Advanced Emergency Nursing Blog from AENJ

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

Thursday, May 31, 2018

Blog – 2018-5
Memorial Day Afterthoughts

Monday, May 28, 2018, a holiday. It was once called Decoration Day, a solemn day to visit cemeteries, and decorate the graves of those who died in service to our country during war. I came across the PBS broadcast of "Going to War." It's oral and video histories of Veterans caught my attention and didn't let go ─I watched until the end.

It progressed, with its tales of training and team building, command structures, committing to 'The Mission', the chaos of battle, not wanting to let down buddies or the team; seeing things humans should not have to see or endure, not being able to 'unremember' nor unburden oneself to friends and family; the post-traumatic stress syndrome change in one's life.

With each new aspect of the show's presentation, I found myself inescapably thinking that these same things happen, too, in the emergency healthcare professions, medicine and nursing, and various field responders. While there are different degrees of mortal threat and violence, no profession is entirely free of it.

In each, there is intensity of education, training, and drills. Inescapable need and responsibility for instant decisions with risk to life. Successes. Failures. Screwups. Logistical failures, Good decisions, and bad decisions. Confusion. Crises of conscience. Disagreements with higher-ups. Moments of intense emotional conduct and human interactions that are memorable for life.

The best professionals in each vocation (remember, the word's classical meaning of being called by God to a Life's Work of service) devote themselves to their craft to the furtherance of their mission.

The Mission, to be achieved with the least loss of life possible, is a high responsibility, a noble calling, and to be successful is a high honor especially when there has been personal risk of injury or death, or when one has gone "above and beyond the call of duty, at personal risk, for the sake of another." One may reflect that morally this applies as much to indigenous health workers, or those of a 'Non-Governmental Organization', as it does to the health services of the superpower militaries.

It is even harder on the local people, or the NGOs when barriers are put in their way, when they are, themselves, impersonated with their equipment expropriated and used for covert and nefarious purposes. Indeed, military assets have been put in and around hospitals which are used as human shields, or hospitals and medical staff have been targeted for attack despite international law.

This is, all, not to say that healthcare are warriors or allied with the notions that drive war. It is to say that there are similarities, subtle or obvious, with those that our servicemen have experienced or with which they've been afflicted, and these, too, may affect us if we are not wary. We must find support for them and ourselves so they are comforted for their experiences and that we continue our health missions and careers with worthy zest and healthy mental equanimity. We can have long and satisfying careers if we can keep it so.

 

"Be kind, for everyone you meet is fighting a harder battle."
—Plato.

"The real index of civilization is when people are kinder than they need to be."
Louis de Bernieres, novelist (b. 8 Dec 1954)

 

Sincerely,
 
Tom Trimble, RN
 
All opinions are solely those of the author.
Suggestion does not equal endorsement.
Readers must verify validity to their own practice.

 

Sunday, May 6, 2018

Blog 2018-4   Passing to another subject 

Have you noticed, as I have, that in recent years, the language of public discourse regarding death has become increasingly euphemistic, polite, ‑--even sanitized? Almost invariably, news anchors or public safety agencies' Information Officers will speak of 'the deceased' or even 'he deceased."

TV detectives will quickly say "I'm sorry for your loss" as easily as the phrase "Thank you for your service" has become so common as to be trite. This is not to say that the intention or meaning is less heartfelt. The phrasing has become ritualized. A web search reveals that many persons find the phrase banal, but others find it a convenient phrase when they might otherwise be at a loss for words. By comparison, the other common phrase, "he passed", almost seems forthright. But where is the frank and homely honesty of "died"?

Those who are experienced in end of life care and palliative care, or who advise on 'giving the Death Tell' say that it is important in the conversation to include the words died or dead so that the family can begin to accept what has happened.

Death has always been an uncomfortable subject, Are we less able to deal with it than formerly? Perhaps, so. Families, now urbanized, no longer have many children (In the past, people might say "Mrs. Jones is so fortunate. She's had eight children, and six have survived.") and there are fewer multi-generational extended family households where one continuously sees birth, maturation, aging, and death close at hand. One might reason that secularization affects the nature and quality of consolation and acceptance. The rise of hospital-based care, extended life spans, and a 'funeral industry', have altered how and where we experience illness, injury, and death. It is no longer common for families to prepare their own dead for a service at home and burial. We are mostly removed from the intimate experience of a cycle of life and death; we do not even think of it as a cycle.

Shakespeare's Julius Caesar voiced the words:

"Cowards die many times before their deaths;

The valiant never taste of death but once.

Of all the wonders that I yet have heard.

It seems to me most strange that men should fear;

Seeing that death, a necessary end,

Will come when it will come."

Julius Caesar: Act 2, Scene 2, Page 2

 

To me, it seems that the important part is not Caesar's soldierly bravery in risking his assassination, but that he comprehends that death is necessary to all life, and his fatalistic acceptance.

The person greatly affected in this scene is Calpurnia, his wife, who pleads and cautions him not to go. For us, then, there are two parts, how we speak with the patient who is confronting his death, should he be aware, then telling the family what has occurred. More often, it is the latter with whom we deal. They are the ones who must receive the news, pluck up, and make arrangements. It is they who are our patients for the while.

I do not feel that we, as health professionals, become inured and hardened to what we see before us or fail to note the significance to loved ones. I do feel that we can, warmly and frankly, say "I'm sorry, but he has died." Our manner can be helpful, and our honest words can be therapeutic.

 

Orman, Rob, MD. The Death Tell. ercast.org. Monday, March 8, 2010.

 

Sincerely,
 
Tom Trimble, RN
 
All opinions are solely those of the author.
Suggestion does not equal endorsement.
Readers must verify validity to their own practice.

 

Monday, March 26, 2018

Blog 2018 – 3. Giving Voice - the personal relations of patient relations

I accompanied my wife to a medical appointment in ophthalmology recently. It was a high-volume setting, and the preliminary screening of scanning the optic nerve, checking visual acuity and intraocular pressures was done efficiently by an assistant of mature years who had first registered us, whose manner was polite (but pro forma) and only directions were given. She got in and out as quickly as possible. There was no discernable interaction on a personal basis. I asked my wife, wryly, "Do you think that she's done this before?"

We both discussed our perceptions and concluded "I think that you were processed!"  Clearly, the work was done, and no one was insulted, but it lacked personal warmth or interaction, however mundane.

As a nurse and former paramedic, I always had to interact directly with people. "What's bothering? How can we help?" Whether assessing, eliciting history and background, reassuring, explaining, teaching, or guiding the patient to use inner resources to distract from pain or persuade them to believe in their own recovery; it was necessary to engage the mind and create rapport.

In fact, our voices, and the words we used, were the most powerful drug and rescue tool that we had. Whether distracting the patient with a fractured hip (in the absence of any analgesia) from noticing the notorious potholes and railway tracks over which we were compelled to drive; or engaging the trust and defusing the hostility of a victim's friends demanding to know why we hadn't gotten there sooner to take care of him. In the former situation, skillful anticipatory driving {lessen the bump) and inducing a distracted focus (to lessen awareness) averted much pain. In the latter, "keep talking (focusing on the crowd's wishes and the patient's needs), keep doing (patient care), and keep moving (do the job and get out). Leaving with that trust, respect, and friendly mood not only marks success, but makes things easier for the next crew to be there.

It may just be that she was being nice and taking the initiative in keeping the flow moving for us. I don't doubt that she's good at her job and has years of satisfactory performance in her files. A few greetings, mild questions (even just the weather), and such are accepted as social lubricant. A few amenities go a long way in opening communication, establishing a relationship, and sometimes you discover that the patient has an interesting tale to tell and is a more interesting person. Do we have entitlement to social discourse? Should we expect to get it every time? No. But, it is a useful tool –that wasn't used.

 Sincerely,
 
Tom Trimble, RN
 
All opinions are solely those of the author.
Suggestion does not equal endorsement.
Readers must verify validity to their own practice.

Thursday, February 22, 2018

The World is, for the most part, currently enthralled with the Winter Olympic Games in Korea. The quadrennial cycles of the Summer and Winter Olympiads are staggered so that we may enjoy the fervor biennially. How thrilling it would be to be part of the medical contingents and volunteers contributing to the health arrangements for the athletes, audiences, and workers.

I have long admired and envied those health workers who are so able to arrange their lives and career obligations to go on humanitarian missions, disaster medical responses, or medical support for mass events. It is their gift to the world and its needy. To not merely use their skills as their livelihood, as we all must, but for the sake of ideals, to give practical compassion when and where needed without personal gain. This noble zest gives luster to our professions and embodies a "do as I do" example for the world while providing care that might not otherwise be there.

In the Olympic Games, one has elements of expedition medicine, environmental  risks, trauma and orthopaedics, sports medicine and exercise physiology, public health, hygiene and sanitation, travel medicine, circadian rhythm changes, venereology, and all the sub-specialties to which the divers attendees bring as their needs. The many athletes are in their prime, and often well-acquainted with strain, injury, acute care, and rehabilitation. Translators are available for this polyglottal population.

So, I offer applause and best wishes to those who represent us in meeting the health challenges of such a large enterprise honoring sport and peace.  "Citius, Altius, Fortius"

Sincerely,
 

Tom Trimble, RN
 

All opinions are solely those of the author.
Suggestion does not equal endorsement.
Readers must verify validity to their own practice.

Blog; 2018-2

Tuesday, January 16, 2018


Automated Vital Signs – Who's the automaton? 

Being, myself, a patient from time to time, I have noticed a disturbing and developing trend. The convenience, automation, and data-recording abilities of monitors, have changed the nature of vital signs measuring and of interactions with the patient.

Consider:

How the presence of a EMR computer in the room often means a computer-driven interrogation of the patient with visual focus on the screen rather than the patient. As a nurse-patient, whom I know, said to her caregiver, "Hey, I'm the patient; I'm over here!"

When there is difficulty detecting the blood pressure, as in the "definition of insanity is doing the same thing repeatedly, expecting a different result," staff perseverate upon running it again, instead of substituting a manual blood pressure cuff.

Patients more often complain "the cuff is hurting me" especially when the machine struggles for a result (arrhythmia, positioning, movement, obesity) and over hours of rechecks develop bruising. There is a vast difference in comfort between older soft cloth cuffs, and newer cuffs of harder material that are disposable or are resistant-to-disinfecting-chemicals.

Pulses are no longer counted by palpation for quality of strength, regularity, equality. nor to assess skin. Instead, the pulse oximetry sensor is held out until the patient complies by inserting a finger (often without an offered explanation). This, of course, allows more time for mandated 'screening' questions that aren't yet pertinent.

How often now is an auscultatory gap in the Korotkoff's Sounds noted and reported, which may be important in accurately determining true systolic and diastolic pressures (gaps of 20-50 mm/Hg are not uncommonly found). Some staff do not even have their stethoscope ready to hand.

Some patients have a disparity in BP between arms (which can be a vital clue if there is dissection of the aortic arch). I recall a patient brought in by EMS on a Dopamine drip, who appeared "pink, warm, and dry" and appeared (as she was found to be) normotensive in her other arm ---which had not been checked before beginning a vasopressor. It was a known piece of her history which was forgotten in the excitement.

We take a lot on trust, nowadays. With the exclusion of Mercury from the clinical environment, there is no reference sphygmomanometer which can be trusted to respond only to the laws of physics, nor, likewise, a thermometer that is not subject to electrical faults. Think of the thermometers that you've used that needed their swinging coiled cord to be held "just so" in order to complete the reading. Even aneroid gauges can be out of whack, forcing a guessing game until it is recalibrated.

Don't get me wrong. I LOVE good equipment that is accurate, discerning and makes work easier, records things, and does the math on a lot of extra data and parameters. But the machine is to be my servant, not I to be its servant. The machine is to be a servant of the patient, and helper to me; it is to be a comforting and abiding guardian protector that does delegated tasks while I unite its data with my findings, diagnostic process, and tasks.

We must remember to build a relationship with our patient, and engage ourselves in the clinical observations and interactions that inform our decisions. Not one of these machines is human enough to glance at a person and decide "Something's wrong here! This person is 'BIG Sick!'" Nor, are they able to give a comforting and reassuring smile.

                

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


BLOG – 2018-1