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Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.
Tuesday, June 7, 2016

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


Anatomic & Physiologic Concepts:

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


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


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


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


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


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


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


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


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


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


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


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


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


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

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


The Triple/Quadruple Airway Maneuver:

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

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


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


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


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


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


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


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


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

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


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


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


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

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


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


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

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

©Murphy, MF &Walls, RM
Based on Langeron

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


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


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


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


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


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


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


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

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


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


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


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

Which bag to use?

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

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


 PDF of Article & References


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


Monday, April 25, 2016

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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


Monday, March 14, 2016

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


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


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


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


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


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


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


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


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


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


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

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


Monday, February 29, 2016

I didn't grow up in a rural area with volunteer or mortuary-run ambulances. My metropolitan city had an official third-service ambulance and aid-station system (free!) and professional commercial ambulances for private patients. Still, except for the public hospital, other hospitals did little emergency work and would have unattended first aid or treatment room in which one could meet one's physician or have an intern provide care in the meanwhile. 

In fact, one of my surgeon grandfather's ortho buddies (perhaps with the help of some lunchtime martinis) took a look at the x-rays of my Boxer's Fracture and snapped it back into place without any analgesia or procedural sedation, casted me, and sent me home. Still no pain medicine. Things were simple then; not much mandated paperwork, either. Nor any computers. Many doctors used fountain pens.

The latter 1950s and 1960s, quested for nerve gas defense studying expired air resuscitation and modern resuscitology; developing intensive care units. I like to think that this changed outlook and purpose, testing what works, rather than generations of ineffective repetitive manual motions of "artificial respiration" with no clue as to whether the airway was open. To me, it harkens a new scientific renaissance of resuscitation science, emergency care, and creating systems for care. Emerging specializations and sub-specialties in medicine and surgery, led ultimately to widespread interest in developing prehospital care, and emergency rooms.

The 1952 Copenhagen epidemic of Poliomyelitis vastly exceeded the number of "Iron Lung" respirators. Anesthesiologists took the lead in establishing a separate are for concentrating patients needing the most intensive care, and used 1,400 medical students in shifts hand-ventilating intubated patients with an anesthesia breathing bag, soda-lime container to absorb CO2, and 50% oxygen given. [Trimble, BVMs] 

Many physicians of this era had experience of WWII and Korean War military medicine; they were joined by younger men who used GI Bill benefits to enter medicine, and then honed their skills in Vietnam. It's not too much of a stretch to think that they had a "can-do" attitude and some confidence in building systems.  

Perhaps, not insignificantly, they were accustomed to receiving systematized government-supplied medical and trauma care, with "shock rooms" receiving an influx of victims, as contrasted to those later who opposed "socialized medicine." 

A booming post-war population and economy led to more travel and recreation outside urban areas and a realization that effective first aid services did not exist everywhere. [Farrington]  

Rebuilding of outdated hospitals put emergency rooms on ground level with nearby X-ray service, and, ideally, sometimes closer to the Blood Bank and the Operating Rooms. 

Thus, there is a stew of necessary developments predicating modern emergency care: Younger physicians with experience in war (and the systematized provision of care by government); specialization and intensive care; a method of artificial respiration (mouth-to-mouth) that actually worked and gave continuous, instantaneous feedback as to success, funded research and reinvestment in the hospitals. 

Efforts in the 1960s by The Committee on Trauma of The American College of Surgeons in improving ORs, emergency rooms, and "Minimal Equipment for Ambulances" gave impetus to better care and more regulation of ambulance services. The National Academy of Sciences – National Research Council (the Federal Government's official science and medicine advisor, in 1966 produced a landmark paper: "Accidental Death and Disability: The Neglected Disease of Modern Society."  

The impact of this paper led to massive government regulation, grants, and reorganization of many local ambulance groups to Emergency Medical Services under administrative authorities and with shifts to contracted operators or public agencies such as fire departments who welcomed additional service justification and operating funds. We applied to "The Golden Hour" the attitudes and abilities that led to a man on the moon.

This led to less reliance upon American Red Cross Standard and Advance First Aid certificates;then to the first official ambulance training manual by the Pennsylvania Department of Health; and ultimately to the federally endorsed 84 hour course for Emergency Medical Technician for which was written the 1971 publication of Emergency Care and Transportation of the Sick and Injured ("Orange Book"} of the American Academy of Orthopædic Surgeons. 

Federal Department of Transportation approved "Design Requirements for Ambulances" followed and were standardized, causing a transition from hearse-type vehicles, station wagons, and panel trucks or delivery vans, to purpose-built (rather than adapted vehicles) Mobile Intensive Care Units on van chassis or modular "box" van or pick-up truck chassis. Local vehicle modifiers, unable to afford the high costs of testing and approval, went out of business leaving an industry of larger corporations and national sales. 

Other more advanced courses developed locally and established themselves in several states, which became a steamroller for Mobile Intensive Care Units, staffed by Paramedics, with proof-of-concept success in Miami, Philadelphia, Seattle, and Los Angeles. Great public support was engendered by the popular success of the television show "Emergency!" (129 episodes from 1972-79." "Rescue 8" had 74 episodes from 1958 (before paramedics). 

The first Emergency Medicine Residency Program began in 1970 at the University of Cincinnati.  

As Advanced Practice Nursing grew, at first in family practice, then into other specialties, emergency care became an area of interest. A natural one, and especially suited for increasing capability without regard to physician residency program output of graduates, and in less-well-served rural areas. 

Below, are in my view, the essential conditions and turning points for advancing to the level of care that we now know. 


Milestones of Modern Progress in Emergency Care: 

                                      Tom Trimble, RN CEN

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


Sunday, January 31, 2016

​​I've been very fortunate in that my careers in emergency care have spanned many years, much of which was transitional and transformative so that I have lived (as the fortune cookie might say) "in interesting times.

There is in photojournalism, an apocryphal story of a prize-winning photo of a suicidal jumper snapped dramatically in mid-flight. The photographer is asked "How did you get that shot?" The reply was "It's nothing; just f/11, and be there."   To which, one might ascribe a translation:

  1. Be present, before or when events happen.
  2. Be alert to possibilities.
  3. Be pre-positioned anticipating events.
  4. Be suitably equipped, dialed-in, and ready to go.
  5. Make the decision (at what photographic-great Cartier-Bresson called "The Decisive Moment.")

This, in a sense, is an allegory to the realities of emergency care. Compare the possibilities of cardiac arrest resuscitation survival while in the Cardiac Cath Lab, the witnessed versus unwitnessed cardiac arrest in the ED, or the witnessed versus unwitnessed out-of-hospital cardiac arrest. There are no guarantees, only varying degrees of potential luck related to opportunity. 

My odyssey began as a younger brother who would frequently spend long periods reading my brother's "Handbook for Boys". I was able to witness (and be the patrol's practice mannequin for) the transition from Shafer's artificial respiration, the back and forth between Holger-Nielsen's and Sylvester's methods, and ultimately the "Rescue Breathing" of Peter Safar, James O. Elam, and Archer S. Gordon. This ultimately led me through Boy Scout first aid; American Red Cross first aid; teaching first aid; ambulance work in the pre-EMT era; teaching in an early EMT class; Paramedic; and nursing as an Emergency Nurse. 

My ambulance service was an early adopter: we were all certified in ACLS when few physicians and practically no nurses were. Have I seen changes? It's said that Sir William Osler remarked to always be sure to use a medication when it's new and still has the power to heal. The joke runs that we're so old that we remember when lidocaine worked. The first drug to go was the

  • aminophylline drip (bronchospasm);
  • then Hyperstat® Diazoxide (hypertensive emergency, but caused MIs and hypotension);
  • Isoproterenol drips for PEA (didn't work);
  • lidocaine drips for ventricular arrhythmias in favor of repeat bolus treatment;
  • Bretyllium came and went without being the hot number that it was expected to be;
  • Furosemide was a mainstay in Acute Pulmonary Edema, along with
  • Rotating Tourniquets (which was temporizing in decreasing preload);
  • Morphine didn't actually come until years later, so it wasn't treatment for CHF.
  • Valsalva's Maneuver could be used for PSVT after the IV (sometimes had to stop on-scene physicians) but one might innocently ask the patient to push himself upwards in the gurney. Adenosine eliminated doing Valsalva.
  • Dopamine was our only pressor.
  • Nitroprusside was not available.
  • I've had one "Precordial Thump" work, and one not: both were complete saves ("… and be there"). 

Our city was fairly compact with shorter transport times and each county devised its own drug list, so some drugs were not part of our drug bag. We believed in "priming the pump" first with a round of epinephrine and NAHCO3 before attempting defibrillation. We did uninterrupted cardiac compressions with interposed ventilations (this is trending again with an advanced airway in place to minimize interruptions). It took years to encounter "primary VF" (due to lack of 911 systems and late discovery/responses) but the switch to immediate shock had taken place: it was a clear very fine low voltage VF ("I've got a bad a feeling about this …"). No priming allowed: the shock converted to unresuscitable asystole and the patient died. One really only needed to know Sinus Rhythm, Atrial Fibrillation, and Asystole: there was rarely anything else. 

To paraphrase Lincoln Steffens, "I have watched the future come to be, and it's working."

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

About the Author

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