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Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.
Tuesday, August 2, 2016

"The crowner hath sat on her and finds it
Christian burial." …
"But is this law?"
"Ay, marry, is 't—crowner's 'quest law."
Hamlet. Act V, scene I

[Text from Folger Shakespeare Library]
[Audio recording of Dramatic Reading; Chapter Vox]
[Video recording of Act V, scene1]

 

Most deaths that are brought to, or occur in, an emergency department will require, at least, discussion with the local Coroner or Medical Examiner. This official inherits the powers of a very old and distinctive office; that of the Crowner or "King's Man" begun by the Normans who had conquered England as their grip and control consolidated.

"After the Norman Conquest, to deter the local communities from a continuing habit of killing Normans, a heavy fine was levied on any village where a dead body was discovered, on the assumption that it was presumed to be Norman, unless it could be proved to be English. The fine was known as the 'Murdrum', from which the word 'murder' is derived and, as the system developed, many of the early coroners' inquests dealt with the 'Presumption of Normanry' which could only be rebutted by the local community, and a fine thus avoided, by the 'Presentment of Englishry'." [Coroners Society]

King Richard I (the Lionheart) needed vast sums of money for the Third Crusade, operation of the kingdom, and for his ransom fro m Duke Leopold of Austria.  Crowners looked for "Treasure Trove", and offenses for which properties or fines could be forfeit to the Crown, in contrast to the local magnates who were Sheriffs and often corrupt. [Gross]

So why, in this era, should we still need an ancient office? Wherever the globe once showed red for the British "Empire upon which the sun never sets", there are Coroners who are now independent judicial officers to rule upon the identification of persons found dead and determine the cause and manner of death. These medicolegal investigations have value to not only find crime or negligence, but now also to determine public health problems and to teach the living what may be learned of their disease or modus exitus.

Despite the proliferation of "police procedural" and criminalistics shows on television, there is no guarantee that any particular locale or case receives the "CSI effect." The ideal is a fully funded Medical Examiner's department when the incumbent or staff are board-certified Forensic Pathologists. The other extreme is when a layman has been lucky in the election, but then works without training or hiring those who are competent; sometimes, autopsy services will be outsourced. In some locales, the Coroner's Office has, for economy, been combined with the Sheriff's Office or upon a local prosecutor. Regardless, there are an insufficient number of qualified forensic pathologists to assume office everywhere. [PBS]

It is good to know the local resources and capabilities, an in-service presentation could help in this respect, and an understanding of when the Coroner/Medical Examiner has jurisdiction, and the procedures to follow to preserve the patient and any evidence.

My experience has been with metropolitan jurisdictions with a Medical Examiner, and with California law, which will be used here for an example.

A Coroner may elect not to investigate a notifiable case in several circumstances. E.g.,

  • Upon discussion with the primary physician finds that death was expected from known pathology, the physician has recently seen the patient, and the physician is able to certify the cause of death.
  • The Coroner determines that the medical care during the final illness has sufficiently elucidated the cause and manner of death to exclude other actionable investigational requirements (by surgery, scans, etc.).
  • The cause and manner of death are sufficiently obvious from known facts or death scene investigation as to make it unnecessary.

Contrariwise, the Coroner may assert jurisdiction when perhaps not suspected from superficial appearances, if the cause of death (toxicity) may suggest a criminal agency, occupational exposure, or potential negligence requiring his action, or if the primary physician is unable to certify the cause of death.

 
Reportability, or those cases in which the Coroner has jurisdiction and must be notified upon declaration of death –whether the Coroner chooses to pursue an investigation or not, typically includes: [Los Angeles Coroner]

Reportable deaths to the Medical Examiner-Coroner
Deaths Requiring a Decision

Certain types of cases not listed in the State Law but which often pose problems or are difficult to evaluate, should be reported to the Coroner for a decision. These include, but are not limited to the following:

·        Persons dying within 24 hours of admission to the hospital, or not medically attended by a physician within 24-hours of the time of death, unless the attending physician has established a natural cause of death.

·        All deaths occurring in operating rooms, during therapeutic or diagnostic procedures or as a result of complications of these procedures (postoperative, e.g., wound infections) or when the patient has not regained consciousness after an anesthetic should be reported.  These are not all Coroner's cases unless the death is known or suspected as being due to misadventure during the surgery, therapy, procedure or anesthetic. These cases are often difficult to evaluate and should be referred to the Department of Medical Examiner-Coroner for a decision. The surgeon or physician with the most knowledge of the circumstances should report the death. The deaths occurring within 24 hours after surgery should also be reported.

·        All deaths in which the patient is comatose on arrival and remains so throughout his/her hospital care unless the cause of the coma has been definitely established as due to a natural disease.

·        The death of an unidentified person will be accepted as a Coroner's case. It is acceptable for the treating physician to opine a cause of death for an unidentified person who dies from a natural disease process. After the death is reported, the Coroner will attempt to identify the decedent. All efforts to identify the decedent by hospital staff, law enforcement agencies or social service agencies should be well documented in the medical records. The cause of death opined by the private physician will be used by the Coroner for the official death certificate. Do not place the name "John/Jane Doe" on the signed death certificate.

·        All deaths involving hip fractures if the attending physician believes the fracture caused or contributed to the cause of death.  If the fracture is to appear anywhere on the death certificate, the certificate must be completed by the Department of Medical Examiner-Coroner and not by the attending physician.

·        All deaths in which an injury or an accident is the cause or a contributing cause regardless of how distant or remote in time or place the accident or injury may have occurred. This includes subdural hematomas, comas, paraplegia, quadriplegia, fractures and seizure disorders, regardless of the time interval between the injury and death.

All cases known or suspected as coming under the jurisdiction of the Medical Examiner-Coroner should be reported immediately to (323) 343-0711. The family or next-of-kin of the decedent should not be approached for permission for an autopsy prior to clearance from the Coroner's office. Removal of tissue from Coroner's cases for scientific or transplant purposes MUST NOT be performed without prior approval of the Coroner, regardless of prior next-of-kin authorization.

The Medical Examiner-Coroner shall have discretion to determine the extent of inquiry to be made into any death occurring under natural circumstances and falling within the provisions of the law. If such inquiry determines that the physician of record has sufficient knowledge to reasonably state the cause of a death occurring under natural circumstances the Coroner may authorize the physician to sign the certificate of death. In all other instances, the Coroner or his appointed deputy shall personally sign the death certificate.  The decision as to whether a death is in fact a Coroner's case rests with the Coroner.  If it is determined, after appropriate evaluation, that the death is not a Coroner's case, it then becomes the responsibility of the attending physician to issue the death certificate.

According to Health and Safety Code 102825, the physician and surgeon last in attendance, or in the case of a patient in a skilled nursing or intermediate care facility at the time of death, the physician and surgeon last in attendance or a licensed physician assistant under the supervision of the physician and surgeon last in attendance, on a deceased person shall state on the certificate of death the disease or condition directly leading to death, antecedent causes, or other significant conditions contributing to death and any other medical and health section data as may be required on the certificate. He or she shall also specify the time in attendance, the time he or she last saw the deceased person alive, and the hour and day on which death occurred. This must be done within 15 hours after the death.  With increasing demand for tissue for transplantation, families consent for organ donation more often.  Many of our decedents are tissue donors (heart valves, cornea, skin, bone). It is therefore important that cases are reported in a timely manner and medical records are available at time of release or removal. 

{End, lengthy quotation of Los Angeles Coroner instructions}

 

In all emergency department cases, it is best to leave in all lines, airways, devices, etc., and contact the Coroner's representative immediately. No "practice procedures" should be done. Wounds should not be washed. All belongings and potential evidence should be appropriately bagged, sealed, labeled, and delivered via chain of custody. Surfaces or tissues with organic contamination should be in paper bags to preclude a "hot-house environment" that may degrade the usability of the material. Objects without organic contaminants may be within plastic bags; when in doubt, ask the Coroner's or Police investigator for advice. Arrangements should be in place for providing medical, imaging, and other records to the Coroner.

In all cases where the Coroner has jurisdiction, and the family claim religious or other scruple regarding death, the remains, or any investigation, any decision is that of the Coroner who will prevail, but will often accommodate insofar as possible given the needs of the case. Advise the Coroner's representative of what circumstances are known, and they will make any necessary statements to the family.

 

The Coroners Society of England and Wales. History. http://www.coronersociety.org.uk/. Accessed 07/30/2016.

Gross, C. (1892). The Early History and Influence of the Office of Coroner. Political Science Quarterly, 7(4), 656-672. Accessed 07/30/2016.

U.S. National Library of Medicine. Visible Proofs: Forensic Views of the Body exhibition at the National Library of Medicine closed on February 25, 2008. Accessed 07/30/2016.

County of Los Angeles. Department of the Medical Examiner-Coroner. Reportable deaths to the Medical Examiner-Coroner. [No Author, No Date.] Based upon California Health and Safety Code 102850 and Government Code 27491. Accessed 07/25/2016.

 
Brent, Nancy J., MS, JD, RN. Pronouncing patient's death should be timely, respectful. April 6, 2016. News.Nurse.com. Accessed 07/25/2016.

Weaver, Maureen. "United States: New Law Permits Registered Nurses To Sign Death Certificates When They Are Authorized To Pronounce Death." January 2005; Last updated May 16, 2005. Wiggin & Dana LLP. Accessed 07/25/2016.

Gentle Care Hospice advice (based on Los Angeles County, CA) upon "Death in the Home." Accessed 07/25/2016.

Lawyers.com. "Autopsies: Finding Out "Why" May Be Required." [No Author; No Date.] Accessed 07/25/2016.

County of Los Angeles. Department of the Medical Examiner-Coroner. Reportable deaths to the Medical Examiner-Coroner. [No Author, No Date.] Based upon California Health and Safety Code 102850 and Government Code 27491. Accessed 07/25/2016.

California Government Code Section 27491 - 27504.1. Accessed 07/25/2016.

California Health and Safety Code 102850-102870. Accessed 07/25/2016.

California Government Code Section 27491 Search California Codes. Searchable statute from commercial site. Accessed 07/25/2016.

CDC. Physicians' Handbook on Medical Certification of Death. 2003 Revision. Accessed 07/25/2016.

CDC. Medical Examiners' and Coroners' Handbook on Death Registration and Fetal Death Reporting. 2003 Revision. Accessed 07/25/2016.

CDC. Coroner/Medical Examiner Laws, by State. Published January 15, 2015. Accessed 07/25/2016.

Dr. Judy Melinek. California Death Certification Tutorial. PathologyExpert.com. Accessed 07/25/2016.

National Academy of Sciences
Medicolegal Death Investigation System: Workshop Summary
Committee for the Workshop on the Medicolegal Death Investigation System
ISBN: 0-309-52642-6, 86 pages, 6 x 9, (2003)
Free PDF may be downloaded from http://www.nap.edu/catalog/10792.html.
Accessed 07/30/2016.

PBS. Frontline® Post Mortem: Death Investigation in America. ©2011. Accessed 07/30/2016.


            Sincerely,

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

​ 


Sunday, July 10, 2016

Why is there a firehose of information from which to drink? FOAMed author, Dr. Natalie May, in early 2015 used that firehose analogy to preface useful tips in controlling and managing the torrential quantity of information to inform our practice. Why is it important to do this?

 

The maxim from respected Emergency Physician Joe Lex is:

  • If you want to know how we practiced medicine 5 years ago – read a textbook.

  • If you want to know how we practiced medicine 2 years ago – read a journal.

  • If you want to know how we practice medicine now – go to a (good) conference.

  • If you want to know how we will practice medicine in the future – use FOAMed.

Joe Lex, MD, just retired from Temple University in Philadelphia after 50 years of working his way up in Emergency Medicine, from a Vietnam Medic, to EMS, Nursing, Medicine, and Emergency Medicine.

 

Dr. May will tell you how to modulate the flow from the hoses. I'd like to tell you how we got to this point, and how it used to be done.

 

Gather around, for a story.
… "A long time ago, before our planet went digital … Well, it wasn't quite copyist monks illuminating vellum, nor was it even Dickens's Bob Cratchit labouring with quill and ink."

 

Data would be collected, authorities reviewed, and printed copies of prior writings had to be found from a library, an inter-library loan, or purchase. Within the library, one consulted a "card catalog" to find the work sought, or make friends with the Reference Librarian" if there was one. This was called "legwork." Alternatively, if the author of the journal article was likely to still be alive, one wrote an obsequious letter to him, or the publisher, hoping for a "reprint" (which had to be bought by the author) If lucky, one might get some interesting foreign postage stamps when receiving the mail.

 

Manuscripts were written by hand, and the final draft would be typewritten. Copies of the typescript would be the 1st, 2nd, or 3rd carbon copies sandwiched within the typewriter. Errors were erased by hand from each layer, with a soft rubber bar, and messy erasures prevented with an "eraser shield". Blow the rubber gums out of the typewriter. Then, the erased area had to be corrected with an over-type. Try to continue without making another time consuming error. If fortunate, (privately rich, or having institutional secretaries) a qualified typist might prepare your typescript (fix your errors, proof read, etc). Remember to thank her greatly in your "Acknowledgements." It took longer than expected. (The standard "QWERTY" keyboard still in use was designed to slow the typist down as a fast typist could stroke the key levers into hitting each other and jamming the typewriter.)

 

Before World War II, most Americans would have a high-school education (if that), and a University education was obtained by the striving upper-middle class, immigrant intelligentsia seeking advancement and respect for their young, and the wealthy.

 

During the war, those with a higher education could count on an officer's commission, and intelligent working-class men with social skills, who might be apt pupils, could work their way through training and be selected for Officers Candidate School ("Ninety-Day Wonders"). Thus, military necessities generated for some the social mobility and respect that gave them a leg up in the world.

 

While such opportunities occurred somewhat in "The Great War" {The Great Gatsby}, the larger (16 million men in the armed forces) and longer mobilization of WWII with the massive economic and social changes of "The Arsenal of Democracy" led to greater opportunities, experiences, and desire for prosperity. The GI Bill allowed many to access higher education, who previously would not have been able to do so. Better education and careers were sought for their baby-boomer children, as well. The general prosperity, the feel-good of having won the war, being able (with The Marshall Plan) to "rebuild war-torn Europe;" ─all gave confidence, tempered with Cold War concerns and the Space Race (Sputnik, 1957) to drive an urgency for more scientific educations than just a "liberal-arts" major.

 

The electronic revolution springing from transistor development gave rise to the digital era that we have now. It seems natural and easy that all this should be so, yet each step was not so certain. Nor, can the economic revolution of easy credit and credit cards be underestimated. Our family's first Apple IIe computer setup was the price of a used car, when I was in high school many years before, but didn't even have a hard drive.

 

Now, to our time … we have a larger population; with a work population no longer only male and white; that is largely prosperous; with higher educations; many professions attained; persons who are ambitious, clever, and passionate in intellectual pursuits.

 

They possess "devices," and computer programs that easily do work in research and writings retrieval, preservation, collation, writing and revisions, illustrations and graphing, layout and formatting, and distributing such instantly anywhere in the world for correspondence or live audio-visual discussion. What single amanuensis of the past could ever do so many things without fatigue or sustenance?

 

It is easier for me to "tweet" or "Facetime" a like-minded colleague in nearly any area of the world, than it is to write a thank you note to a relative. Indeed, the more "social" the medium, the easier it is, and self-reinforcing, to do it repetitively like B.F. Skinner's pigeons. A form of communication that draws one in. Easier to communicate, or "for the increase & diffusion of knowledge among men" than attending conventions.

 Everyone who wishes to can now self-publish almost instantly on The Internet in a process that saves months, even years of work heretofore. This immediacy and diffusion spreads quickly, and inspires others to do the same.



May, Natalie, Dr. "JC: Drinking From the Firehose – Keeping Up with the Literature. How to stay on top of the Published Literature." February 25, 2015. St. Emlyn's Blog: Journal Club.

 

"for the increase & diffusion of knowledge among men " from the bequest by James Smithson, FRS, of his estate to found what became The Smithsonian Institution.

 
            Sincerely,

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


Tuesday, June 7, 2016

Global definition: Masks are the interface between the rescuer and the patient with failing breathing - when a more technical solution is desired than mouth to mouth expired air resuscitation. {Other adjuncts may be used instead as an interface, but the essence is a mask or device between the patient and his helper.}

 

Anatomic & Physiologic Concepts:

The normal support of the natural upper airway is a dynamic neural balance of tone in soft tissues, pharyngeal dilating muscles, and the sensing of the presence and passage of gasses, liquids, or solids in the aerodigestive tract while appropriately activating protective reflexes in the epiglottis and glottis to prevent contamination of the lungs.

 

The airway is at risk if any of these controls fail and flaccidity occurs or physical blockage by foreign substances occurs. Life is preserved if timely actions are taken to remove obstruction, support an open airway, and support or replace natural breathing.

 

The quickest and simplest effective means of assistance is with the hands and lungs of the first willing rescuer. If it is desired to have an artificial interface (avoiding close personal contact) or to use adjuncts, oxygen, and mechanically control and monitor breathing, a mask is usually the first such used.

 

The layman's simple opening of the airway (for rescue breathing) has an air path that is somewhat zigzag; air does go in and out but the visual path for intubation is not the same. The layman will likely only have head-tilt and chin-lift in a supine patient. You can give more effective bag-breathing and also be prepared for laryngoscopy/intubation by ramping the torso to a 25° to 35° angle (or reverse Trendelenburg's Position) with the ear canal level with the manubrium/sternal notch and the face parallel to the ceiling.

 

This coordinates axes of line of sight and the angle of the glottic vestibule (c.f., K.B. Greenland's two-curve theory); unloads the visceral weight that impedes the diaphragm, thus, increasing functional reserve capacity; and may well minimize silent aspiration of regurgitation. [Frank emesis in an unconscious patient will require tipping the table head-down with aggressive suctioning and mopping of the oropharynx and additional tracheal suctioning to determine if aspiration has occurred.]

 

#1. The worst: The classic errors are placing a pillow under the head of an unconscious person to "make him comfortable" and pressing the mask downwards on the face. The pillow lifts the head flexing the neck and lowering the chin. Pressing the mask downwards further collapses the airway, and rotates the head forward. Soft tissues are squeezed together and obstruct the air flow; airway pressures increase; air more likely is diverted into the stomach; vomiting is likely. Safar's research found "​Flexion of the neck caused complete obstruction in all 80 patients previously studied."

 

#2. Gasp: Overcompensating for an uncorrected partial airway obstruction by bagging harder, faster, without an adequate expiratory interval, will stack breaths (as the lungs don't deflate, before the next breath is forced in). Great harm such as pneumothorax or migration into other spaces may occur. Little true ventilation occurs. Excess volume is diverted into the stomach and vomiting will ensue.

 

#3. Grasp: Excessive pressure using the mask fatigues your hands, makes leaks more difficult to seal, can abrade the corneas, injure facial nerves, and leave bruises in the shape of your hands and the mask in those who are over-anticoagulated.

 

#4. Poor Fit: Choosing (or making do with) the wrong mask size makes controlling leaks more difficult. Some adjustments can be made: sliding the nose of the mask a little farther down; the lower edge can be sealed between the lips; invert the mask to use as a nasal mask while holding the lips shut. A large mask is often easier: spread the mask more widely on the face; or invert the mask using the wide base across the nasion and malar area while cupping the chin by the point of the mask. An oral airway can lengthen the face slightly, while a nasal airway does not.

 

#5. Poof: Not separating the lips blocks outflow. Obstruction by a floppy soft palate acts like a one-way flutter valve that blocks outflow. Sleep breathing would be inspiratory snoring and expiratory poof or sputtering between the lips. Expiratory obstruction occurs when both palatal obstruction and closed lips happen at the same time: this is about 20% occurrence. Keep the lips apart. Drop the chin from the mask during exhalation. An oral or nasal airway solves it. The nasal airway is less likely to "gag" the patient if level of consciousness varies and is more easily tolerated than the oral airway.

 

#6.  Too Tight: Holding the mask too tightly is the reflexive reaction of the panicked and frustrated person. It can cause injury; may worsen mask fit (especially with an overinflated cuff on the mask); and does not examine or fix actual problems. If this carries over to not noticing regurgitation or vomiting and ventilation efforts continue without clearing the airway, disaster follows as the soiling is blown into the trachea and lung.

 

#7.  Too Loose: Persistent defects in sealing the mask to the face cause leaks that deliver ineffective volumes and dilute any oxygen delivered. Novices and persons with small hands may find it difficult to impossible to adjust the mask in several places simultaneously especially with one-hand bagging. Contributory defects of facial contour (wounds, edentulous, cachexia, scarring) may require filling of the defect, a different rescuer, two or more hands on the mask, or bypassing the problem with airway devices.

 

Teeth & Leaks; Dentures should be in place to maintain contour (with caution to prevent damage or swallowing); they are removed to make room for intubation efforts. A soft mask cuff helps if dentures are not available. Cheeks can be plumped out with gauzes or towels (with caution to avoid migration into the glottis or "losing" them. Using a two-hand mask hold, one can cup the cheeks upwards from below with the sides of the hands and "bunch" them into the cuff of the mask; the mask is held by the two thumbs in parallel.

 

Beards: There are two problems with beards when managing the airway.

1). A large bushy beard can cause air leaks and poor seal, especially when compounded with vomitus, blood, etc. The traditional suggestion is to apply surgical lubricant to minimize leaks, although this, too, may be messy. A newer recommendation is to use plastic wrap or an adhesive transparent dressing over the beard, fitted well to the lips and provide an oral slit through which to breathe. This blocks leaks and keeps the mask from slipping. Always remember to bypass this problem by a better interface: a modified nasopharyngeal airway; supraglottic airway; or intubation.
2). Even a tidy beard may conceal the reason for which it might be worn –to disguise a receding chin which may represent a short mandible that can make for difficult intubation, and possibly difficult ventilation if the tongue base is large.

 

The Triple/Quadruple Airway Maneuver:

  1. The head is extended back from a taut neck;
  2. The mouth is opened;
  3. The lower jaw is advanced to place lower teeth in front of the upper teeth. If the head is very heavy, a helper may grasp the jaw with an overhand "skyhook" by a thumb in the mouth and grasping the jaw for additional lift.

    Redundant soft-tissue and bilateral fat pads in the neck (often present in obesity and Obstructive Sleep Apnea) may, under negative pressure, come together and collapse the elliptical shape of the pharynx in the partially obstructed airway, completing the obstruction.
  4. This flaccidity may be overcome by rotating the head and neck ~45° either way to find the better. Reinforce your improvements with an oral airway and two nasal airways; or move to a supraglottic airway or intubation.

     

    Two-Handed Mask-Hold is best: The two-hand variation of the common "C-E" hold works to equalize bilateral support. There can be better cheek-mask seal added to the jaw-lift, but without additional advantages for smaller or weaker hands. The Thenar Eminence method holds the mask with two parallel thumbs and the bases of the thumbs; this lets four fingers of each hand pull the jaws and face into the mask. Small or weak hands may find using 3rd, 4th, 5th fingers to cup and pull forward the ramus of the mandible to bring the lower teeth in front of the upper teeth gives a wider airway.
    It is easier to initiate and maintain the triple airway maneuver with two hands. One hand may maintain this maneuver (so-so) but it's harder to initiate and may not maintain it as well under adverse conditions.

     

    In One-Handed Use, leaks usually occur on the off-side from the hand; at the nasion and corners of the eye; and at the corners of the mouth or chin. Use any malleability of the mask body and cuff to spread and mold its shape to fit the face carefully. Doing so sequentially from the nose to cheeks and to mouth/chin will help. Avoid any gas leak into the eyes or drying and abrasion will occur. If leak persists on the off-side, roll the mask towards the leak to adjust the pressure, and counter any new leak on the palmar side with inward pressure of the hand to the cuff to compensate.

     

    #7. Too much: Breaths given to the patient that are: too large volume; too rapidly given (fast inflation); too rapid in rate (too many BPM); too short expiratory time; are non-physiologic, produce adverse alteration in the patient; and cause stacking of breaths, gastric distention, promote vomiting, cause hypotension, and lead to barotrauma (pneumothorax, gastric rupture, and pneumoperitoneum).

     

    Breath-Stacking: When breaths have been stacked and the patient is hyperinflated, immediately lift the mask or open the circuit for the patient to exhale and deflate. Maintain an open airway for this to happen. If there is expiratory resistance, as from bronchospasm and asthma, apply careful manual pressure to the patient's chest to aid in expiration. Resume ventilations, but allow longer intervals between breaths to allow exhaling. Take active measures (bronchodilators, etc.) to reduce the resistance and the work of breathing.

     

    In truth, very little oxygen is consumed by the body yet it is supplied in profusion by the rescuer. Currently, research on hyperoxia indicates that it is not as innocent and helpful as once thought; moderations in treatment recommendations are evolving.

     

    The reversal of normal chest physiology by positive-pressure ventilation decreases refill of the heart, coronary perfusion, cardiac output, and blood pressure; it's important to minimize adverse effects of what we do.

     

    #8. Not Enough: Breaths should be given in an approximately normal rate, volume, and rhythm, and pressure. Simple normal chest expansion is sufficient; larger breaths will have adverse effects. Use your watch or count intervals to avoid giving too few or too many breaths, but do not force your inflation when the patient is making his own effort; this leads to adverse pressures and volumes.

    Lessen Strain: Avoid imposing additional work of breathing on the patient during his efforts. The patient's strain in struggling to breathe through an inadequate or obstructed airway can produce sufficient negative pressure within the lungs to cause fluid to transude into the alveoli (negative pressure pulmonary edema or post obstructive pulmonary edema).

     

    DSI: If the patient is agitated, avoid a "head-wrestling" contest, and protect from injury. Give essential breaths in-between the patient's efforts to lessen hypoxia. You may need to "blow-by" some oxygen if you cannot ventilate a hypoxic and struggling patient. This is a good time to dissociate the patient with Ketamine to take away the combativeness, allowing oxygenation and ventilation, while still preserving airway reflexes and spontaneous breathing. This can aid in a "Delayed Sequence Intubation" during which the patient is optimized before attempting intubation.  "Another way to think about DSI is as a procedural sedation, the procedure in this case being effective preoxygenation." [Weingart]

     

    #9. Too dirty: Fluids or debris in the oropharynx can partially or completely block airflow; be inhaled or blown (by ventilations) into the glottis or past the vocal cords into the trachea; or irritate the vocal cords to a life-threatening laryngospasm. The awake patient able to cough or clear his own airway should be assisted to do so.

     

    Obtunded patients must have fluids swabbed (own T-shirt, or gauze) or suctioned, and solids removed. Gravity is your friend. A sitting position favors spontaneous ventilation (and easier bag breaths in the obese), but also may keep silent regurgitation in the stomach, and minimize vomiting. Gastric insufflation may burp out this way without soiling. The table or bed should be able to tilt downward immediately into a Trendelenberg's Position to gravity-drain fluids out of the airway and towards your suctioning. (Know how to operate the table.)

    When stable, resume a ventilation-favorable position. Supine, the trachea naturally tracks down ~20-25° from horizontal so any regurgitation is likely to drain into lung. Tracheal suctioning may be needed. Decompress the stomach with a gastric tube. If the suction tubing can be crimped or pinched while moving towards the "pharyngeal puddle" and released when the suction tip is immersed in the fluid, air will already be sucked from the tubing and higher suction applied when opened.

     

    #10. Use adjuncts wisely: A thorough understanding of airway devices is needed for their effective and safe use. Devices can improve the conformation of facial contours; displace interfering tissues; create, or increase, an air passage; access for suctioning; and hook-up to the bag or ventilator. There can be a better overall experience, and steps taken can transition to higher level care such as supraglottic airways that shield the glottis from contamination and can be a conduit for intubation.

     

    #10. How to remember: Studies of anesthetics and resuscitations (hospital) show "difficult {or impossible} mask ventilation" to be a small component of "difficult airway" situations. Acronyms of commonalities in "difficult' mask ventilation are:

     
Mnemonics for   ​DIFFICULT ​MASK​VENTILATION
MOANSBONESBOOTSOBESE
     M=Male    B= Beard     B= Beard     O=Obese
     O= Obese    O=Obstructed/
             Obese/OSA
     O=Obese     B= Bearded
     A=Aged>55    N=No teeth     O=Old Age     E= Elderly
     N=No Teeth    E=Elderly >55     T=Toothless     S= Snorer
     S=Stiff Lungs    S=Stiff lungs/           S=Sounds;                                   E= Edentulous
    Sleep Apnea/ Snores, Stridor,
     Snoring          Stiff Lungs
         (Rales, Wheezes)
©Walls, et al
After Kheterpal.

©Murphy, MF &Walls, RM
2001
Based on Langeron

©Kovacs, G & Law, J. A.
SketchyMedicine.com
Unknown Author: seen here;
Based on Langeron

 

#11. Not Monitoring Clinical Effect: Whenever possible, pulse oximetry and waveform capnography should be in place. Even a colorimetric CO2 detector, in austere circumstances, should be used to detect obstruction or ventilation. Pulse oximetry is limited in being masked by oxygen supplementation and in delay of detecting decreased saturation. The clinician should continuously "look, listen, and feel" for effectiveness of ventilation.

 

#12. Cervical Spine Injury? When neck injury is suspected, caution is urged. Maintaining alignment, avoiding flexion or extension, and using a jaw thrust that juts the lower anterior teeth forward of the upper; it then should be reinforced with an oral airway or supraglottic airway. Endotracheal intubation should be done by those with the experience and tools for doing so with the least neck movement.

 

#13. Why aren't you using an SGA, or ETT? Mask breathing is a transitional and sustaining treatment when breathing efforts are inadequate. If support must persist, the airway should be kept open with an appropriate device. Personnel entrusted with face mask ventilation should also be provided with appropriate devices and skills suitable for longer periods or adverse circumstances.

 

#14. Why are you bagging at all? Humans are not very consistent with bagging. Ventilators are consistent, untiring, adjustable, and monitors itself for performance. They're better at oxygenating and maintaining the patient. Both hands are free if you're holding the mask, or you can prepare for a more definitive airway.

 

#15. Have a PEEP valve! A PEEP (Positive End-Expiratory Pressure) valve holds in part of the last breath given allowing the residual pressure to hold open the airway and alveoli like a partially filled balloon; this aids in oxygen penetration and overcoming shunt physiology.

 

PEEP isn't CPAP without continuous forward flow. CPAP is Continuous Positive Airway Pressure throughout the respiratory cycle. Bag-Valve-Mask units are binary; inflation flow & pressure, and after expiration = zero flow. BVMs vary in how easily a patient can take a spontaneous breath. In the NODESAT method of preoxygenation and apneic oxygenation that additional forward flow is by a nasal cannula at 15+ LPM plus the BVM at 15+ LPM; this is intended to provide a refilling of the "reservoir" effect of the natural dead space so that blood flowing through the lungs can by pressure gradient have oxygen diffuse into the blood stream and allow a longer safe apnea interval.

 

The flow-inflating bags in various anesthesia circuits classified by Mapleson's system can provide CPAP seamlessly with a good face mask seal, adjusting flow, and monitoring or limiting airway pressures by gauge or a pressure limiting valve; however, those not familiar with these tasks feel think it more difficult and are discouraged that it's too hard. If there's no mask leak, there are no problems; just watch the patient, track flow and pressure, and provide exhalation.

#16. The Distressed Patient Hears You. Remember that the "sense of hearing is the last to go." He hears your anxiety; he is comforted by your calming voice directed to him. He may hear what you don't expect or what you hope that he doesn't hear. Speak to him by name, calmly and frequently, to convey assurance and expectation of relief or what is to come. No surprises - for either of you. A soothing voice soothes autonomic change.

 

DIDACTIC CONSIDERATIONS: Studies show that many levels of health care workers perform better bag ventilation when combined with an SGA than when using a mask. Most HCWs, other than anesthesia, emergency, and critical care staff, or paramedics, are obliged to only use a mask, or a mask/OPA ±NPA. Yet, while entrusted to use a BVM —arguably, the most difficult means of artificial respiration, use of an SGA is seldom permitted. Is it not reasonable that those responsible for and entrusted with BVM should likewise be entrusted with an approved SGA?

 

Recall that mouth to mouth and mouth to mask consistently outperform bag ventilation; and have an exquisitely sensitive feedback mechanism: the rescuer's own lungs. However, few individuals will actually apply mouth to mouth outside their own family.

 

Two is better than one: In training sessions, it's probably best to start practice with two-handed mask hold to learn and feel the mechanics of providing a really good airway. A triple or quadruple airway is easily achieved, and eliminating mask leaks is easier. Ideally, practice would occur on live patients or high-fidelity simulator to study the feedback and effectiveness. When this skill is mastered, then the student should learn one-hand masking, after which use of airway adjuncts can be introduced. Controlling the airway is like high-level equitation; the interactions must be continuously sensitive and sympathetic with the response.

Which bag to use?

Those with a professional obligation to rescue, including health care settings, should use a self-refilling bag with approved adjuncts.

Those rescuers and health care workers with high frequency exposure to critical patients (and a relatively inexhaustible supply of oxygen) should also be competent with a flow-inflating bag learned with mentored supervision. The elegant versatility of the anesthesia bag will awaken the provider to many subtleties of mask ventilation. It does many things well, better than a self-inflating bag, but it must be in the hands of a skilled provider. In transport situations and others where the supply of compressed oxygen is limited, not only should a spare tank be available, but a self-refilling BVM, also, so that ambient oxygen can be given if failure occurs.

 

 PDF of Article & References

 

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

 


Monday, April 25, 2016

A Reuters News Service report commenting on the recent "Hartford Consensus" headlines "The Average Bystander Won't Know How to Control Bleeding." This is something that any Boy Scout should know how to do. What has happened?

After World War II, there was a de-emphasis on using tourniquets in the field except as a last resort. Rightly so, for tourniquets are not needed except for rapid massive bleeding, which is seldom encountered in the civilian world. Times have changed, and fortunately, so has the science. Notably, field care and rapid evacuation to forward medical facilities has greatly evolved.

The wars of the Middle East have shown us that the leading cause of avoidable death is exsanguination. Without a sufficient quantity of circulating blood, one dies. If enough remaining blood can be conserved by the patient or his helper, the victim survives. With quick application of an effective tourniquet, the blood stays in. Many "improvised" tourniquets, e.g., belts, scarves, rope, unless applied tightly and secured to stay, will otherwise increase the bleeding.

When there is torrential bleeding, it must be stopped immediately by the patient or others who are there. It's not just "Call 9-1-1!" The "First Responder" is actually the patient or someone already there. For the soldier, it is self-aid, buddy-aid, the Combat Lifesaver in his squad, the Medic in the platoon. With immediate care and prompt evacuation (minutes, instead of the hours or days of yore) and prompt surgical care, they survive.

Having studied the avoidable causes of death, and finding the erstwhile fears of a prolonged tourniquet time in place to be no longer valid, the military has striven that each man has a tested and chosen tourniquet. Victims now survive rapid bleeding if it is stopped. When blood spurts from a large artery with each heartbeat, the body is soon emptied. With such wounds, a tourniquet becomes the FIRST RESORT, not the last resort. Here we give up the usual mantra of "Airway – Breathing – Chest Compressions" and instead keep the hemoglobin from spilling on the ground, as the patient's hearts  are still breathing and beating.

Improvised Explosive Devices have come to many places that are not battlefields except in the minds of those who bring them there to assault the enemy in his safest places or homelands. People at the Boston Marathon did not expect a battlefield injury, but they were made victims of battle nonetheless. Survivals occurred because rapid bleeding was stopped immediately with effective tourniquets.

This year's Hartford Consensus (IV) undertook by bilingual telephone survey to sample the knowledge and willingness of the public to successfully intervene against bleeding. Only 47% had any first aid training; about half had it> 5 years ago; only 13% had training within the last two years. Of those who could give first aid, 92% claimed they would try to help in a car crash, but only 75% would try to help in a mass shooting if it was safe to do so. However, 98% would try to help a family member with a leg wound, but only a third would use a tourniquet.

I said that a Boy Scout should know how to stop bleeding. Indeed, he should, as should a Girl Scout, --or anyone else, for that matter. But how often have people refreshed or practiced what they know, or take advantage of learning it from organizations such as the Red Cross. Kids now, so often overscheduled, or with multiple sports commitments and extra-curricular activities, cannot be assumed to have been trained or to use what they once learned. If accustomed to Internet style learning, the knowledge points and skills may not have been fully mastered into active memory.

Does your department have an outreach public education program or a display in the waiting room from the local training organization?

Does your department even have tourniquets ready to go (without improvising) in case of need for a trauma victim? Or, for you or others, if you become the battlefield and yourselves your own First Responders?

Rapaport, Lisa. The Average Bystander Won't Know How to Control Bleeding. Tuesday, April 19th, 2016 4:58pm EDT. Reuters.

Jacobs, L. M., Burns, K. J., Langer, G.,& de Jonge, C. K. (2016). The Hartford Consensus: A National Survey of the Public Regarding Bleeding Control. Journal of the American College of Surgeons. Online March 31, 2016.

Jacobs Jr, L. M. (2015). The Hartford Consensus III: Implementation of Bleeding Control--If you see something do something. Bulletin of the American College of Surgeons, 100(7), 20. PMID: 26248396.
Republished, by permission, by The Tourniquet Project. (q.v.)

Kellermann, A. L., & Mabry, L. T. C. (2015). Bringing a Battlefield Lesson Home. Academic Emergency Medicine, 22(9), 1093-1095.

Kragh Jr, J. F., O'Neill, M. L., Walters, T. J., Dubick, M. A., Baer, D. G., Wade, C. E., ... & Blackbourne, L. H. (2011). The military emergency tourniquet program's lessons learned with devices and designs. Military medicine, 176(10), 1144-1152.

Lex, Joseph R., MD. Combat Wounds: Vietnam Perspective, from One on the ground. ppt, (Updated, with Iraq, and newer treatments e.g. Tourniquets, Quick Clot, Asherman Chest Seal, etc.) Presented at DevelopingEM 2013. Presentation slides. Presentation audio.

Alam, H. B., Koustova, E., & Rhee, P. (2005). Combat casualty care research: from bench to the battlefield. World journal of surgery, 29(1), S7-S11.

U.S. Army Medical Department Center and School. Department of Combat Medic Training. COMBAT LIFESAVER COURSE: STUDENT SELF-STUDY. The Army Institute for Professional Development.

 

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

 


Monday, March 14, 2016

​We're all aware of the "graying of nursing", and in the population at large of "the Silver Tsunami" as Baby Boomers withdraw themselves from their working years, whether in whole or in part. Many AENPs are in the maturity of their careers having "worked long and hard" to achieve Practitioner status, and are now, just plain, "working long and hard". AENPs, and Nursing, face a critical shortage of the most experienced members. Yet, each decision to leave is an individual calculation. Can I do the work? Do I enjoy it? Can I afford to go? Can I do a different kind of work? Shall I work at something full-time or part-time?

 

We encourage the young'uns, —who were able to enter, early in their careers, the programs that we had to wait to see created; to persevere gaining the experience which makes practice more successful and satisfying.

 

However, I poignantly remember a staff nurse colleague, who left the ED to work in the Post Anesthesia Care Unit, who when pressed for an explanation, said "I just wanted to be able to sit down!" It was true. Our constant succession of shifts were arduous and unrelenting. I wished him luck and envied his gumption in resolving his situation, and resumed work.

 

At times, it seems as if everyone is looking for a "day job," "a better gig," or just "greener grass." Retention of the wise, older, and skillful, —"OK, OK, I'll say it: —grayer", nurse. IS important. We know, among ourselves, that lower nursing ratios are safer and better for both patient and nurse. We want to be able to help them do that. We know that mentoring, leading, counseling, and giving institutional continuity and memory is beneficial to our workplace. Yet, our institutions know not how to do this nor make it feasible.

 

The tyranny of numbers in calculated FTEs or "productive" and "non-productive" hours work against us. In California, bedside nursing had the protective influence of  a state-mandated Staffing Ratio. For EDs, the minimum ratio is 1 nurse: 4 patients. That ratio was not exceeded unless there was a major community event with likely increased patients and disruption. Hallway patients were staffed for during most likely hours. But the admitted patient 'without a bed" could not go upstairs to a lower ratio unit (Tele or ICUs) until a bed there was available, so the patient remained at 1:4, unless tying up the Code Room at 1:1.

 

The only options for respite were to take a leave of absence or accept a lower % appointment: i.e, if working 96-100%, one could not drop to 60% hours without resigning the original, and with no guarantee of ever getting it back if needed. Hours worked also militated against accrual of retirement credit if not full-time. Older staff would have to continue a grueling pace in order to maintain expectation of retirement "on time."

 

One might feel, too, as if there was, perhaps, (am I too paranoid?), perhaps, a benefit to management to replace exhausted older nurses with younger/cheaper nurses just grateful for a job (or two jobs, to pay rent or mortgage, student loans, or travel plans). Out go the Master Nurses, in come the "burger-flippers."  Diluted staff would be filled in with "Travelers", migrants from low-paying states, and foreign recruits or migrants.

 

With aging and graying, most will acquire some combination of lower stamina, sore feet, bad back, vision and hearing changes, bladder problems, slower actions, and problems of short-term recall ("what did I come in here for?"). As these build up, one must modify and overcome workplace difficulties with them, or calculate for oneself what will be the trigger point for changing jobs.

 

If one is in the Provider hole, or Caregiver hole, the hole is not usually changed for an individual. Thus, some may withdraw to academia (depending on degree pressure), go entrepreneur (usually consulting, lecturing, or CE), go commercial in representing someone's product line, or find some grant or project upon whose bandwagon to ride. Much depends on personal and family resources or needs, and how much income or child care one must provide.

 

I've known nurses whose hearing was such that they worried of missing a clue at triage, or of not being able to tell a family what were the patient's last words. Nurses wearing back braces or boots and orthotics to be able to stand a while. Or whose hypertension was increasingly hard to control due to work. On it goes. Everyone, it is said, is carrying some burden. We should help support each other, as we will all get to the same point.

 

I don't know the solutions, but if some can be conceived or found, they should be tried. It's common to endow academic chairs or departments. Perhaps, a way could be found to endow fellowships that reimburse hospitals for so-called "non-productive" hours turned to resourcing directly for nurses and patients in novel ways, without losing work and retirement benefits. 50[50 or 75/25 ratios of direct care and other work to ease the physical burden yet enrich the environment of care. It might be a hard sell: it's hard to put a bronze plaque on a working person!

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

 

About the Author

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