2002). Celebrity patients, VIPs, and potentates. Primary care companion to the Journal of clinical psychiatry, 4(6), 215.


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.