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Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.
Tuesday, April 22, 2014

In the last blog entry, I expressed my belief that the Venti-Breather® was perhaps the commercial version of the Roswell Park Rescue Breathing Mask (sic) designed by James O. Elam. I was wrong. I worked from a contemporary faulty memory. The reference that I had ordered arrived well after the posting.

 

In the chapter “Insufflation Methods with Simple Equipment” written by Dr. Elam in the book Artificial Respiration Theory and Applications by Fifteen Authors, edited by James L. Whittenberger, M.D., Elam describes and illustrates the differences between the two devices (which, in fact, are quite similar but for the design of the valve).

 

The Venti-Breather® has a spring-loaded diving-bell shaped occluder that opens under positive pressure for rescue breaths, then pops up to permit exhalation or spontaneous breaths through the expiratory port.

 

The Roswell Park Pocket Mask has but one moving part in its dog-legged blow-pipe: a delicately balanced weighted ball that moves aside for positive pressure to let air in or to pass outwards.

 

Elam’s references include:

"1. Elam, J. O. Rescue Breathing with the Roswell Park Pocket Mask, The Roswell Park Handbook for Training in Rescue Breathing. Buffalo. Health Research Press, 1959."

which could seem most likely to be the product insert for the device.

 

I also referred to Gordon’s device as the Gordon Airway; Elam, also a colleague of Gordon calls it the Gordon Rescue Breather, although Bauer also calls it “the Gordon airway.”

There are several relevant illustrations to be seen in the book, which, unfortunately, is out of print. It is an exceptional reference for its era, and is often cited by others. I cannot reproduce the illustrations here, but it is definitely worth going out of your way to read.

Artificial Respiration Theory and Applications by Fifteen Authors, edited by James L. Whittenberger, M.D. ©Hoeber Medical Division, Harper & Row, Publishers, Incorporated. New York.
Library of Congress Catalog card number: 62-18205

 

Bauer, Robert O. Emergency Airway, Ventilation, and Cardiac Resuscitation

Anesth Prog. 1967 November; 14(9): 236–249. PMCID: PMC2235452

 

Sincerely,

 

Tom Trimble, RN CEN

 

All opinions are those of the author.


Tuesday, April 08, 2014

From the early 1950s to the early 1960s, validation by researchers such as James O. Elam, Archer Gordon, and Peter Safar, occurred:

·       of the efficacy of expired as a resuscitating gas

·       that manual methods of artificial respiration were ineffective with no attention to airway patency and generating tidal volumes less than dead air space {and relied on tissue elasticity in a deteriorating corpse}

·       that mouth-to-mouth or mouth-to-nose positive pressure methods successfully ventilated the lungs with 1 to 2 liters of gas

·       that the natural airway could be opened and maintained with simple maneuvers, as used in anesthesia, and that these maneuvers could be taught to lay public and public service rescuers

·       that through incremental steps of scientific and public acceptance could be made the basis of a modern system of rescue breathing suitable for world-wide use (subsequently to be combined with external cardiac compression to form a system of cardiopulmonary resuscitation).

 

Work was also done to develop a means of coupling military gas masks to allow one soldier to aid another overcome by chemical, biological, or nuclear warfare.  –It is a curious paradox of history that Nerve Gas was the product of agricultural research by the burgeoning chemical industry in Germany in the latter 19th and early 20th centuries, and that modern understanding of resuscitation came from WWII military investigations (Edgar A. Pask) into drowning and funded early Cold War research into protection from Nerve Gas, that sprouted the saving of thousands of lives.

 

Having established mouth-to-mouth as the only effective artificial respiration (and the only that provided breath-to-breath attention to and feedback from the airway) instantly available wherever there is a living helper, the difficulty is in persuading the public to be willing to go lips-to-face of a dying stranger.

 

Let's look at the early expired air resuscitation adjuncts!

Gordon Airway; Brook Airway; Safar-type S-tube
Click for larger image

©Allen Press, by kind permission, from Bauer, R.O.
[L->R: Gordon Airway; Brook Airway; Safar-type S-Tube
uncertain manufacture, probable reversed & fused black-
rubber oral airways; plastic Safar-type, unknown manufacture.

As the patent application for the Safar S-Tube states:

"the average person has a natural instinctive aversion to placing his mouth over that of the patient. The idea of placing one's mouth on the mouth of an apparently dead victim, particularly where the mouth may be covered with foam, mucus or blood, as often the case in asphyxia victims, as well as the fear of possible transmittal of disease is revolting to the average person and is difficult to overcome."

 

Thus, it is natural that thoughts turned to airway devices that could serve as a less interpersonal interface. As an anesthesiologist, Safar was familiar with oral airways in metal and rubber; he devised one with an oral blowpipe, then was advised to reverse two sizes of OPA by Dr Austen Lamont (who wished no credit; this was revealed in a tribute forty years later), and subsequently patented by Safar with Captain MC McMahon, of Baltimore Fire Department. Captain McMahon later claimed that "The S-shaped tube that Johnson & Johnson puts out as the Resuscitube is the offspring of my brain child to make mouth-to-mouth more acceptable in the emergency field."(sic)

Safar S-Tubes, unknown variant, Berman Airway
Click for larger image
©Tom Trimble, RN CEN, from Author's Collection.
[L->R: Johnson & Johnson commercial version of adult/child & pediatric
Safar S-tubes; middle: S-Tube of unknown manufacture of 2 OPAs conjoined with a plastic flange allowing use in either mode; right: comparison Berman airway, 100mm. Note grommet in plastic bag for hanging on emergency cart, etc.

Author used adult Resuscitube in 1971 to save life of apneic comatose patient overdosed on Secobarbital.

 

There was concern at the time as to the potential from lay public using pharyngeal length airways and causing injury. Safar's Resuscitube is only 90 mm on its greater curvature. Gordon's Airway is just an interdental bite block with a flange and mouthpiece without valve.

 

The Brook Airway, the only significant competitor to J&J's Resuscitube, has additional design features: a short-length glossal curvature; a flexible cuffed flange with nasal cut-out; a flexible shaft enclosing a fish-mouth valve, and diversionary expiratory exhaust.

 

James O. Elam was an early researcher ─whose practical experience began in 1946 with an outbreak of Polio in Minnesota by spontaneously and instinctively using mouth-to-mouth on victims when no iron lung was available; and who later recruited Archer Gordon and Peter Safar to the resuscitation research field. He did resuscitation research for the Army in the 1940s and 1950s that was published much later, and encouraged researches with Gordon and Safar that in combination accomplished acceptance for what he called "Rescue Breathing."

 

My recollection (which is now difficult to confirm) is that he designed or was associated with what commercially was known as Venti-Breather®. He is known to have designed a pocket mask, but Safar thought it never came to market. I believe that  the “Roswell Park Rescue Breathing Mask” may have been the same device (he had worked at Roswell Park Memorial Institute). The Venti-Breather® was a shaped flattened plastic mask with a short blow-pipe with an expiratory diversion valve to the side of the blowpipe. (c.f., ebay listing in bibliography for images) Neither it, nor the Gordon Airway, seem to have done well on the market, when compared with Resuscitube or Brook Airway and are rarely seen.


 

Bauer, Robert O. Emergency Airway, Ventilation, and Cardiac Resuscitation

Anesth Prog. 1967 November; 14(9): 236–249. PMCID: PMC2235452

** Co-author, at times, with Elam. Photo from which, by kind permission of Allen Press, shown above of early mouth-to-airway devices. Probably only Internet-accessible extant photo of the Gordon Airway.

O’Donnell, C. P. F., Gibson, A. T., & Davis, P. G. (2006). Pinching, electrocution, ravens’ beaks, and positive pressure ventilation: a brief history of neonatal resuscitation. Archives of Disease in Childhood-Fetal and Neonatal Edition, 91(5), F369-F373.
**Review of old methods for resuscitating babies.

 

Tercier, J. (2002). The lips of the dead and the ‘kiss of life’: the contemporary deathbed and the aesthetic of CPR. Journal of historical sociology, 15(3), 283-327. DOI: 10.1111/1467-6443.00180
**45 pp, cultural aspects of avoidance of mouth-to-mouth.

Waters, R. M., & Bennett, J. H. (1936). Artificial Respiration: Comparison of Manual Maneuvers.*. Anesthesia & Analgesia, 15(3), 151-156.
**Review of prominent manual methods before WWII that would persist until 1950s; no discussion of mouth-to-mouth. Waters was a "giant" in American Anesthesiology.

 

Brooks, CJ Dr. Chapter 9B – All You Need to Know About

Life Jackets: A Tribute to Edgar Pask Survival Systems Ltd.

Dartmouth, Nova Scotia
**Interesting report on life jackets and Pask's research.

 

Enever, G. (2005) Resuscitation Greats: Edgar Alexander Paska hero of resuscitation Resuscitation, 67(1), 7-11.
**Tribute to WWII RAF research into drowning, life jackets, and artificial respiration.

 

LeFanu, James (1997) Hero who put himself through hell The Sunday Telegraph 16 February 1997
**Blog recounting Pask's intrepidity and personal experimentation.

 

Writer, D. (2004). Sir Edward Sharpey-Schafer and his simple and efficient method of performing artificial respiration. Resuscitation, 61(2), 113-116.
**The work and personality of Schafer, whose method was used until the post WWII era.

 

Comroe, Jr. J.H. "Retrospectroscope. ". . . In Comes the Good Air".
Part I: Rise and Fall of the Schafer Method'
, American Review of Respiratory Disease, Vol. 119 (1979), 803-09

**These three articles are not to be missed. The history of learning to reject manual methods for mouth-to-mouth.

Comroe, Jr. J.H. "Retrospectroscope."  "…In Comes the Good Air" Part II: Mouth-to-Mouth Method. American Review of Respiratory Disease, Vol. 119 (1979), 1025-1031

**As above.

Comroe Jr, J.H. (1979). "Retrospectroscope."... In comes the good air." Part III. There will always be an England. American Review of Respiratory Disease, 120(2), Vol 120 (1979) 457-460
**As above. Was it Schafer in the photograph?

 

Safar-McMahon S-Tube Patent US3013554.pdf
http://patentimages.storage.googleapis.com/pdfs/US3013554.pdf

**Patent and description of the S-Tube.

 

Resuscitation of the Unconscious Victim, a Manual for Rescue Breathing. By Peter Safar, M.D. Chief, Department of Anesthesiology, Baltimore City Hospitals, Asst. Prof. Anesthesiology, Johns Hopkins University School of Medicine, Clinial Associate Professor of Anesthesiology University of Maryland School of Medicine, and Martin C. McMahon, Captain, Baltimore Fire Department Ambulance Service, with 15 illustrations by Colin E. Thompson, Jr. Paper $1.75. Pp. 80. Charles C. Thomas, Publisher, Springfield, Illinois, 1959
{Book Review} Morris, Lucien E. M.D. Anesthesiology: January/February 1960 - Volume 21 - Issue 1 - ppg 125
**Review of the book, which is out of print, but sometimes available. Implementation and care directives for "EMS" mouth-to-airway.

 

Training in Ambulance and Emergency Programs McMahon, Martin C. Captain, Baltimore Fire Department in Training and Education in the Fire Services Proceedings of a Symposium April 8-9, 1970 Conducted by Committee on Fire Research, Division of Engineering, National Research Council

http://goo.gl/8GtL4E

**Claims S-Tube was his "brain child"; reorganization of ambulance services.

 

Rasmussen, Frederick N. Chief Martin McMahon, 94 first-aid pioneer [Obituary] The Baltimore Sun February 13, 2005

 

Safar,P. (1997). Tribute to Dr. Austin Lamont. Anesthesiology, 87(2), 461.

**Safar states Lamont's contribution to S-Tube; personal details of relationship.

 

Lee, W. L., Tarrow, A. B., & Ward, R. J. (1959). Evaluation of a new oral resuscitator for expired-air artificial ventilation. Journal of the American Medical Association, 169(1), 33-35. {Venti-Breather®}

**Review of Venti-Breather®

Safar, P. (2001). {The Resuscitation Greats} James O. Elam MD, 1918–1995. Resuscitation, 50(3), 249-256.
**Tribute of Elam's life in the journal's series "The Resuscitation Greats."

 

Elam, J. O. (1977). Rediscovery of expired air methods for emergency ventilation. In Advances in Cardiopulmonary Resuscitation (pp. 263-265). Springer New York

**Elam recounts hisearliest experiences and research that standardized Expired Air Resuscitation.

Elam, J. O., Brown, E. S., & Elder Jr, J. D. (1954). Artificial Respiration by Mouth-to-Mask Method — A Study of the Respiratory Gas Exchange of Paralyzed Patients Ventilated by Operator's Expired Air. New England Journal of Medicine, 250(18), 749-754.

**Landmark paper refuting old beliefs and giving scientific basis for primacy of expired air resuscitation.

SAFAR, P., AGUTO-ESCARRAGA, L. O. U. R. D. E. S., DRAWDY, L., McMAHON, M. C., NORRIS, A. H., & REDDING, J. (1959). The Resuscitation Dilemma*. Anesthesia & Analgesia, 38(5), 394-405.
**Issues in expired air resuscitation; Venti-Breather® is cited in table of volumes delivered.

 

Vintage Rescue Mouth 2 Mouth Breathing Venti-Breather Emergency Kit 1960 Cross ebay.com; accessed 4/7/2014
**Photographs (3) of Venti-Breather® device.

 

Sands Jr, R. P., & Bacon, D. R. (1998). An inventive mind: the career of James O. Elam, MD (1918–1995). Anesthesiology, 88(4), 1107-1112.
**Excellent "life and times" tribute.

 

Sincerely,

 

      Tom Trimble, RN CEN

 

All opinions are those of the author.


Monday, March 24, 2014

The commonplace oropharyngeal airway, often useful and sometimes essential, has had different designs and manufacturers. The most common style is Guedel’s airway, so much so that Arthur Guedel is sometimes erroneously thought to have invented rather than developed the oral airway.

 

The earliest written invention is Hewitt’s airway: at first, a straight wide rubber tube, then curved, with a metal flange for dental and labial separation. Many followed, often metal for sterilization (but risky to teeth and tissues, if there was clenching or seizure), sometimes with nipples for gas insufflation. In fact, I recall using flangeless wire airways that required a tape-pull for withdrawal.

 

Later developments included airways designed for mouth to airway resuscitation. We can cover that next time.

 

Before the modern era, airway management and resuscitation had a fitful history. There are descriptions of tracheotomy in Egypt, 3600 BC, and Alexander the Great is said to have saved a soldier by opening the trachea with his sword tip. At various times, physicians would use metal tubes, catheters, or quills to bring air past the glottis, or open the trachea to admit a bellows for insufflation. These were for resuscitation with dismal but occasionally successful results, but modern understanding was lacking. Avicenna, ~1000 AD, writes upon intubation to rescue, but the first intubation for surgical anesthesia was by Macewen in 1878.

 

Management of anesthesia via natural airway (“rag & bottle” ether or chloroform) had sudden deaths due to dosing errors, indifferent administration, and poor airway management. Reading those accounts shows a hit and miss proposition.

 

What we call the Triple Airway Maneuver (neck straightening, head extension, lifting the jaw into an open-mouthed prognathic position with the lower teeth (& jaw) advanced anterior to the maxillary teeth) was a great step, probably developed in several areas at first (in different combinations) attributed to Esmarch, then Heiberg, then Little, then Clover in the 1860s.

 

Pulling the tongue forward, perhaps with pliers, some bite-sticks, and gags had to suffice until Hewitt’s 1908 invention. Then came more anatomic curvature, teeth-protecting bumpers, gas nipples, and then Guedel’s terse description of a oval tube with metal bite guard, and flange to keep position above the lips. Things have remained so with changes in material to plastics, and other styles to avoid blockage, or to facilitate intubation.

 

Please explore the links provided for greater detail and interest.

 

Hewitt, F. (1908). AN ARTIFICIAL" AIR-WAY" FOR USE DURING ANÆSTHETISATION. The Lancet, 171(4407), 490-491.  doi:10.1016/S0140-6736(00)66510-8

 

Haridas, R.P. HISTORICAL NOTE: The Hewitt airway – the first known artificial oral ‘air-way’ 101 years since its description  Anaesthesia, 2009, 64, pages 435–438 doi:10.1111/j.1365-2044.2008.05755.x

 

McIntyre, John W. R. s Oropharyngeal and nasopharyngeal airways: I (1880–1995)

Canadian Journal of Anaesthesia June 1996, Volume 43, Issue 6, pp 629-635

 

Defalque, Ray J. M.D.; Wright, Amos J. M.L.S. Who Invented the “Jaw Thrust”? Anesthesiology:

December 2003 - Volume 99 - Issue 6 - pp 1463-1464 Correspondence

 

Baker, A. Barrington  ARTIFICIAL RESPIRATION, THE HISTORY OF AN IDEA Artificial respiration, the history of an idea. Med Hist. 1971 Oct;15(4):336-51 PMID: 4944603

 

Resuscitation: An historical perspective (A catalogue of an exhibit at the annual meeting of the American Society of Anesthesiologists in San Francisco, October 11-13, 1976). Conserved at Wood Library Museum of American Society of Anesthesiologists.

 

Trubuhovich, R. V. (2005). History of mouth-to-mouth rescue breathing. Part 1. Critical Care and Resuscitation, 7(3), 250.

 

Trubuhovich, R. V. (2006). History of mouth-to-mouth rescue breathing. Part 2: the 18th century. Critical Care and Resuscitation, 8(2), 157.

 

Trubuhovich, R. V. (2007). History of mouth-to-mouth ventilation. Part 3: the 19th to mid-20th centuries and “rediscovery”. Critical Care and Resuscitation, 9(2), 221.

 

Greenberg, R. (2002). Facemask, nasal, and oral airway devices. Anesthesiology Clinics of North America, 20(4), 833-861.  doi: 10.1016/S0889-8537(02)00049-4

 

Snow J. On the cause and prevention of death from chloroform, 1852. Wood Library Museum American Society of Anesthesiologists

 

Brandt, L. (1987). The first reported oral intubation of the human trachea. Anesthesia & Analgesia, 66(11), 1198-1199.

 

Sincerely,

 

Tom Trimble, RN CEN

 

All opinions are solely those of the author.

Monday, March 03, 2014

On FaceBook, my niece, who is also an Emergency Nurse, shared a link, “Extrordinary” about our specialty by another Emergency Nurse:  <http://ourfrontdoorblog.wordpress.com/2014/02/25/extraordinary/>.

 

There have been many attempts to describe the occupations and outlook involved in emergency care as a chosen specialty. None is perfect. This has done better than many, and is well worth a read. It reminds one what a privilege it is to practice our trade within this field and as a profession.

 

There are newer and more occupations within the healthcare field than when the classic descriptions of Profession were developed in the middle ages. The classic three were Divinity, Medicine, and Law.

 

Defining characteristics included long study (latterly, academic) of specialized knowledge; self-regulation and control of entry to the profession (as like a guild) although in modern eras it is increasingly modified by statutory regulation albeit with input from the professions; and access to guilty knowledge (that being the client’s secrets in relationship to God, his health practices, and crimes vs the law) which are held in confidence to better guide the client and the intercessory role of the professional mandates an organized ethical basis.

 

If these seem reminiscent of us, it is because we, too, are professionals within the compass of these characteristics, our status, and our relationship with patients –and each patient relationship springs from the trust and respect they accord us as an act of faith. Thus, the newer degrees (e.g., DNP) and specializations derive from an honored and classical precedent rooted in a basis of caring for the patient’s welfare.

 

These musings reflect upon how we came upon our professional basis, but do not typify the emergency nature of the work we do. When people ask us “what’s it like in Emergency?” they seek anecdotal examples. Such an anthology would illuminate a facet, but not define the whole. “Sampling error” occurs, as with the blind men examining and describing an elephant. Each event is different; each memory is individual; each response though scientifically based, even on a humanist basis, is individualized. There is “selection bias” in what to recall, the mood in which one holds it, and in what one chooses as worthy or instructive to share and leaving out those that “We’ll never tell them.

 

How then to describe what we encounter, what we do, and how we deal with it? Inevitably, in bits and pieces; yet conscious of how random the presentation is, and how each is an individual (and his family), and of the needed human connection to inspire coping. This necessitates our acceptance of clinical fact, utter pragmatism in seeking a better solution, and an ongoing gratitude for the blessings of our own lives.

 

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


Tuesday, February 18, 2014

,The highest development of emergency medicine is now. We benefit ourselves and our patients with organization and technological advances that were undreamt of in past eras. Each revolutionary development grows and evolves into more than its beginning. In the whirl of every day coping, we sometimes forget how far we’ve come. Let’s review some developments. [From time to time we will review past and present milestones.]

 

In my opinion, at present, the key ongoing revolution in emergency medicine is bedside ultrasound. From the early days of FAST, to the present ability to estimate vena cava filling, find and verify peripheral and central access, sliding lung, heart motion, even aortic dissection, etc. The powerful imaging modalities of CT and MRI have been with us for a generation and are increasingly adjacent or en suite with the ED. Bedside Sonography gives the emergency clinician trained in its use immediate data for clinical decisions and the god-like power to see pathology in action within the body.

 

The art of surgical diagnosis used to be by "laying on of hands", and it was felt that unless there was a “negative appendectomy rate,” that one was not operating often enough and would miss cases that should have been operated. Now, the expectation voiced is “get the scan and then I’ll come see him.”

When was the last time that you did a Diagnostic Peritoneal Lavage?

 

Also, in my opinion, the other key ongoing revolution in emergency medicine is alternative laryngoscopy for intubation (usually optical or video). Far from the days of waiting for “Anesthesia” to get free from an operating room to come down and intubate one’s patient, emergency clinicians now manage airways previously thought impossible, or that would have necessitated cricothyrotomy or tracheotomy.

 

Some argue that videolaryngoscopy should be primary and always used; others still assert the simpler technology of direct laryngoscopy is vital and versatile; clearly both are needed, yet the virtual ability to put one’s eyeball around the curve and see where the tube is going, or verify tracheal rings or carina has given us great power.

 

ACEP on Ultrasound

 

Sincerely,
 
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.

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