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

Monday, January 26, 2015

When I was a Paramedic, there were two bêtes-noirs (black beast) calls that I did not wish to encounter. The first would be a birth upon the third floor up, with a prolapsed cord, as maintaining displacement pressure and carrying the stretcher on the stairs would be so awkward. The other, not discussed today, would have been to be confronted with an absolute need for an unavoidable cricothyrotomy, as there was no protocol to do one at all. (Either a Hero, or "the schmuck who used to work here.")


Another crew did have the prolapsed cord case, and resolved the issue by carrying Mom's stretcher down the stairs head-first providing steep reverse Trendelenburg's position (not clear if genupectoral position was used) to take pressure off the cord. All went well. Not in the textbook, but it worked.


Usually, in the ED, the simple and great goal is to get the parturient upstairs to OB-GYN, if you have one, as soon as possible. Sometimes, you can't just get away with a smile, wave, and hearty “Good Luck!” spoken.


Always, the concern is that not just one patient is being treated, but two. Whether, the problem is chronic or incidental disease or a trauma in a gravid patient; a complication of the pregnancy; morphological changes of pregnancy that impact the care that you would give for an emergency condition; placental abruption or praevia; fetal demise, or a disaster of the labor,  delivery, or post-partum; --You may be the best available or timeliest provider.


Here, then, are some links for Third Trimester Emergencies. Keep your ultrasound handy. Verify your own laws and protocols for your practice before instituting change. Understand the application of the EMTALA law (Emergency Medical Treatment and Active Labor Act [USA]) to your situation. Know and mobilize your resources and referral centers that might send a team.


Montefiore & NYMC Phelps Family Medicine Residents have some obstetric presentations for you.


Management of Cord Prolapse & Shoulder Dystocia [ppt] Eliza Rivera-Mitu, RN, MSN


Cord Prolapse - Perinatal Services British Columbia [pdf]


Umbilical cord prolapse A plan for an ob emergency

By Sharon T. Phelan MD, Bradley D. Holbrook MD September 01, 2013


Umbilical Cord Prolapse and Other Cord Emergencies Marybeth Lore, MD


Complications of Labor and Delivery by Jeanie Ward


Pulmonary Embolism: Evaluation in the pregnant patient. (2014) Emergency Care Institute, New South Wales.


Gist, R. S., Stafford, I. P., Leibowitz, A. B., & Beilin, Y. (2009). Amniotic fluid embolism. Anesthesia & Analgesia, 108(5), 1599-1602.


Third Trimester Bleeding [ppt] Scott Ramshur, MD


Third trimester bleeding [ppt] Tom Archer, MD MBA UCSD Anesthesiology


Kinney-Ham, L., Nguyen, H. B., Steele, R., & Walters, E. L. (2011). Acute aortic dissection in third trimester pregnancy without risk factors. Western Journal of Emergency Medicine, 12(4), 571.


Western Journal of Emergency Medicine, Vol 15 Issue 6 has five articles related to pregnancy.



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


Mhyre, J. M., & Healy, D. (2011). The unanticipated difficult intubation in obstetrics. Anesthesia & Analgesia, 112(3), 648-652.


California Maternal Quality Care Collaborative. Preeclampsia/ Eclampsia - Emergency Department Resources.  {3 abstracts}


Luckett-Gatopoulos, S. (2014) Tiny Tip: PRE-eclampsia.


Nickson, C. Postpartum Emergencies. Life in the Fast Lane.


Egan, D. J., Bisanzo, M. C., & Hutson, H. (2009). Emergency department evaluation and management of peripartum cardiomyopathy. The Journal of emergency medicine, 36(2), 141-147.


Shaikh, N. (2010). An obstetric emergency called peripartum cardiomyopathy!. Journal of Emergencies, Trauma and Shock, 3(1), 39.


Capriola, M. (2013). Peripartum cardiomyopathy: a review. International journal of women's health, 5, 1.


Fett, J. D. (2014). Peripartum cardiomyopathy: A puzzle closer to solution. World journal of cardiology, 6(3), 87.


Jeejeebhoy, F. M., & Morrison, L. J. (2013). Maternal cardiac arrest: a practical and comprehensive review. Emergency medicine international, 2013.


Dijkman A, Huisman C, Smit M, Schutte J, Zwart J, van Roosmalen J, Oepkes D. Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training? BJOG 2010;117:282–287.


Weingart, S., MD (reviewing presentation of Salil Bhandari; article link, videos, related links) EMCrit Conference Blast Winner: Peri-Mortem C-Section .


Reid, C (2011) Prehospital resuscitative hysterotomy op.cit.


Roe III, EJ, MD, MBA, FACEP, FAAEM, MSF, CPE. Perimortem Cesarean Delivery. (2014)


Sullivan, MG (2007) Time Is Critical for Success in Perimortem C-Section ACEP News.


Status Asthmaticus in Pregnancy from Life in the Fast Lane Literature Review by Dr Chris Nickson


     NEW Link added after initial posting of blog.
Geoff Jara-Almonte, MD and Hilary Fairbrother, MD  // Editor: Alex Koyfman, MD Resuscitation of the Pregnant Trauma Patient – Pearls and Pitfalls 2/6/2025


Desjardins, G. (2005). Management of the injured pregnant patient. Trauma. org.


Hill, CC. (2009) Trauma in the Obstetrical Patient.


Schwaitzberg, SD. (2013) Trauma and Pregnancy.


Roemer, B., et al. (2014) Trauma in the Obstetric Patient: A Bedside Tool. American College of Emergency Physicians.


Beauchamp, Luanna, MD FACOG (no date) Trauma in the Pregnant Female. [ppt] Eastern Idaho Regional Medical Center.


Kapadia, S., & Parmar, K. (2014). Antepartum Intrauterine Foetal Deaths In Third Trimester At A Tertiary Care Center. Emergency, 129, 80-1.


Fatima, U., Sherwani, R., Khan, T., & Zaheer, S. (2014). Foetal Autopsy-Categories and Causes of Death. Journal of clinical and diagnostic research: JCDR, 8(10), FC05.


Long, long ago, an Instructor gave the blithe and authoritative injunction to not worry about childbirth: "It's easy. It's just like catching a football." To this all-too-free assurance, there could only be one reply: "I've never seen a football come at me feet-first, or with a cord wrapped around its neck!"


Good Luck!


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

Thursday, December 18, 2014

Mankind seems to like making lists. Grocery and to-do lists; “Lists of Ten” in the books “for Dummies” series; various “books of lists.” Moses and God had a discussion that was rendered as a list of Ten Commandments. Many professions impart important rules as “Ten Commandments.” Jokes about physicians and God aspiring to each other’s job, aside, there seem to be a quantity of “Lists of Ten.”


It is not only common in Medicine (remembering that Divinity, Medicine, and Law were the classic doctoral professions), the form occurs in many fields when someone wishes to convey a declarative, injunctive, pronunciamento on essential matters, often borrowing the literary tones of English from the King James Bible to add gravitas.


Here are some useful and informative commandments from many fields: ours; allied fields; those that are helpful with other committees or responsibilities; are socially practical; and may help cope with regulatory compliance and challenges by law.


All are links, therefore minimal citations are made. Chosen from available material, some links may seem to be odd choices, but give insight into the work of others, or may be a springboard for thought. All knowledge is useful, if carefully selected and applied correctly.


Effort has been made to stick to “Ten Commandments” sources, with few exceptions. As always, assure for yourself whether they are currently valid, appropriate, permitted, and safe for your practice.





Emergency Medicine

The Ten Commandments of Emergency Medicine

Wrenn, K., & Slovis, C. M. (1991). The ten commandments of emergency medicine. Annals of emergency medicine, 20(10), 1146-1147.




Advice to New Interns

(Commentary upon 10 Commandments of EM)


Ten Commandments of Emergency Medicine


Luke & Cusack

Cork Emergency Medicine 2014


The Derriford twelve commandments of emergency medicine: a model for good practice in a changing world, or a survival guide for new medical staff

Smith, J. E., Higginson, I., Guly, H. R., Grant, I. C., Belsham, P., Hicks, A., ... & Boon, D. (2008). The Derriford twelve commandments of emergency medicine: a model for good practice in a changing world, or a survival guide for new medical staff. Emergency Medicine Journal, 25(12), 824-826.




The Ten Commandments of Medical Emergency Management for Dentists


Pediatric Emergency Medicines

Ten Commandments of Pediatric Emergency Medicine

Givens T. The Ten Commandments of Pediatric Emergency Medicine. J Emerg Med. 2004 Aug;27(2):193-4. PubMed PMID: 15261366.



What are the ten new commandments in severe polytrauma management?
Kam, C. W., Lai, C. H., Lam, S. K., So, F. L., Lau, C. L., & Cheung, K. H. (2010). What are the ten new
commandments in severe polytrauma management. World J Emerg Med, 1(2), 85-92.`




The „10 commandments“ of pediatric trauma

[07. Kinder und Jugendliche im Schockraum]
(English & German)

Dr. med. Ruth Löllgen, OÄ, Notfallzentrum für Kinder und Jugendliche




Electrocardiography Pitfalls and Artifacts: The 10 Commandments

Baranchuk, A., Shaw, C., Alanazi, H., Campbell, D., Bally, K., Redfearn, D. P., … & Abdollah, H. (2009). Electrocardiography pitfalls and artifacts: the 10 commandments. Critical care nurse, 29(1), 67-73.




The Ten Commandments of Wound Management

Ernst, A., Herzog, M., & Seidl, R. O. (2006). Head and Neck Trauma: An Interdisciplinary Approach. Thieme.




Ten commandments of burn management

Gupta J L. Ten commandments of burn management. Indian J Burns 2012;20:7-10




Transfusion ten commandments



The Ten Commandments of Airway Management

Slovis, C. M. (2005). Simple lessons to guide oxygenation & ventilation. JEMS.


Primary Care

10 commandments of primary care


Urgent Care

Deconstructing the Ten Commandments of Urgent Care Medicine



Vascular Emergency

The ‘Ten Commandments’ for European Society of Cardiology Guidelines on Aortic Diseases




The Ten Commandments of Good Psychiatry: Perspectives of a Fundamentalist Psychiatrist




Calming agitation with words, not drugs: 10 commandments for safety




Stress Aversion: 10 Commandments of Stress Avoidance for Working Moms




The 10 Commandments of Patient Engagement




Ten Commandments the Hearing Impaired Wish You Knew




The Ten Commandments of Communicating with People With Disabilities




The Ten Commandments Of Interacting With People With Mental Health Disabilities




Ten Commandments of Communicating about people with Intellectual Disabilities




Ten Commandments for Parents of Special Needs Children




10 Commandments of Good Parenting




10 Commandments of Dysfunctional Families


How they become that way


The 10 Commandments for Delivering Bad News


Workplace Human



Ten Commandments for the Care of Terminally Ill Patients




10 Commandments of Great Customer Service




10 Commandments for Hospitalists


An Oncologist’s view of patient needs when the patient is a caregiver.


10 Commandments for Nurses



Clinical Decision Support

The ten commandments of laboratory testing for emergency physicians

Lippi, G., Cervellin, G., & Plebani, M. (2014). The ten commandments of laboratory testing for emergency physicians. Clinical Chemistry and Laboratory Medicine, 52(2), 183-187.




Teaching in accident and emergency medicine: 10 commandments of accident and emergency radiology.

Touquet, R., Driscoll, P., & Nicholson, D. (1995). Teaching in accident and emergency medicine: 10 commandments of accident and emergency radiology. BMJ: British Medical Journal, 310(6980), 642.




“The Ten Commandments” for the Use of Iodinated Contrast Media




Ten Commandments to Reduce Cognitive Errors




Ten Commandments to Reduce Diagnostic Errors




Commandments to reduce cognitive and diagnostic errors


Blog adaptation of above two items.


Presentation ten most famous medical mistakes





Ten commandments for implementing clinical information systems




Ten Commandments for Effective Clinical Decision Support:

Making the Practice of Evidence-based Medicine a Reality



Risk Mgmt.

10 Commandments of Risk Management


(Camp Operations)


THE "20 Commandments" of EMTALA




Ten Commandments For Malpractice Depositions




The Top Ten Ways to Ensure Frustration, Miscommunication, and Poor Patient Care the Next Time You Provide (or Request) a Consult

[N.B. This is one of 15 articles in the same pdf relating to legal risks of consultations in the E.D.]


Patient Safety

Ten Patient Safety Commandments

A Health System’s view of patients helping their own safety.


The Ten Commandments of Emergency Care Research (p59 ff)


Mass Casualty

Management of Conventional Mass Casualty Incidents: Ten Commandments for Hospital Planning
Lynn, M., Gurr, D., Memon, A., & Kaliff, J. (2006). Management of conventional mass casualty incidents: ten commandments for hospital planning. Journal of burn care & research, 27(5), 649-658.



The 10 Commandments of Emergency Management (Opinion)



Psychosocial Response to Mass Casualty Terrorism: Guidelines for Physicians

(Not a Ten Commandments)



"Ten Commandments of Security and Law Enforcement" or "The Ten Deadly Sins."

Personal Security at Operational Level


The 10 Commandments of Preparedness

“Prepper” Philosophy


Ten Commandments of Emergency Preparedness Training

Trainer’s Tips for Training


Crisis and Critical Risk Communication

CDC guide for public messages & spokespersons


Crisis Management's 10 Critical Commandments


Explaining to the Public


Ten Commandments for using SMS in natural disasters

Text Alert Programs


Ten Commandments of security design



Top Ten Government Healthcare IT Security Commandments




Black Hat 2014: The 10 Commandments of Modern Cybersecurity




The ‘Ten Commandments’ of hospital design





The 10 Commandments For The OHS Person



The 10 Commandments of Safety for Supervisors


(Electrical Industry)


The 10 commandments of workplace safety



The Ten commandments of Safety Stop Taking Avoidable Risks - NOAA

(Detailed ppt for formal accident prevention program)


The 10 Commandments of Workplace Wellbeing Practitioners


Outdoor & Occupational


Ten Commandments of First Aid For Divers - First Aid for Diving Emergencies - Does the Diagnosis Matter?



Bush Survival 10 Commandments




10 Commandments of Avalanche Safety – Bruce Tremper




The Ten Commandments of Tractor Safety




The 10 Commandments of Event Safety



The Ten Commandments of Goal Setting



Ten Commandments for Implementing Change




The 10 Commandments of Steve Jobs [Infographic]




Quality Corner--Part 4: The 10 Commandments of Quality EMS



The Other Ten Commandments  10 Simple Steps to EMS Success



Fire Service

10 Commandments of Fire Safety




The Fire Department PIO Ten Commandments




10 Commandments Of Awesome Hot Chocolate




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

Friday, November 21, 2014

Unfortunately, most people learn most of what they think they know about firearms usage, ballistics, and gun handling from the entertainment industries. When stories are devised for entertainment, errors, or lies, are tolerated for “dramatic effect” and greater profits in a very competitive high-stakes industry with ever-evolving demands for yet more “cool” and bigger bang explosions. Truth, good sense, and science have nothing to do it with it.


True cowboys carried five rounds in their simple six-shooter for safety; the TV cowboys of our youth fired many more without reloading. The stunt man who is “shot” has a wired harness to yank him backwards off his feet. There’s no such thing as a handgun that is not detectable at the airport. Silencers don’t.  You can’t dance away from bullets as in Matrix, nor outrun an explosion.


All firearms-related events must be explained by laws of physics, mechanical and chemical engineering, and variables such as climatic effects and altitude, misadventure, human anatomy, physiology, and psychology. Very few conclusions can be drawn from the impressions of initial exam and treatment.


Because of skin elasticity, and wounding variables, it is not possible from wound appearance to judge the caliber of the missile. With measurements by thousandths of an inch, laboratory examination and measurement is more accurate.


Likewise the small hole is not necessarily the entry, nor is the large wound the exit. A contact wound may have gasses reflected backwards from a hard surface that blows the wound outwards. A round may dissipate its energy within the body and make only a small exit wound or none.


Projectiles do not travel in a straight line, neither in air nor through human tissue. The bullet may take an erratic path within the body as it meets different densities, or even be embolized. Be suspicious and thorough. Check for pulses and vascular insufficiency, or murmur. Sonography/radiography may help localize.


There is a vast difference in wounding effect between handguns and rifles or shotguns. There is no perfect weapon; and stopping a determined or drugged assailant may require many wounds; even wounds which will ultimately be fatal may not slow the aggression.


Wounding locations may not be what was initially perceived or stated due to movement during reaction time from detection of danger, response to assault, or delay in noting the ending of the fight. Natural psycho-physiological responses may alter perceptions during the life-threatening event.


It is critically important to document the physical findings in a plain-seeing, plain-speaking, non-judgmental manner that will not color or taint future investigations. In short, describe the simple appearance of wounds and findings, and the body’s response, without any forensic conclusions.


Avoid using wounding holes in clothing or tissue as the start of cutting with shears or incising tissue. Photograph whenever possible. Remember the confusion from JFK’s tracheotomy in the neck wound, and information recorded (or not recorded) in the chart.


Use paper bags, NOT plastic bags, for removed clothing, or to bag hands and feet, due to the “hot-house environment” created within the plastic that will degrade organic matter.

Call investigators and evidence technicians as soon as possible for best preservation and chain-of-custody evidence trail for all possible evidence. One must be prepared to state who had the evidence, when and for how long, and to whom and how it was transferred, at all times.


Recovered projectiles are preferably handled with gloved fingers, rather than toothed forceps that may alter evidentiary striations.


Accurate time entries are important to document.


It is not possible during acute resuscitation or at any time before a complete investigation, or even trial, to know who is innocent, guilty, or what occurred during the altercation. If you think your patient is the perpetrator, he may well be

an innocent, or even an off-duty or undercover officer. Do not compromise your care.


If there is active shooting around you, move, duck, get behind impenetrable cover, and leave by the safest way as soon as possible. Bullets, splinters, secondary missiles, do not discriminate or have a conscience; there is no self-destruct for a projectile in flight –it will not care whom it hits or discern if it was deserved or not. Police officers have poor hit probability, ricochets may occur, suppressive fire may be used (“keep ‘em pinned down”), or even ‘spray and pray.” Being a health care worker does not protect you from fire coming your way.


You are not safer in an area that is posted as a “gun-free zone.” Many potential, and defenseless, victims draw crazy “active killers.” 92% of recent events have occurred in such areas. Regardless, the number of such terror attacks is far less than public perception, is decreasing, and outnumbered by less obvious dangers.


The Eddie Eagle GunSafe® Program, an effective and suitable safety program for young children, is provided by the National Rifle Association, It only promotes safety, not gun use.


Discussion of safety issues have led to safety rules for firearms in different forms  for many years. The most durable and concise modern expression is the Four Rules of Gun Safety by Col. Jeff Cooper, a USMC officer, academician, firearms trainer and expert. Any accidental or negligent shooting is a violation of one or more of these rules.


1. All guns are always loaded. Even if they are not, treat them as if they are.

2. Never let the muzzle cover anything you are not willing to destroy. (For those who insist that this particular gun is unloaded, see Rule 1.)

3. Keep your finger off the trigger till your sights are on the target. This is the Golden Rule. Its violation is directly responsible for about 60 percent of inadvertent discharges.

4. Identify your target, and what is behind it. Never shoot at anything that you have not positively identified,


The Eddie Eagle GunSafe® Program, an effective and suitable safety program for young children, is provided by the National Rifle Association, It only promotes safety, not gun use.


Simple Ballistics
Duke Orthopaedics presents Wheeless' Textbook of Orthopaedics: Gun Shot Wounds
Simple Reviews
Prehospital Care  Blog of medical and trauma care by Orthopaedic Surgeons in an austere environment in association with Society of Military Orthopedic Surgeons

Norouzpour, A., Khoshdel, A. R., Modaghegh, M. H., & Kazemzadeh, G. H. (2013). Prehospital Management of Gunshot Patients at Major Trauma Care Centers: Exploring the Gaps in Patient Care. Trauma Monthly, 18(2), 62.

PMID: 24350154 [PubMed] PMCID: PMC3860682

Tactical Combat Casualty Care (ppt)

Dan S. Mosely, Maj USA MC FS  20 Jun 05

Treatment Reviews

Bruner, D., Gustafson, C. G., & Visintainer, C. (2011). Ballistic injuries in the emergency department. Emergency medicine practice, 13(12), 1-30.

PMID 22232864 EB Medicine: Full text

Motamedi, M. H. K., Ebrahimi, A., & Shams, A. (2013). Current trends in the management of maxillofacial gunshot injuries: a critical review. Annals of Oral & Maxillofacial Surgery, 1(1), 8.

Rohit Shahani, MD, MS, MCh  & Jan David Galla, MD, PhD Penetrating Chest Trauma Treatment & Management  Medscape Updated: Dec 13, 2013

Dicpinigaitis, P. A., Koval, K. J., Tejwani, N. C., & Egol, K. A. (2006). Gunshot wounds to the extremities. BULLETIN-HOSPITAL FOR JOINT DISEASES NEW YORK, 64(3/4), 139.

de Barros Filho, T. E. P., Cristante, A. F., Marcon, R. M., Ono, A., & Bilhar, R. (2014). Gunshot injuries in the spine. Spinal cord. Spinal Cord (2014) 52, 504–510; doi:10.1038/sc.2014.56; published online 29 April 2014

Evolution of Care and Survival

In Medical Triumph, Homicides Fall Despite Soaring Gun Violence

By Gary Fields and Cameron McWhirter.  The Wall Street Journal Updated Dec. 8, 2012 12:12 a.m. ET

Hostile Fire Environments

Murphy’s Law of Combat Operations 
[includes coarse military humor]

Firearms in the Entertainment Industry
Horman, GS. 10 Movie Myths Dispelled “American Rifleman July 16, 2012

Pappalardo, Joe Anatomy of the Perfect (Undead) Headshot  Popular Mechanics website ©2014 Hearst Communication, Inc.

Seymour, Mike The Art of Wire Removal 10/27/07
{How stuntmen’s wires are removed from the image that you see on screen.}
Gun Safety
Gun Control Controversy

GunFacts.Info website 119 pp pdf

Lott, John R. New CPRC Report: Errors in Bloomberg’s latest report on Mass Shootings October 2, 2014 Crime Prevention Research Center

Lott, John R., Jr .Report from the Crime Prevention Research Center

The Myths about Mass Public Shootings: Analysis

October 9, 2014 Revised 36pp pdf

The Facts about Mass Shootings  It’s time to address mental health and gun-free zones. By John Fund. National Review Online December 16, 2012 4:00 PM


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

Saturday, October 18, 2014

Much of what we do is to educate, whether patients, peers, or other staff. How often have we encountered the self-assured “newbie” staff member who is genuinely clueless, yet confidently not knowing what is not known? And there are those who always instinctively do the right thing, yet feel they are not masterful.

A1999 paper, by the two eponymous authors from Cornell University, describes the phenomena. Essentially, “If you’re incompetent, you can’t know you’re incompetent. […] the skills you need to produce a right answer are exactly the skills you need to recognize what a right answer is. —David Dunning (as cited in Wikipedia article, below).

An example would be the recent ACLS graduate who tells the airway manager, who is ventilating the patient well without a leak, that he/she is holding the mask “upside-down”. This deliberate choice is known to the expert, but not well-published in basic literature. The so-called “merit badge courses” may contribute to this than a more comprehensive training program.


Unfortunately, there is a popular tendency to use the reference as a pejorative and jocular epithet. To apply such an indignity is without merit. Inevitably, in our complicated profession, we will encounter workers with different backgrounds and experiences. As those who continually share and teach, we owe it to the person to better their knowledge, and to better understand the intricacies of a more nuanced practice. It isn’t always possible to so immediately, but a simple “I’d like to explain it, later” will do.


Wikipedia Article: Dunning-Kruger Effect

Wikipedia Article: Four Stages of Competence

RationalWiki Article: Dunning-Kruger Effect

Lee, Chris. Revisiting why incompetents think they’re awesome

Dunning-Kruger study today: The uninformed aren't as doomed as the Web suggests. Ars Technica blog. May 25 2012, 9:00am PDT




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.