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Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.
Monday, April 25, 2016

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

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

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

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

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studied the avoidable causes of death, and finding the erstwhile fears of a prolonged tourniquet time in place to be no longer valid, the military has striven that each man has a tested and chosen tourniquet.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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 


Monday, March 14, 2016

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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

 


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."

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


Friday, December 11, 2015

 

There is news [Gever] that the FDA has approved the sale of Naloxone, to consumers, as a nasal spray for rescue of opioid overdose. This follows the g-r-a-d-u-a-l introduction to police and non-EMS basic responders of naloxone for this purpose, and prescribing to family and friends of opioid abusers. California, for example, now permits pharmacists with a one-hour in-service training to prescribe such to the public.

 

This is altogether “a good thing.” In the 55 years since its discovery [Wikipedia], it has garnered a well-earned reputation as an unparalleled specific antidote or remarkable safety. Taken in the whole, for emergency use, undesired side-effects are few (most often none) requiring only observation, supportive care, and to ensure that the opioid level is below a toxic level before discharge with appropriate referral and education about supportive services to prevent relapse in the addiction.

 

It is so specific in its effects that its maker, “Endo Laboratories, a division of E.I. du Pont de Nemours,” during the 1970s advertised with the slogan: The response is the diagnosis.”

 

The truth is that this initiative is more than four decades late in arriving. Even in that era, some EMS personnel, whether rogue or liberally supervised depending on your viewpoint, felt able to give away doses of naloxone to the victim’s friends for potential use in an overdose by the persons present.

 

During the intervening years, little was done to move towards availability of naloxone outside of professional circles. Feelings and arguments were rife  that “junkies” couldn’t be trusted with it; that the therapeutic half-life is shorter than that of heroin upon which the victim would fall into greater harm if not medically supervised; that it should or should not be a routine part of  the “coma cocktail” by EMS or EDs; or even that ready availability of a rescue drug would "encourage" the abuse of heroin.

 

Of course, in the interval, the patent has expired upon this drug of singular use, which does not have a “mass” market to drive sales. Industry changes for “Big Pharma" haven't made it easy to market naloxone to the public [Drum] One might surmise that new profits from an old drug could come from extending availability and outreach. Development of intranasal application devices and auto-injectors now make it easier for laypersons to give the drug with minimal training.


 

Ironically, the most important life-saving care in opioid overdose arrives with the companion or first responder regardless of any equipment present: respiratory support with mouth-to-mouth artificial respiration (if the rescuer is willing to perform it).

Of course, the HIV scare, associated with shared needles, frightened the public into avoiding the most effective means of artificial respiration. The recent substitution of  “Hands-only CPR” being taught --largely because the public is unwilling to do direct oral contact-- has further deemphasized artificial respiration.

 

However, “Hands-only" is more appropriate for a “sudden-death” cardiac event (the heart stops first in an oxygenated body), whereas an hypoxic-anoxic state from respiratory arrest would benefit from artificial respiration –a different scenario entirely, wherein the body runs out of oxygen before the heart stops. But, mouth-to-mouth lacks the magical pizzazz of a miracle antidote in a special device. And, “if I just inject him, I don’t have to put my mouth on his!

 

Nonetheless, naloxone use by friends or bystanders is a good thing. It won’t save everyone by itself (respiratory support delayed ; too long; or aspiration has occurred; brain damage from prolonged hypoxia ensues; or the addict didn't set aside $75 for the antidote to be on hand "in case" . . . ) but naloxone will save some. Just have a CPR mask or filter, and the willing skill to support breathing, also.

 

How many more lives might have been saved in the last four to five decades?

 

 

Gever, John. Naloxone Nasal Spray OK'd for Sale. —FDA approves fast-acting reversal agent for opioid overdose. MedPageToday – Emergency Medicine. 11/19/2015. Accessed 11/19/2015.

 

Metropolitan Boston Emergency Medical Service Council, Inc. Nasal Narcan Education Program [PPT]] narcan.ppt” Accessed 11/19/2015.

 

No author. Narcotic antagonists —newest weapon against addiction. Links to original article  in Chemical & Engineering News, July 3, 1972 History of; antagonists compared; early strategy attempts to counter addiction; controversies.

 

Drum, Kevin. A Cheap and Easy Way to Treat Drug Overdoses. Mother Jones magazine’s motherjones.com blog & commentary. Tue Apr. 16, 2013 11:04 AM EDT.  .

 

 

 

Sincerely,
 
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.