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Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.
Thursday, November 24, 2016

      I am very thankful for the modern tools and techniques which we now have. I am thankful for having a career of wonderful care at supportive institutions. I am thankful for the family that I have been able to raise and sustain.


What I wish that I had then, that we have now …


  1. POCUS. While Point of Care Ultrasound has made limited entry in prehospital care, largely with physician-led services and some Advanced Paramedics; it has largely been as a proof of concept rather than everyday care. It is training and resource-intensive for prehospital care and indicated treatment may not be feasible, especially in austere environments and economies. Yet, clearly in good hands it delivers real-time anatomic, physiologic, and pathological information that can be life-saving; it has been revolutionary; once having it, one never wishes to regress. Its dissemination in poorer countries might be a better first-step than having one CT or MR scanner.

  2. 911. At the beginning of my career, making an emergency call involved finding a working wired telephone; either knowing and dialing a 7-digit number for each needed service in that jurisdiction, or calling the Operator; explaining the need (if one spoke the national language), or calling a bilingual family member to place the call, —his would sometimes be first to the doctor, then the emergency service; which was connected by telephones or telegraphic alarm systems with their dispatchers. Adding these delays, response times, and in a vertical city -reaching the patient's level meant that there were only two primary rhythms: Asystole, and Sinus (A. Fib, if elderly). There were no coordinated multiple-agency responses.

  3. Really-good 2nd Generation Supraglottic Airways, & Video Laryngoscopy. How great it would have been to have these modalities! In the seventies, there were oral airways; plastic, if you were lucky; metal wire, if you weren't. In the mid-seventies, we began using nasopharyngeal airways. (This was pretty esoteric.)

    We were even more exotic, with 15 mm endotracheal tube connectors fitted in ours. This allowed us to bypass mask facial fit problems by using the nose. If doing what was called "the one-man-band resurrection shuffle" [single person CPR in the back of a moving ambulance], this worked very well, as the bag would stay hanging there on the patient's face. At the ventilation break, without changing kneeling or sitting position, move the hands over for a head-tilt chin-lift that sealed the lips and squeezed the open nostril shut for quick inflations, then resume compressions. Absence of teeth was no problem.

    There was no field endotracheal intubation. Not even an "Esophageal Airway." {By the time we were allowed to do that, we were able to go directly to the Esophageal Gastric Tube Airway. Years later, ETI was finally allowed, but only in extremis with unconscious patients; RSI is still not allowed. There was no protocol for cricothyrotomy: had the need for it occurred, do you follow the rules? If you do one, you might either be a successful hero, or the unlucky schmuck who used to work here. Airways were a highly contentious and polarizing issue: directors and doctors with no field experience; medics with much field experience and no authority to do things already studied; "status-quo politics" remained the order of the day.

    Had we had a good Gen 2 SGA, we might have avoided some aspiration problems, better ventilation in difficult circumstances, and "conduit intubation" might have been the next step. Video Laryngoscopy might have lessened concerns about laryngoscopic intubation, or been a back-up for the difficult intubation.

  4. Pulse Oximetry & End-Tidal Capnography. Wow. How useful these would have been to let us know how well the patient was oxygenating and ventilating! These indices would have reinforced the clinical decision progress and avoided bad outcomes from unsuccessful estimates. So much more than just a BP cuff and a rhythm monitor.

  5. Disposable BVMs (one at every bedside). Yes, there's a crash cart —at the end of the ward's hallway from me. Meanwhile, the patient has just returned from a scan and had a seizure in front of you because his brain is speckled with contrast; post-ictus, he's apneic despite airway measures, and now one must give mouth-to-mouth because there's no bag at the bedside … see what I mean?

  6. Intraosseous Infusion. Not as often resorted to promptly, as it should be. An elderly lady in cardiogenic shock (BP 60/40) with no veins, I was lucky to get a 24-gauge PIV into the back of her wrist. It was all she had.

  7. GPS, Mobile Data Terminals, and Cell Phones. There were times that units were delayed or lost on calls, relying upon local knowledge and paper maps. In foggy or white-out conditions, one might not even see the curbs or intersections, and be dazzled by the flashing lights. Confusion might arise from similar or sound-alike names, the same name on a street, avenue, drive, or court.

    The isolation from having only two-way limited range radio, and no alternate means unless a pay telephone could be found, is not well-understood now. Once, while taking a patient to the hospital, Dispatch radioed us to call ASAP (radio rules didn't allow explanation). By the time that we delivered the patient and called, the five-minute radio-station contest call-back window had elapsed, and I did not win the brand-new car for which they had called my name. This was a sad blow for a poor young medic and family-man whose cars were very old and no money to spare.

All of The Editors, The Publisher, and Staff of Advanced Emergency Nursing Journal wish you a very happy time of thanksgiving and holiday celebration.


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

Monday, October 31, 2016

Recurring clinical situations and personal interactions may need an astutely apt phrase or bon mot. It's good to have a mental library of successful phrases to use again. 

For example, instructions for the peak flow meter can be confusing. Most people try to "blow-blow-blow" as if for birthday candles. Say that the needle is "like a highway patrol speedometer –it flies up to your fastest speed and stays there" may get a laugh and a better performance. 

  • Sharing one's own allergy problems, "I feel like my Life is attached to my nose!" shows sympathy and empathy.

  • The acute-on-chronic respiratory distress is eased in hearing "You know, ordinary people don't realize what a privilege it is to draw an easy breath." {Let me help position you to breathe with less work, and get you some treatments to help."} {"What do you need most, right now, to help you feel better?"}

  • The person straining with back pain will understand "there's an old song with the line 'Every little movement has a meaning all its own!"  While the reference is not the same, the emphasis on movement is relevant to the present reality.

  • A silly pun such as "needing a good understanding" highlights the importance of a good footing.

  • Novices with crutches tend to look at the floor and their feet which makes them off-balance. Remind them that in diving "the body follows the head; --if you look at the floor, you'll end up on the floor."

  • Persons dwelling on their symptoms, or if you're cautioning about a potential side-effect can be told: "But, you don't have to pay any attention to that and don't need to remember it … 'these are not the droids that you're looking for'" will remind them of Star Wars and that your 'Jedi Mind-Trick' is fun and that they may safely not remember.

  • If more emphasis is needed, or you wish to enhance amnesia as wakening from sedation occurs, say again they don't need to remember, then add "just forget to remember, and remember to forget "  This creates a psychological double-bind that loops itself creating confused 'forgettery'.

  • When doing a shoulder pull-down to see C-7 on x-ray, decrease the muscle tension with visualization of walking through the airport carrying heavy bags (no wheels) and you're staying tall to carry them but your arms are stretching l-o-n-g-e-r … "

  • Not sure which way the differentiation will go? Politely stall with "We'll know more when certain tests have been done." This also helps induce buy-in to the plan by the patient and family.

  • Those anxious prognosis questions can be given assurance as my surgeon grandfather did with "you're doing as well as can be expected considering the circumstances." This non-committal phrase can be fine-tuned with different tone and affect to either be encouraging or cautionary.

  • "How am I doing, Doc?" can get a hearty rejoinder "Why, you're doing the best that you possibly can!considering). "And, I expect that with a little more rest and medicine, you'll be feeling better yet." "How soon, I wonder, do you think you'll be able to feel that way?" " I imagine that you'll want it to be soon." This puts into play the powerful forces of expectation of a positive outcome.

  • Have some simple accurate descriptions of pathophysiology and therapy. E.g., "The heart isn't pumping out all the blood that it receives, so it backs up like traffic at the toll gate, so the liquid part is oozing out into the lungs." "No, it's not really a 'blood-thinner' like paint thinner, it just slows down the clotting a little bit so that it's less likely to sludge up in tight spaces." 

  • You and the patient are working with different mental lists during history-taking and review of systems. Avoid important omissions or kept secrets and anxieties, with a kind and trustworthy: "Tell me, now, anything that you haven't yet told me." If you've established a good rapport, and a yes-series or positive responses, then you will likely get some useful replies.

  • Every good clinician will develop, over time, a personal 'patter' or internalized ready answers, ready questions, and ready assurances appropriate to many situations. You, too, should definitely do so. 

The key is to be warm, engaging, cognizant of present difficulties yet optimistic and good-natured as to outcome and how to get there. If it comes from the heart, it will be received and felt in the heart.

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


Tuesday, September 13, 2016

Readers of this blog may have read of the death of Dr. Peter Josef Safar in 2003, who is often called "The Father of Cardiopulmonary Resuscitation," or noted citations of his work in articles written and references given by me here at and the Advanced Emergency Nursing Blog. 

Truth to tell, Peter Safar was not only justifiably given his many accolades, he is one of my personal heroes: inspiring and modelling a life-long devotion to the resuscitative arts; a belief that these skills are needed by all and that they are capable of learning it; and showing how to lead a life worth living.

I was pleased and excited when a Twitter reference, {Haney Mallemat ‏@CriticalCareNow Sep 7 Great piece of Resus history  Thx @expensivecare …this was obviously pre-IRB #FOAMcc #FOAMed}, indicated a YouTube video was available: Respiratory Resuscitation Techniques by Peter Safar, MD. It is a 11:39 minute film, by Walter Reid Army Institute of Research Production of experimental research done by Peter Safar, MD, and associates, at Baltimore City Hospital's Department of Anesthesiology.  

Here is the opportunity of seeing and hearing one of the pioneers of mid-20th Century resuscitation research that put artificial respiration and later closed-chest cardiac compressions on a sound and successful basis of research, testing, teaching, and evaluation of results.  

Safar was not the first, or only, researcher, but his ongoing enterprise, organization, and promotion, co-opting newly-found allies around the world created a phenomenal success that saved an uncountable thousands of survivals world-wide.  

Safar's work, in a series of studies and papers,

  • validated manual methods of opening the airway, in use by anesthesiologists but relatively unknown outside the operating room, as effective and able to be taught and used by lay people.

  • tested and compared the then-common manual (push-pull) methods of "artificial respiration," and found them to be ineffective, prone to failure by not attending support to the airway and volumes "breathed" incapable of transiting the "dead air space."

  • established that exhaled air was a satisfactory gas for resuscitation.

  • demonstrating that unconscious and paralyzed volunteers, without a breathing tube, could be sustained, by lay public rescuers of different ages and stature, for long periods. By rendering the volunteers unconscious and paralyzed by curare, they had the flaccid weakness of an apneic victim, and were dependent on the "rescuers" to keep them alive.

  • Consistent attention was given to the teachability and practicability of recommendations for the public so that it would be accepted readily and used.

  • His research and demonstrated superiority of method was so remarkable that authoritative bodies made mouth to mouth rescue breathing a universal recommendation in approximately a year's time. 

Brief Summary of Life Acheivements by Safar:

  • Too numerous to count; consider the following:

  • Established academic departments of anesthesiology, independent of Surgery.

  • Founded first ICU that was multi-disciplinary.

  • Research: an integral function of anesthesiology department.

  • Established "think-tank" laboratory devoted to resuscitation.

  • Many International projects, thinking, research, dissemination, with global viewpoint including the Soviet Union and "Iron Curtain" countries.

  • Validation of methods of controlling the unprotected natural airway; comparisons of methods of artificial respiration, validating mouth-to-mouth as the most effective means, training and popularizing mouth-to-mouth, and linking and coordinating external cardiac massage (the Johns Hopkins Group) to be Steps A, B, & C of CPR.

  • In collaboration with Asmund S. Laerdal, and Dr. James Elam, led to development and adoption of "Resusci Anne" as a training mannequin.

  • Helped establish the Freedom House ambulance with paramedic level care.

  • Expanding focus of resuscitation to include the brain: CPCR; CardioPulmonary Cerebral Resuscitation.

  • Research into post-arrest after-care, therapeutic hypothermia, reanimatology.

  • Support of prevention activities to lessen the need for resuscitation.

  • The recurring Wolf Creek Conferences on Cardiopulmonary Resuscitation, organized in conjunction with Jude and Elam, served as a pattern for summit meetings of CPR and the ILCOR and AHA scientific meetings of our time.

  • Promotion of a global approach to disaster management, firstly in "The Club of Mainz," then in the World Association for Disaster and Emergency Medicine.

  • Named author of more than 1400 articles; and ten books listed by the Library of Congress.


Respiratory Resuscitation Techniques by Peter Safar MD

YouTube copy of filmed demonstration by Dr Safar for the US Army (which funded studies) of tested methods of airway opening and control, and the use of expired air resuscitation, as performed on anesthetized and paralyzed volunteers. **Nearly twelve-minute black & white 16 mm film in the original, now digitally available to all. 

Johns Hopkins Medicine Celebrates 50 Years of CPR
A retrospective on developing of the cardiac aspects of CPR and defibrillation at Johns Hopkins, and its integration with Safar's work to be CPR. Features interviews with Kouwenhoven, Knickerbocker, Jude, and Elam 

CPR History and science of Resuscitation
YouTube video of evolution of CPR and Paramedics, with reenactments of older methods attempting resuscitation. 

Hands of Time: Celebrating 50 Years of CPR, 5:42-Minute Webcast
American Heart Association video includes Doctor Elam describing the first of several improvised mouth-to-mouth saves of apneic patients which were to later inspire Doctor Safar.


Safar named as a "Resuscitation Great": 

Baskett, Peter JF. "Peter J. Safar, the early years 1924–1961, the birth of CPR." Resuscitation 50, no. 1 (2001): 17-22. 

Baskett, P. J. (2002). Peter J. Safar. Part two. The University of Pittsburgh to the Safar Centre for Resuscitation Research 1961–2002. Resuscitation, 55(1), 3-7.

**These two articles are the best start in learning more about Safar's life.


Selected Articles by or about Peter Safar:

A comparison of the mouth-to-mouth and mouth-to-airway methods of artificial respiration with the chest-pressure arm-lift methods
Safar, P., Escarraga, L. A., & Elam, J. O. (1958). A comparison of the mouth-to-mouth and mouth-to-airway methods of artificial respiration with the chest-pressure arm-lift methods. New England Journal of Medicine, 258(14), 671-677.

Manual versus mouth-to-mouth methods of artificial respiration

SAFAR, P., & ELAM, J. (1958). Manual versus mouth-to-mouth methods of artificial respiration. The Journal of the American Society of Anesthesiologists, 19(1), 111-111. 

Upper airway obstruction in the unconscious patient

Safar, P., Escarraga, L. A., & Chang, F. (1959). Upper airway obstruction in the unconscious patient. Journal of Applied Physiology, 14(5), 760-764. 

The Resuscitation Dilemma*
SAFAR, P., AGUTO-ESCARRAGA, LOURDES, DRAWDY, L., McMAHON, M. C., NORRIS, A. H., & REDDING, J. (1959). The Resuscitation Dilemma*. Anesthesia & Analgesia, 38(5), 394-405. 

Discussion on Artificial Respiration
Discussion on Artificial Respiration by eight speakers. WHITTINGHAM, President, Air Marshal, Sir Harold. (1959). Meeting of the United Services Section, December 3, 1959. Proceedings of the Royal Society of Medicine. **Contemporary UK panel discussion of not-yet-official expired air resuscitation vis a vis standard methods and as to whether it should be adopted. Safar not named, but evident in the discussion. 

S-Tube Airway

Safar, P. (1961). Airway.  U.S. Patent No. 3,013,554. Washington, DC: U.S. Patent and Trademark Office. **The patent for Safar's double-ended airway, marketed by Johnson & Johnson as Resuscitube®.
C.f., Trimble, Tom, RN CEN. Mouth-to-Airway (adjunct). Advanced Emergency Nursing Blog. April 8, 2014, for additional background history. 

Safar, P., & McMahon, M. C. (1961). Resuscitation of the Unconscious Victim: A Manual for Rescue Breathing. Thomas. 

Ventilation and circulation with closed-chest cardiac massage in man
Safar, P., Brown, T. C., Holtey, W. J., & Wilder, R. J. (1961). Ventilation and circulation with closed-chest cardiac massage in man. Jama, 176(7), 574-576.

Closed chest cardiac massage.

SAFAR, P. (1961). Closed chest cardiac massage. Anesthesia & Analgesia, 40(6), 609-613. 

The Intensive Care Unit.
SAFAR, P., DeKORNFELD, T. J., PEARSON, J. W. and REDDING, J. S. (1961), The Intensive Care Unit. Anaesthesia, 16: 275–284. doi: 10.1111/j.1365-2044.1961.tb13827.x 

Failure of closed chest cardiac massage to produce pulmonary ventilation

Safar, Peter., Brown, T. C., & Holtey, W. J. (1962). Failure of closed chest cardiac massage to produce pulmonary ventilation. Dis Chest, 41, 1-8. 

Safar, P. (1962)  Resuscitation Controversial Aspects: An International Symposium Held at the First European Congress of Anaesthesiology of the World Federation of Societies of Anaesthesiologists Vienna / Austria, September 5, 1962. Springer. 

Resuscitative principles for sudden cardiopulmonary collapse*.
Safar, P., Elam, J. O., Jude, J. R., Wilder, R. J., & Zoll, P. M. (1963). Resuscitative principles for sudden cardiopulmonary collapse. CHEST Journal, 43(1), 34-49. 

Teaching and testing lay and paramedical personnel in cardiopulmonary resuscitation

WINCHELL, S. W., & SAFAR, P. (1966). Teaching and testing lay and paramedical personnel in cardiopulmonary resuscitation. Anesthesia & Analgesia, 45(4), 441-449. 

SAFAR, P. (1967). Principles and Practice of Exhaled-Air Ventilation. Proceedings: Conducted by the Ad Hoc Committee on Cardiopulmonary Resuscitation, Division of Medical Sciences of the National Research Council, with the support of the Division of Health Mobilization. US Public Health Service, Department of Health, Education, and Welfare, 35. 

Mobile intensive care by" unemployable" blacks trained as emergency medical technicians (EMT's) in 1967-69.

BENSON, D. M., ESPOSITO, G., DIRSCH, J., WHITNEY, R., & SAFAR, P. (1972). Mobile intensive care by" unemployable" blacks trained as emergency medical technicians (EMT's) in 1967-69. Journal of Trauma and Acute Care Surgery, 12(5), 408-421.

N.B. c.f, also: Freedom House Street Saviors Documentary. Website, articles, photos, trailers, videos, re above. 

From Back-Pressure Arm-Lift to Mouth-to-Mouth Control of Airway, and Beyond

Safar, P. (1977). From Back-Pressure Arm-Lift to Mouth-to-Mouth Control of Airway, and Beyond. In Advances in Cardiopulmonary Resuscitation (pp. 266-275). Springer New York. 

Initiation of closed-chest cardiopulmonary resuscitation basic life support. A personal history.

Safar, P. (1989). Initiation of closed-chest cardiopulmonary resuscitation basic life support. A personal history. Resuscitation, 18(1), 7-20. 

James O. Elam MD, 1918–1995
Safar, P. (2001). James O. Elam MD, 1918–1995. Resuscitation, 50(3), 249-256.
**Recounts meeting, interest found in Elam's experience with expired air resuscitation, and their association thereafter. 

From control of airway and breathing to cardiopulmonary–cerebral resuscitation

Safar, P. (2001). From control of airway and breathing to cardiopulmonary–cerebral resuscitation. The Journal of the American Society of Anesthesiologists, 95(3), 789-791. 

Peter Safar: father of modern cardiopulmonary resuscitation

Acierno, L. J., & Worrell, L. T. (2007). Peter Safar: father of modern cardiopulmonary resuscitation. Clinical cardiology, 30(1), 52-54. 

The incredible career of Peter J. Safar, MD: the Michelangelo of acute medicine

Grenvik, A., & Kochanek, P. M. (2004). The incredible career of Peter J. Safar, MD: the Michelangelo of acute medicine. Critical care medicine, 32(2), S3-S7. 

On the history of emergency medical services

Safar, P. J. (2001). On the history of emergency medical services. Bull Anesth History, 19, 1-11.
**Companion piece to an article by Nagel on first paramedics in Miami and telemetry. 

A history of cardiopulmonary resuscitation
Eisenberg, M. S., Baskett, P., & Chamberlain, D. (2007). A history of cardiopulmonary resuscitation. Cardiac Arrest: The Science and Practice of Resuscitation Medicine, 11-20. 

Wolf Creek V Conference on cardiopulmonary resuscitation: Addressing the scientific basis of reanimation

Weil, M. H., & Tang, W. (2000). Wolf Creek V Conference on cardiopulmonary resuscitation: Addressing the scientific basis of reanimation. Critical Care Medicine, 28(11), N181-N182.  

History of mouth-to-mouth ventilation. Part 3: the 19th to mid-20th centuries and "rediscovery"

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. 

Training in cardiopulmonary resuscitation

Schrogie, J. J. (1965). Training in cardiopulmonary resuscitation. Public health reports, 80(1), 68.

Kofke, W. Andrew, M.D. "An Interview With Peter Safar, M.D." "AUA Update". Winter, 2002. Association of University Anesthesiologists. **Peter Safar reports that the "Laws" are from an "unknown source" and given to him on his 70th birthday and reflective of his colleague's perceptions. 

Ebemeyer, Uwe, and others. Peter Safar (1924-2003). Prehospital and Disaster Medicine. March-April, 2005. 

Birnbaum, M. L. (2005). Impossible Dreams. Prehospital and disaster medicine, 20(02), 73-75. **Contains a copy of "Laws for the Navigation of Life." 

Nickson, Chris. [No Date] "Laws for the navigation of Life". Life in the Fast

Trimble, Tom, RN CEN. How the BVM began. Advance Emergency Nursing Blog. October 20, 2013. 

Trimble, Tom, RN CEN. Mouth-to-Airway (adjunct). Advanced Emergency Nursing Blog. April 8, 2014. 

Trimble, Tom, RN CEN. Early Modern Resuscitators. Advanced Emergency Nursing Blog. May 3, 2014. 

Trimble, Tom, RN CEN. The Nose: the other route to the lungs. Advanced Emergency Nursing Blog. March 27, 2015.

Trimble, Tom, RN CEN. Sir William Osler, and, "f/11, and be there … " Advanced Emergency Nursing Blog. January 31, 2016.


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


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. 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. 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. "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. 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
Accessed 07/30/2016.

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


                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.


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

About the Author

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