Compressions Only CPR

 

Chest Compressions Alone Best With CPR

Studies support bystanders not using mouth-to-mouth breathing

By Serena Gordon HealthDay Reporter

WEDNESDAY, July 28 (HealthDay News) -- If you haven't been well-trained in CPR and you see someone having what appears to be a heart attack, just doing chest compressions to help keep the blood flowing can be as effective as CPR that includes mouth-to-mouth breathing, new research claims.

Two new studies, appearing in the July 29 issue of the New England Journal of Medicine, found that when bystanders were instructed by emergency dispatchers to give either standard CPR, which includes mouth-to-mouth breathing, or chest-compression-only CPR, survival rates were similar between the two techniques.

Experts hope that by simplifying the procedure and removing the mouth-to-mouth contact that more bystanders might be willing to attempt CPR.

"Bystander CPR can double your chances of survival, but the biggest thing is getting more people to try it. Only one in three people who need it get bystander CPR," explained the lead author of one of the studies, Dr. Thomas Rea, medical director of the Emergency Medical Services Division of Public Health for Seattle and King County in Washington. "If we can make it less complicated, it may enable more people to perform CPR."

Rea said that rescue breathing can be difficult, especially for someone who isn't trained in the technique. Even in people who are trained, but don't often have the chance to practice rescue breathing, it can be hard to do.

"Even for myself as a physician, because I don't do mouth-to-mouth on a regular basis, it's hard to do," said Dr. Dana Peres Edelson, director of clinical research at the emergency resuscitation center at the University of Chicago Medical Center.

Edelson said that if you see a seemingly healthy adult suddenly drop, call 911 and then begin chest compressions. Emergency dispatchers can provide instructions on where to place your hands. If someone else is available to help, she said to have them call 911 and to go look for an automatic defibrillator, which are now present in many public places, such as malls, schools and stadiums.

"Push hard, push fast and don't stop unless you have to give a breath or use a defibrillator," said Edelson. "If you do stop, keep the pause as brief as possible."

"Chest compressions are paramount," said Rea.

Rea and his colleagues conducted a multi-center randomized trial of dispatcher-assisted bystander CPR. Adults who needed CPR were randomly assigned to receive either traditional CPR or chest-compression-only CPR. A total of 1,941 people were included in the study and 981 received chest-compression only CPR.

Survival rates (at hospital discharge) were 12.5 percent for the chest-compression-only group and 11 percent for those who received chest compressions plus rescue breathing.
The second study was similarly designed, but conducted in Sweden. This study included 1,276 people, with 620 receiving chest-only CPR.

The Swedish researchers measured 30-day survival rates and found that 8.7 percent of those receiving chest-only CPR had survived compared to 7 percent of those receiving standard CPR.
Both groups of researchers concluded that compression-only CPR with instructions from emergency dispatchers was likely to be as effective as traditional CPR, possibly even slightly more so.

The findings do not apply to emergency workers and others who are well-trained in CPR, Rea stressed.

There are some times when rescue breathing is necessary. Edelson said that it's recommended that children generally receive rescue breathing, as well as anyone who was choking or looked like they were having trouble breathing before they became unconscious.

But, Edelson said that lay people might not be able to discern who needs rescue breathing or not, so she advised, "If you haven't been trained in CPR, just start doing chest compressions as fast as you possibly can."

Rea agreed. "You can make a life-and-death difference by providing chest compressions. You don't have to be perfect; all you can do is provide benefit. Your actions can save a life."

More information
Learn more about hands-only CPR from the American Heart Association.
SOURCES: Thomas Rea, M.D., medical director, Emergency Medical Services Division of Public Health for Seattle and King County, Wash.; Dana Peres Edelson, M.D., assistant professor, section of hospital medicine, and director, clinical research, emergency resuscitation center, University of Chicago Medical Center; July 29, 2010, New England Journal of Medicine

What? 80% of ED patients have insurance?

Wow!  When I first read this I thought "no way" -it's got to be more than that!  We've all heard it before, "ED patient's don't have insurance - that's why they come to the ED in the first place".  Well information relased by the Federal HHS Department shows that lack of insurance in our ED population is the minority when all is tallied up.  


Original article can be found at: http://tinyurl.com/20percent-uninsured
___________________________________________________________________________________________

New Data Say Uninsured Account for Nearly One-Fifth of Emergency Room Visits

July 16, 2010

HHS Secretary Kathleen Sebelius today released new data from the Nationwide Emergency Department Sample -- the largest, all-payer emergency department database in the United States.  The Nationwide Emergency Department Sample is designed to help public health experts, policymakers, health care administrators, researchers, journalists and others find the data they need to answer questions about care that occurs in U.S. hospital emergency departments.


These data indicate that uninsured persons accounted for nearly one-fifth of the 120 million hospital-based emergency department visits in 2006. 


"Our health care system has forced too many uninsured Americans to depend on the emergency room for the care they need," said Secretary Sebelius. "We cannot wait for reform that gives all Americans the high-quality, affordable care they need and helps prevent illnesses from turning into emergencies."


The database is managed by HHS' Agency for Healthcare Research and Quality (AHRQ) and generates national estimates on the number of emergency department visits in all community hospitals, by region, urban/rural location, teaching status, ownership and trauma designation.  It also provides in-depth information on acute management of patients for all visits, including why patients were seen in the emergency department, the treatments they received, what happened to them at the end of the visit (admitted to the hospital, discharged home, transferred to another hospital, died in the emergency room or left against medical advice), the charge for their care and who was billed.


The Nationwide Emergency Department Sample contains 26 million records from emergency department visits from approximately 1,000 community hospitals nationwide.  This represents 20 percent of all U.S. hospital emergency departments.  The database also provides weighted calculations for national estimates of the 120 million emergency department visits in 2006.
"AHRQ has a long history of supporting health services research related to emergency medicine, and the richness of these new data will increase our capacity for research and decision making," said AHRQ Director Carolyn M. Clancy, M.D. "The new database will give emergency planners and other policymakers the data they need to help improve the quality, safety and effectiveness of emergency medical care."  


AHRQ also released its latest Nationwide Inpatient Sample-- the largest, most powerful database on hospital care in the United States, covering all patients, regardless of their type of insurance or whether they were insured. The 2007 Nationwide Inpatient Sample provides users with an in-depth look at why patients were hospitalized, the treatments and procedures they received and what happened to them at discharge. Researchers can use the Nationwide Inpatient Sample to examine trend data as far back as 1988. The 2007 Nationwide Inpatient Sample is based on discharge data from 8 million hospital stays at more than 1,000 community hospitals.


The two databases, as well as the 2006 Kids' Inpatient Database on pediatric inpatient care, are part of AHRQ's Healthcare Cost and Utilization Project (HCUP), a federal-state-industry partnership for building a standardized, multi-state health data system. In addition to databases, HCUP includes software tools and statistical reports to inform policymakers, health system leaders, researchers and the public.


HCUP databases can be accessed by using the AHRQ on-line query tool, HCUPnet. Researchers and analysts who need the most in-depth data should contact the HCUP Central Distributor about purchasing the 2006 Nationwide Emergency Department Sample and the 2007 Nationwide Inpatient Sample datasets and for further information about their composition and technical requirements.

Health Care Reform Might WORSEN ED Crowding

Reform To Exacerbate Emergency Department Crowding, Experts Say

The new health reform law might exacerbate emergency department overcrowding, according to health care facility experts, The Hill reports.

Advocates of the overhaul said the law would help address ED overcrowding by ensuring more U.S. residents had insurance to cover physician visits.

However, EDs likely will experience higher patient volumes over the next four to eight years because of a dearth of primary care physicians in the U.S., according to Rich Dallam, a partner at health care architectural firm NBBJ.

Lessons From Massachusetts?

Rep. Jim McDermott (D-Wash.) agreed that increased stress on EDs is a possibility. He pointed to Massachusetts, where a 2006 health law that created near-universal health coverage for state residents has failed to abate ED demand

 A recent American College of Emergency Physicians poll found that nearly two-thirds of Massachusetts residents said ED wait times have increased or remained the same since the law was enacted.

In addition, a report by the Council of State Governments released in February found that wait times had not declined since Massachusetts' law took effect.

Fireworks Related Mortality Report

(NOTE: The data for 2009 and 2010 has not been compiled yet)
Below are some interesting factoids about fireworks related mortality.


     This report provides the results of the U. S. Consumer Product Safety Commission (CPSC) staff analysis of data on non-occupational fireworks-related deaths and injuries during 2008. The report also includes a summary of CPSC staff enforcement activities during 2008.
     Staff obtained information on fireworks-related deaths from news clippings and other sources in CPSC’s Injury and Potential Injury Incident (IPII) database. Staff estimated fireworks-related injuries from CPSC’s National Electronic Injury Surveillance System (NEISS). More detailed analyses of injuries including the type of injury, the fireworks involved, and the characteristics of the victim were based on a special study conducted by CPSC staff between June 20 and July 20, 2008. About two-thirds of the annual fireworks-related injuries for 2008 occurred during that period.

Highlights of the report are as follows:
•CPSC staff has reports of 7 fireworks-related deaths during 2008. Two people were killed in incidents involving aerial and display fireworks. One person died in a fire where a firework was the ignition source. Three people were killed in incidents involving homemade fireworks. One person, on oxygen, suffered serious burns when a firecracker exploded near his face. He died 18 days later in the hospital. CPSC staff has reports of 11 fireworks-related deaths in 2007.

•Fireworks were involved in an estimated 7,000 injuries treated in U. S. hospital emergency departments during calendar year 2008 (95 percent confidence interval 5,200 – 9,000). CPSC staff estimated that there were 9,800 fireworks-related injuries during 2007.

•An estimated 5,000 fireworks-related injuries (or 70 percent of the total fireworks-related injuries) were treated in U.S. hospital emergency departments during the one-month special study period between June 20, 2008 and July 20, 2008 (95 percent confidence interval 3,400 – 6,500). CPSC staff estimated that there were 6,300 fireworks-related injuries (66 percent of the annual total) during the 2007 special study period.

Results from the special study include the following:
•Of the fireworks-related injuries sustained, 62 percent were to males and 38 percent were to females.

•Injuries to children were a major component of total fireworks-related injuries with children under 15 accounting for 40 percent of the estimated injuries. Children and young adults under 20 had 58 percent of the estimated injuries.


•There were an estimated 900 injuries associated with firecrackers. Of these, 500 were associated with small firecrackers, 100 with illegal firecrackers, and 300 where the type of firecracker was not specified.

•There were an estimated 800 injuries associated with sparklers and 300 with bottle rockets.

•The parts of the body most often injured were hands and fingers (estimated 1,400 injuries), eyes (1,000 injuries), and legs (900 injuries).

•More than half of the injuries were burns. Burns were the most common injury to all parts of the body except the eyes, where contusions, lacerations, and foreign bodies in the eye occurred more frequently.

•Most patients were treated at the emergency department and then released. An estimated 8 percent of patients were treated and transferred to another hospital or admitted to the hospital.

Need And Use For Air Ambulance Service Is On The Rise

Despite the debate between providers and various authorities, demand for air ambulances is rising. Before hiring an air medical transport, patients and their families should make sure that the operators are licensed and bonded, that the life support systems and other medical equipment meet all requirements and that pilots and medical personnel have the experience necessary to provide for safe transport.

While it has its origins in the wartime transport of injured soldiers, air ambulance services have come to be used by medical facilities everywhere. Thousands of aircraft engage in aeromedical transport, from short-range, rotary-winged flights to more extensive journeys aboard small fixed-wing jets. Air ambulances are available for emergency and non-emergency use, and the costs can be quite high. Services range from basic medical monitoring to airborne surgical facilities. While all agree that safety and uniformity are of paramount importance, the industry lacks the regulation necessary to create equitability between all interested parties. Still, demand for this service is not going away, so regulatory change is inevitable.

An air ambulance has two basic functions: to provide fast transport from the scene of an accident to the appropriate medical facilities in an emergency situation; and to provide timely, sometimes long-distance shuttling of patients from one facility to another. Helicopters provide a more mobile, short-range solution in an emergency. Fixed-wing aircraft, such as private jets, are more suited to long-range trips. However, aircraft in both cases can be outfitted with a variety of life support systems and trained medical staff.

Private medical transport via small jets typically starts with a base fee in addition to the expense of trained staff and mileage. It is not uncommon for an intercontinental medical transport to cost $50,000 or more, although domestic flights are generally much less expensive. Depending on a patient’s insurance coverage, air evacuation might be included but only in emergencies and over limited distances. Fixed-wing medical transport specializes in long-distance movement of patients, most commonly in non-emergency situations.

Onboard medical personnel must be trained and certified according to the requirements of their profession, as well as in operational procedures and in-flight safety. While regulation generally eludes the industry, aeromedical service providers must hold an Operations Specifications Part 135 certificate authorizing them to operate an air ambulance.

The Uniform Fixed-wing Air Ambulance Regulation Project has been attempting to create a cohesive set of rules that coordinates the actions of federal and state health regulators, as well as the FAA, with regards to these medical transporters. But for now, those seeking to utilize these services for themselves or loved ones should look into safety records and customer testimonials before a final decision is made about which service to book.

Original article can be found at: http://tinyurl.com/38e3b6v

Woman shoots self to get surgery

Desperate and uninsured, Kathy Myers hoped wound would lead to shoulder repair she couldn't afford

By DEBRA HAIGHT - H-P Correspondent

Published: Saturday, June 12, 2010 1:08 PM EDT

NILES - A woman suffering from severe shoulder pain and without any health insurance shot herself in the upper arm Thursday so she could get emergency room care.

Police said the incident happened around 4 p.m. at a home in the 1500 block of Michigan Street on the city's southeast side. Niles police found 41-year-old Kathy Myers suffering from a gunshot wound.

City firefighters and SMCAS ambulance staff tended to her wound, and she was taken to Lakeland Hospital in Niles, where she was treated and released a few hours later.

The bullet, from a .25-caliber handgun, entered her upper arm and exited a few inches lower on her arm.

She told WNDU-TV that she couldn't see a specialist about her lingering shoulder pain because she couldn't afford health insurance.

"If it's not a threatening situation then they won't do anything about it," she said. "So I thought I would give them a life-threatening situation.

"I really didn't accomplish what I hoped it would accomplish," Myers told WSBT-TV. "I was really hoping it would hit an artery or bone so they would do the surgery and fix me. I have no suicide wish. My life sucks right now, but I want to live."

Paul Smallmon, the father of Myers' friend, spoke with The Herald-Palladium Friday evening. Myers lives in the Smallmons' home.

"She had a shoulder injury from about a month ago and was trying to get some help for that," Smallmon said. "She went about it the wrong way."

It was the Smallmons' gun that she reportedly used to shoot herself.

The WNDU story said Myers had been injured when she tried to restrain her bigger dog after it lunged at her Chihuahuas.

Smallmon said Myers had her shoulder injury checked out by doctors, who said she didn't have any broken bones but likely a torn or stretched ligament. They gave her pain pills, which he said hadn't taken away all the pain.

"She was in so much pain, she went out of her head," he said about Myers shooting herself. "She was at her wit's end."

Smallmon said Myers had been out of work as an asbestos remover for close to a year, had run out of unemployment benefits and didn't have any health insurance.

He said she had tried to get work recently in order to get some health insurance but couldn't work because of her shoulder injury.

By Friday evening people had come forward to try to help Myers get the medical attention she needs for her shoulder injury.

Smallmon said the gunshot wound was minor and not causing her much pain, if any, in comparison with the pain from the shoulder injury.

As for the possibility of criminal charges being filed against Myers for shooting herself, he said, "We're hoping nothing happens."

Niles Police Capt. Jim Millin said Friday that the information was turned over to the Berrien County prosecutor Friday as a routine matter. He said it would be up to the prosecutor whether charges are filed.

Millin said possible charges would be discharge of a firearm in the city, which is a local ordinance violation, or careless or reckless discharge of a firearm.

Original article can be found at:
http://www.heraldpalladium.com/articles/2010/06/12/local_news/1497527.txt

Is The ED still for "Emergencies"?

Below is a commentary I posted on an online bulletin board a few days ago.  The original poster was discussing the fact that yet another hospital system has gone public with their "ER Wait Times" (see original article at: http://www.inova.org/emergency-room-wait-times/ )

COMMENTARY
I think the elephant/rhino/gorilla in the room here is that we need to aknowledge that ED is "not just for emergencies" any more!

As a nation and a culture, we have shifted the mindset to "Now" care regardless if it's an ER Wait Times"emergency"or not.

People that are working in emergency medicine or nursing need to realize that this IS the way it IS now - it's not what it WAS before and it's NOT going back to that anytime soon.

If emergency staff find themselves being upset, disgruntled, frustrated, mad etc about "non-emergencies" coming in, they need to either (a) adjust their mindset or (b) find a new line of work because an unhappy employee is an unsatisfied employee and (i) more prone to mistakes (ii) more likely to give bad customer service etc, etc.

What the "secret" is that your admin is NOT telling you, is that they WANT the business.

The PRIMARY role of the ED is that which is mandated by federal law (EMTALA), the SECONDARY role of the ED is an "intake" or "access" point for hospital admissions. Hospital admissions = revenue, which equals profit for the shareholders/stakeholders.

Ah, but the old argument that "all our patients have no insurance"....
...this is only partly true.

The national average is that approximately 30% of your ED patient mix has NO insurance whatsoever. The other 60% has some form of payor status (private, third party, auto, medicare, medicaid). That 60% is what the hospital wants.

And if you think about it, who are you more likely to admit?
a) a medicare patient (someone typically over 65 +/- who has health conditions)
b) an unisured patient (who typically is <45, and has many fewer comorbidities)

Look at your trauma patients.
What is the #1 cause of trauma? ANS: Blunt trauma
What is the #1 cause of blunt trauma? ANS: MVC's
For the most part, what payor status are MVC patients - INSURED (auto liability insurance in MOST states)....This pays big $$$$$

Even if your ED patient doesn't get admitted, think of all the referrals that come out of the ED: referrals for outpatient testing, office visits, specialist consults, procedures etc - if your hospital is networked with the providers of THOSE services, then it's a 2/3 (60%) chance that the pt being referred has insurance and thus the referrals will have about a 60% payor status.

So, you give away 1/3 of your care to capture the 2/3 that are paying...not too shabby.

But wait, there's more....

If your facility is not the "average" and your unisured payor status is greater than 30%, you argue that you're loosing money...
Well, maybe, but that's where state and federal matching money comes in to subsidize uninsured care based on your percentage uninsured.

Also, if your facility is listed as "non-profit", then the tax benefit for writing off "charity care" is even more beneficial to them which helps keep their income taxes reduced even more which means MORE of the 60% payor's money goes into their pockets.

Why am I saying all this...?

When it was the time that I finally realized that the ED was not "the" money-maker, but rather it played a role in the hospital making money - it all became much easier to swallow and understand the bigger picture.

For when you see the big picture, you start to see your role, your department's role in it.

Use of glucometer testing to detect CSF leaks

Emerg Med J 2005;22:556-557 doi:10.1136/emj.2004.022111

• Short report

New insights into the glucose oxidase stick test for cerebrospinal fluid rhinorrhoea

Abstract

Rhinorrhoea is a clinical sign of cerebrospinal fluid (CSF) leakage in patients with skull fracture, but can also be attributable to respiratory secretions or tears. Laboratory tests confirming the presence of CSF are not sufficiently rapid to support clinical decision making in the emergency department and may not be universally available.

Detection of glucose in nasal discharge was traditionally used to diagnose CSF leak at the bedside, but has fallen into disuse as it has poor positive predictive value. We propose an algorithm to improve the diagnostic value of this test taking into consideration factors we have found to affect the glucose concentration of respiratory secretions. In patients at risk of CSF leak, nasal discharge is likely to contain CSF if glucose is present in the absence of visible blood, if blood glucose is <6 mmol.L⁻¹, and if there are no symptoms of upper respiratory tract infection.

FREE CEU's - Emergency Preparedness Courses in SC

FREE !

Preparedness Courses

For SC Pre-Hospital Personnel

 

(EMTs, paramedics, and other non-hospital emergency care personnel)

Brought to you by: SC DHEC and Emergency Services Special Operations Group

Mass Casualty Incidents/START Triage (Lecture with practical exercise/scenario) During a mass casualty incident (MCI), local resources will be overwhelmed. By utilizing the Simple Triage and Rapid Transport/Treatment method of sorting victims of an MCI responders will be able to “Do the best for the most.”

Meth Lab Awareness (Lecture)

Meth labs are more prevalent than ever and first responders need to know how to identify the properties and uses for methamphetamines, identify the hazards associated with and what actions to take when responding to a methamphetamine lab, and treat victims of a methamphetamine incident appropriately.

Pandemic Influenza (Lecture) Considerations for Emergency Medical Services participants will support the development of or review their organization’s pandemic influenza plan, know their role, and ensure they are ready to clinically respond in the event of pandemic influenza.

May 15^th 

Greenville Tech, Pandemic Influenza for EMS and WMD Awareness

Berkeley County Emergency Services Training Center, START Triage and Meth Lab/IED

May 22^nd  

Florence EMS Training Center, Pandemic Influenza for EMS and WMD Awareness

Lexington County EMS, START Triage and Meth Lab/IED

May 29^th  

Berkeley County Emergency Services Training Center, Pandemic Influenza for EMS and WMD  
Greenville Tech., START Triage and Meth Lab/IED

June 5^th  

Lexington County EMS, Pandemic Influenza for EMS and WMD Awareness
Florence EMS Training Center, START Triage and Meth Lab/IED

Session times: 10:00 a.m. – 3:00 p.m. Lunch is on your own from 12:00 to 1:00

No Registration Required

For additional information please contact:

C. J. Johnson, BHS, NREMT-P (Ret.), Owner/President, Emergency Services Special Operations Group, LLC, Medford, Oregon, 843-991-3928

or

Lorraine Dillon, MS, CHES, LPN, BT Training and Development Director, Division of EMS & Trauma, SC DHEC, (803) 545-4273, dillonla@dhec.sc.gov

Feb 18th 2010 ~ National Critical Care Transport Nurses Day~

Study questions the standard of C-Collars

Baylor study doubts neck brace standard
In some cases, device might hurt accident victims

By TODD ACKERMAN
HOUSTON CHRONICLE

1/25/10

   Applying a brace to the neck of a trauma patient, standard procedure for many decades, can worsen the injury and lead to severe paralysis or death, according to a new study by Houston researchers.

   Baylor College of Medicine doctors used cadavers to confirm that so-called cervical collars can be counterproductive, a finding that could upturn the way emergency medical personnel and doctors act to stabilize and protect the upper spine in potentially fatal neck injuries, such as those that commonly occur in bad automobile accidents.

   "This study is a proof of concept that in cases of severely unstable neck injuries, cervical collars are not only not helpful, but harmful in many situations," said Dr. Peleg Ben-Galim, a professor of orthopedic surgery and the study's lead author. "More research needs to be done, but it might be that we can prevent some of the deaths and quadriplegia that occur in these injuries."

   The study appeared this week in the Journal of Trauma.

   Dr. David Persse, medical director of Houston's Emergency Management Services, called the study "compelling" and "concerning" and said it will come up for discussion at the annual meeting of the nation's 30 largest EMS departments in Dallas next month. But he also said he doesn't want to overreact.

   "We need to look at this thoughtfully before we change the standard of care," said Persse. "It concerned a particular kind of injury. It may apply to other injuries as well, but we don't know that yet."

   But Persse added that he understands the need to act quickly, that "it's not like a lot of areas where there's not as serious downside to waiting for the next study."

Car-crash victims

   Ben-Galim said cervical spine injuries are found in the autopsies of up to 94 percent of people who die in car crashes, which claim about 44,000 U.S. lives annually. There are about 11,000 people annually who survive spinal cord injuries.

   There is no obvious alternative to cervical collars, though hospitals often place sandbags under the back of the patient's head and, less commonly, some EMS teams at the scene of the crash wedge the head of the patient between foam bolsters on the backboard.

   The injuries in question involve the area where the brain connects to the spinal cord. Doctors treating such injuries work to stabilize the ligaments, muscle and bone to prevent secondary injury and to protect the brain stem and cord.
  
   Baylor researchers undertook the study after a case in which a broken jaw precluded the use of a cervical collar on the survivor of a car wreck brought to Ben Taub. When the doctors started to put a collar on the patient, fluoroscopy showed two of the patient's vertebrae separate, causing doctors to immediately remove the collar. The treated patient ultimately walked out of the hospital on his own.

   Ben-Galim noted that there are other such case histories in medical literature.

   To study the phenomenon, Baylor researchers made an incision in cadaver neck ligaments based on patient X-rays, then simulated clinical scenarios by applying cervical collars and putting the bodies in ambulances and driving a distance.

   In all of the cadavers, imaging technologies found that the collar increased the rupture.

   In effect, the collars pushed the head away from the shoulders, Ben-Galim said.

   He said the rupture stretching occurs because of both the application of the collars and their continued use.

   One national expert called the study interesting but said he wasn't sure it would one day change the standard of care.

   "There are certain cases, like the ones in this study, that can be dangerous, but they're rare -- most people who suffer high neck injuries die immediately," said Dr. Tom Scaletta, the past president of the American Academy of Emergency Medicine. "I think the study's importance will be to raise awareness about the special care that must be taken -- preserving patients' normal head position, making sure they're not having difficulty breathing."

Anecdotal cases

   Dr. Walter Lowe, director of the Memorial Hermann Sports Medicine Institute and team physician for the Houston Texans football team, said the study wouldn't change the care of injured football players removed from the field in collars and on stretchers because those injuries tend to involve lower areas of the spine.

   Ben-Galim said that since the study was undertaken, Ben Taub doctors have saved patients with severe neck injuries by loosening or removing cervical collars early and rushing them to the operating room, but he acknowledged such cases are anecdotal.

   He said the research team looked at 400 articles and found no scientific evidence that cervical collars can stabilize severely unstabilized spine injuries.

Original source: http://www.seattlepi.com/health/414631_Neck25.html

Pain Scale - "Zero to Ten"...!

In this business of ER/EMS/Healthcare, we have been tasked with an attempt to objectify a patient's "pain".  Apparently many bean-counters and doctoral candidates have done research on how to do this, and as such the "Zero to Ten" scale was born.

Now most of you reading this are undoubtedly of the ER/EMS genre' and are all too familiar with this "scale".  Our instructors, mentors, preceptors, managers, educators (ad nauseum); pound it into us to use this scale.  It's pretty easy for them to say that because on paper it looks good, but as most of you, my readers know, it is haphazard at best to apply effectively...  Oh, wait, let me also throw in what they told us in feel-good-nursing-school, "pain is whatever your patient says it is".   So, we are asked to unquestioningly document "whatever" the patient says about their pain.

By itself, this is not too bad, however, it is when the patient is savvy to this whole pain scale thing that they begin to manipulate it to suit their own needs and wants.  We are left to unquestioningly just "write it down" with no practical attempt to help the patient understand what we are trying to measure.

So we write what the patient says, then we spend the next 5-10 minutes charting all those "little things" that we observe about the patient's behaviors - those things that seem to make the patient's self-assessment inconsistent at best....

"patient talking/texting/IM'ing on cell phone..."

"patient laughing, joking with friends..."

"patient walks to room with steady, coordinated gait..."

"patient smiling..."

"patient resting (sleeping) on stretcher spooning with boyfriend...!"

...and on and on

Sometimes we go further to note more objective findings such as the vital signs:

-reported pain score "10"

-Pulse rate: 56....???

However, in an attempt to further quantify this pain scale, and maybe to help the patient understand what we're looking for, I came across this table (see below) which strives to put some defining characteristics to the different pain levels....

Comparative Pain Scale
	0	No pain. Feeling perfectly normal.
Minor Does not interfere with most activities. Able to adapt to pain psychologically and with medication or devices such as cushions.	1 Very Mild	Very light barely noticable pain, like a mosquito bite or a poison ivy itch.
	2 Discomforting	Minor pain, like lightly pinching the fold of skin between the thumb and first finger with the other hand, using the fingernails.
	3 Tolerable	Very noticable pain, like an accidental cut, a blow to the nose causing a bloody nose, or a doctor giving you an injection.
Moderate Interferes with many activities. Requires lifestyle changes but patient remains independent. Unable to adapt to pain.	4 Distressing	Strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe real hard
	5 Very Distressing	Strong, deep, piercing pain, such as a sprained ankle when you stand on it wrong, or mild back pain. Not only do you notice the pain all the time, you are now so preoccupied with managing it that you normal lifestyle is curtailed.
	6 Intense	Strong, deep, piercing pain so strong it seems to partially dominate your senses, causing you to think somewhat unclearly. Comparable to a bad non-migriane headache combined with several bee stings, or a bad back pain.
Severe Unable to engage in normal activities. Patient is disabled and unable to function independently.	7 Very Intense	Same as 6 except the pain completely dominates your senses, causing you to think unclearly about half the time. Comparable to an average migraine headache.
	8 Utterly Horrible	Pain so intense you can no longer think clearly at all.. Comparable to childbirth or a real bad migraine headache.
	9 Excruciating Unbearable	Pain so intense you cannot tolerate it and demand pain killers or surgery, no matter what the side effects or risk. Comparable to throat cancer.
	10 Unimaginable Unspeakable	Pain so intense you will go unconscious shortly. Most people have never experienced this level of pain. Those who have suffered a severe accident, such as a crushed hand, and lost consciousness as a result of the pain and not blood loss, have experienced level 10.

So, now, here's your clinical story to illustrate the use of this scale...

Dr: "Between zero, being no pain and 10 being the worst you can imagine, how would you rate your pain?"

Pt: (calmly)..."a 10"....

Dr: "Okay, at 10 would be you getting hit in the face with a 15 pound sledgehammer, and unconscious from the pain, not the head injury.  Most people have never and will never experience this pain level ~ and if they do, will undoubtedly be unconscious..."

Pt: (again calmly)..."okay, 9-and-a-half..."

Twas' the Night Before Christmas - Nurse Style

Twas the Night Before Christmas -A Nursing Version

Twas the night before Christmas, and all through the floor
Lasix was given, filling foleys galore.
Stockings were worn to prevent emboli,
they came in two sizes, knee and thigh high.

The patients were nestled half-@$$ed in their beds,
while visions of stool softeners danced in their heads.
We in our scrubs, and they in their gowns,
Fashion created to hide extra pounds.

When down in the ER it became such a zoo,
they called with admissions for me and you.
They're coming, they're going, and they're all looking the same.
My patience for patients is starting to wane.

Now call lights are ringing, the patient 400 pounds,
says "Didnt get my pericare, send my nurse now".
And now delegation seems the best plan,
We try to send others, for the needs of this man.

When what to my wondering eyes should appear,
But Santa himself and 8 tiny reindeer.
Hey says he comes from Central Supply.
To bring us LR, NS, & D5.

The doctors then scribbled what no one could read.
Orders on patients, to measure their pee.
We try to decipher illegible words,
orders for patients, to guaiac their turds.

The new shift arriving, our day is now through,
How did stool & emesis get in my shoe?
We give them report and pass on the facts,
and tell them of duoderm lining the cracks.

And the nurses exclaim as they limp out of sight,
"Ativan to all, and to all a good night".

Nurses' Perks For Working on Christmas

There truly are advantages to working on Christmas and other holidays.  If you are scheduled to work a holiday, don't despair!  Look at the bright side.

OVERTIME PAY:  This is one perk that most nurses appreciate when working a holiday like Christmas.  The extra money can help with holiday expenses.  If you are really on the ball, you can start paying off your bills quicker – get a jump on your New Year's resolution.  If your loved ones are upset that you are not going to be there part of the day on Christmas, plan something special with them later in the week!  Let them know in advance what you will be doing.

YOU DON'T HAVE TO COOK:  Health care facilities go full scale on Christmas to make a fantastic meal for patients and family members.  Staff members working Christmas reap the benefit of a great holiday meal without the cooking and clean-up!

YOU GET TO WITNESS SPECIAL MOMENTS BETWEEN PATIENTS AND FAMILY MEMBERS:  You get a front row seat to those special holiday moments shared between patients and their family members.  You see the hugs from grandkids, the gifts exchanged, and hear the resolutions and hopes for the New Year.  This is a gift you can't and won't want to exchange!

YOU ARE REMINDED HOW LUCKY YOU ARE:  By seeing those special moments, you are reminded of how lucky you are and all of the great gifts in your own life.  After all, you get to leave the health care facility after your shift – conversely the patients have to stay!

YOU ARE NOT WORKING THE ENTIRE 24 HOUR PERIOD:  You still have about 12 hours of the day to spare.  Make plans to do something special on the holiday before or after your shift.  Create a unique and new tradition for your holiday this year!


Credit for this essay goes to Sue Heacock, RN

Some Pearls for EMS/ER to live by...

Credit for this goes to Thom Dick as publised in his JEMS article...

Following is a list of 30 Pearls for EMS/ER practice.... 

1. People don’t change. 
2. Some of the most beautiful people in the world come wrapped in the plainest packages .
3. You can stir up as much trouble as you need to. Just make sure you do it only to make things better, your care is always top-notch and your certs are always up to date.
4. You may be a medical genius. But sometimes it’s your job to just take people to the hospital.
5. Never plan anything until after noon on the day after a 24-hour shift.
6. People make stuff up, sometimes.
7. This is medicine we’re doing here.
8. There are two kinds of leaders in EMS: good ones, and those who spend just enough time in the field to realize they hate it—then presume that qualifies them to lead those who don’t.
9. It’s not enough to be nice. You have to be competent and nice. 
10. There’s a very good reason why you’ve never met a dual-role surgeon. 
11. The genius who first presumed that one person could do two full-time jobs at once was an administrator who meant some other person.
12. Liars lie—that’s why we call ’em liars.
13. A whole lot of stuff is funnier than you think.
14. Paramedics/ER Nurses get lied to for a living. There’s only one thing dumber (sic) than lying to one, and that’s lying to a whole room full of them at once.
15. Anybody can be a former Paramedic/ER Nurse. All you have to do is quit.
16. Never do anything you know is stupid (especially if the person who tells you to do it is stupid).
17. You can break bad rules, especially if you’re funny.
18. Your life insurance company wants you to be in perfect health, because that means you can keep on paying premiums. They don’t care if you’re happy.
19. The concept of fear is not discussed in any EMS/Nursing text. That’s too bad, because fear is a component of all suffering.
20. What’s right is not always popular; what’s popular is not always right.
21. People who cut corners eventually find themselves running around in circles.
22. If most people were smart, we would be unemployed.
23. Be nice to people on your way up. You may meet them again on your way back down.
24. If the patient tells you they’re about to die, they’re probably right.
25. Nothing in the EMS/Nursing curriculum makes us judges.
26. We should probably listen about twice as much as we talk.
27. People don’t care how much you know until they know how much you care.
28. If you’re tired of taking care of poor, old, dirty, naked sick people, take a rest. Do something else.
29. Your ambulance is a machine that can either earn you a living or kill you on any day of your career. It probably deserves your respect.
30. A partner who tells you not to worry about their driving because they "can handle it" most likely isn’t so sure. Maybe you’d better take the keys.

US Panflu Update - 11/12/09 "Are we in the clear yet???"

US Pandemic Situation Report- Nov 12th

The overall national trend is now one of declining impact. Reporting nationwide continues to be highly variable from location to location. Some locations are reporting decreases in case loads while others are reporting dramatic surge. The below information pertains to those locations within the US reporting challenges related to pH1N1.

School Absenteeism

Student absenteeism rate (elementary and high school): 10-40% (10-20% usual range reported)
Teacher absenteeism rate (elementary and high school): not specified but still documented

Local Medical Infrastructure

EDs and outpatient clinics continue to be overwhelmed by anxious well and truly ill patients.

EMS and first responders report no appreciable impairment in operations reported.

Hospital ward level inundations have been reported. Excession of capacity was not noted since last report. Healthcare worker absenteeism has contributed to strain.

ICU capacity has been reported to approach near- to at-capacity. Demand for ECMO or HFOV continues to be observed.

San Joaquin County, California declared a local state of emergency due to broad medical infrastructure strain.

Mortuary services have not reported strain.

Fewer people are donating blood in the United States due to the pandemic. In addition, some blood centers nationwide have had to throw out blood donations after learning that the donor had influenza-like symptoms. Although the centers claim that they have sufficient blood supplies now, a further decrease in blood donations, particularly during the Christmas season, is a concern.

General Infrastructure Strain

Main sectors affected this week include primarily education, public health, and medical care. Government and corporate sectors have not reported strain since last report.

A pork producer from Clinton, North Carolina filed for bankruptcy after owing about USD three million to various vendors. The company, Coharie Farms, blames the loss on an increase in grain prices, a decrease in hog prices, and pandemic (H1N1) 2009 "fears". The owner of Coharie Farms plans to liquidate the company and "some" of the 170 employees will be laid off. The company lost about 17 million dollars this year. Coharie Farms is the largest independent pork supplier to Smithfield Foods Company. North Carolina has the second largest pork industry in the United States.

Social Anxiety

Frustration and anxiety associated with failure of meeting expected public access to pandemic vaccine and public perception of uneven distribution of vaccine to priority groups has become the primary focus for public anxiety. This relates to public outcry due to a perception of politicians and other non medical-risk groups observed to be vaccinated ahead of those groups identified and publicized by CDC for vaccine priority.

Worried well influx to emergency departments and parents keeping well children home from school continues to be documented. Limited instances of parents refusing vaccination after reports of adverse vaccine reactions (regardless of credible proof the vaccine was the cause of the reaction) continue to be documented.

The current focus for social tension revolves around vaccine availability and uneven distribution.

In addition to strain and anxiety, medical staff are dealing with threats, insults, and bribes from patients. Doctors are compelled to reassure patients that they are waiting their turns for the vaccine and not prescribing Tamiflu for themselves or their families unless necessary. Two vaccine clinics in New York were canceled after parents began to threaten nurses. According to staff members, one parent stated that he would "hunt down" the nurse if anything happened to his child while another parent threatened to sue a nurse if something happened to his child.

Primary triggers for social outcry and anxiety behavior continue to be 1) the death of children or 2) pregnant mothers in a community. Publicly perceived violation of expectation regarding availability (and now) distribution of pandemic vaccine has become a prominent driver of social anxiety.

Environmental Conditions

Environmental conditions are currently moderately optimized for transmission throughout the majority of the US and are projected to optimize fully within the next 3 months.

Expected Progression

While national epidemiological statistics indicate a past peak and decline in cases, high variability in local experience is still observed. Overall national impact is declining.

Pandemic H1N1 is expected to continue to strain local medical capacity, however now at lower levels. Variables in local transmission include herd immunity levels achieved through prior community exposure to the virus, public and healthcare worker uptake of pandemic vaccine, and virus genetic stability.

Veratect's West and East Coast Operations Centers remain vigilant for possible resurgence following mass mixing events such as Thanksgiving and especially the Christmas / New Year's holiday seasons. It is unclear to what degree the pandemic will impact social functioning when environmental conditions are maximally optimized in January-February. Veratect remains vigilant for reporting of virus drift or recombination.

 James M. Wilson V, MD
Chief Technical Officer and Chief Scientist
Veratect Corporation
Kirkland, Washington
571.225.3671
jim@veratect. com

CAMTS Accreditation - Blessing or Curse?

NOTE: This is my commentary/response to the original article which appears at:

VerticleOnline and published Oct 21, 2009

MY COMMENTARY:

CAMTS accreditation has become double edged sword.

On one hand your HEMS program may not be able to live without it (either by regulatory requirement of your state, OR by lost revenue via third party insurers who require accreditation), but on the other it may be hard to live WITH it too! -recurring site visits, 3 year applications for reverification, continually updating standards etc.

One of the big problems with CAMTS accreditation is that in some circles it is legislatively mandated (see the 8 states that require it) and by definition, accreditation conflicts with "mandatory" -- so which is it? Mandatory or voluntary???

Personally I believe the original intent of CAMTS was good for the following reasons:

1) It's not governmental: for those of us who dislike big brother running everything. (This is a HUGE plus in my book)

2) Technically, it's still voluntary (debatable)

3) Nursing/carregivers: involvement with heavy focus on requirements for the medical crews, in my opinion, is good. I believe the industry is moving towards recognizing the medical crews as AIRCREWS. I think there will be needed discussion when/if this happens (I hope it does) because then there is more FAA oversight in that aspect.

4) CAMTS uses widespread representation. Argue if you like about how the pilots are not as strongly represented, but there are a few other "non-specific" seats on the CAMTS board of directors which could be occupied by qualified pilots as well.

---->NOTE: if the HEMS pilots do not feel they are represented adequately by CAMTS, then they should lobby their professional organizations to develop some type of accreditation program as well, OR, get their representative body to work more collaboratively and intertwined with CAMTS

5) In my personal opinion, in what I have read and researched over the years, I feel CAMTS strives to stay "ahead of the curve" in as much as incorporating or leaning towards industry leading "best practices" as well as those practices which may be recommendations by federal investigative/review committees. I have always felt that CAMTS was dynamic and responsive to the HEMS community.

I realize there are more problems and concerns with CAMTS which I have not listed here; I will look for part two of this article to help stimulate more discussion.

My bottom line however, is directed towards the skeptics and nay-sayers.. and I say to those that are (1) unhappy, (2) dis-enfranchised or (3) mis-represented by CAMTS - "sorry", CAMTS has ONLY become so influential and powerful by the VOLUNTARY submission to it's program requirements and accreditation processes by programs across the US... The more programs that seek the CAMTS "Merit Badge", give the CAMTS machine more influence, power and presence....

National Emergency Nurses Week Oct 11-17, 2009

Emergency Nurses "Prepared for the Unexpected"

Emergency nurses across the US will be celebrating Emergency Nurses Week, Oct. 11-17, and Emergency Nurses Day on Oct. 14. This year’s theme is "Prepared for the Unexpected," a perfect theme as every day brings the unexpected. There is no "usual" or "typical" day in an emergency department.

Emergency patients are just that — emergencies requiring acute, episodic care. We care for patients across the lifespan, with a vast range of problems. It is not uncommon to care for a two-year-old boy with a fever, a 75-year-old woman with a fractured hip and a 22-year-old man involved in a car crash, all in the same hour.

We are frontline health care providers, often a person’s first and only interaction with the health care system. Every day, we interact with other disciplines — including physicians, paramedics, respiratory therapists and police officers. We do not work alone, but as part of the health care team, relying on each other’s skill and expertise. Each day, we touch people’s lives, from providing CPR, to explaining the signs of infection to a mother whose child just received stitches for the first time. We are there for our patients and families during happy and sad times — we are also there for each other.

We need to acknowledge the great work done by all our emergency nurses across the US. We are truly a unique specialty, caring for a multitude of diseases and injuries from infancy to adulthood. Every day, we are faced with increased demands, from violent patients, short staffing to overcrowding, but we do our best to provide safe and competent care.

*****
Since 1989, the Emergency Nurses Association has celebrated the second Wednesday in October as Emergency Nurses Day, a day set aside to honor emergency nurses for their commitment to patient care. Starting in 2001, ENA expanded the celebration to devote an entire week to honoring emergency nurses, because it was felt that one day was not enough to recognize all contributions made my emergency nurses.

ENA is the only professional nursing association dedicated to defining the future of emergency nursing and emergency care through advocacy, expertise, innovation, and leadership. Founded in 1970, ENA serves as the voice of more than 36,000 members and their patients through research, publications, professional development, injury prevention and patient education.

ENA General Assembly Day #1 - Town Hall Report

Day #1 of the ENA General Assembly (GA) finished up with a Town Hall style meeting. This is an activity which has been done at the last several ENA GAs and has continued since. It is an opportunity for members to meet in a collegial and informal setting and ask quetions and engage in an "open forum" with the ENA leadership. This provides an opportunity for members to directly ask questions or discuss ideas with the leaders in a setting in which they might not otherwise be able to so easily. Each town hall meeting has several ENA leaders and members of the board present.

The town hall meeting Wednesday evening went quite well. Participation was good and there were approximately 40-50 members present to share.

Some of the topics/items shared are presented here...

One member brought up discussion that they were having a hard time getting "buy in" on TNCC education at her small community hospital because they aren't a "trauma" center and apparently the adminstration felt that they didn't need "trauma" education.

The presenter aknowledged that TNCC was an outstanding course that taught good ED nursing skills as far as patient assessment. Members of the ENA board and those involved with TNCC development responded. They said they understood the point and suggested that this person try to promote TNCC education from the standpoint that a lot of trauma doens't come into the ED by EMS/prehospital, but also by private vehicle or "walk in". As such, it seems that "trauma" education even in the non-trauma centers is definitely of benefit. There was no indication that the naming of the TNCC product was going to be changed, but that maybe a strategy for marketing it differently to address the broader needs of all EDs.

Another question was presented regarding the newest BCEN certification, the CPEN (Certified Pediatric Emergency Nurse). It was pointed out that the CPEN is the only BCEN credential which includes a clinical practice requirement in order to sit for the exam. Currently the other BCEN credentials do not have this (CEN, CTRN, CFRN). The question was asked as to why this practice requirement was made and if in the future, the other credentials would move to include a clinical requirement also.

The response was that the CPEN was developed in conjunction with the Pediatric Nursing Certification Board (PNCB). The joint venture was necessary to establish core content and competencies and as such necessitated the CPEN mirror the pre-existing clinical practice requirement of the PNCB.

So basically the CPEN is a "joint-certification" and shares similarity with PNCB. The other BCEN credentials (CEN, CFRN, CTRN) are unique to BCEN and share no joint development with other certifying boards.

Finally a member from California ENA brought up for discussion that in her state they were having a new mandate from their state legislation. AB 911 mandates that the EDs use a matematical formula to calculate how "full" or "busy" they are with high acuity patients. The presenter discussed how they are not sure how these numbers are going to be used but they are having to dedicate resources to fulfilling this obligation. There was also concern that this mandated a certain softward package or method to do this. Another speaker, also from California, stated that she felt it was a useful tool because part of the calculation was taking into account some patient/system acuity beyond just the ED as it includes numbers of ventilators available etc.

The ENA town hall board responded that they were not as familiar with this recent legislative madate, but would keep their eyes on it in the future. It was stressed to the attendees that this was an example of needing to keep active on the legisltative forefront via our ENA's support structure.

Conclusion:
The town hall meeting ran up until the end of time and probably would have gone on longer if there was not a time constraint.

This author has attended the GA Town Hall meeting for th past 4 GAs. I have always appreciated the venue and felt that it was beneficial. It's a nice forum to get a "direct line" to the people with answers or to get referred to those who may be able to help more. It has always been open, informal and a good use of time.

I'm going to suggest to the ENA conference committe that we continue this forum, maybe even to have it repeated on one of the days of the "reguular" conference too, or to extend the time to 90 minutes or so because there has always seemed to be more topics pending that people wanted to discuss.

ENA Conference/General Assembly Opening in Baltimore

Wednesday October 7.
8:00am

ENA president Bill Briggs called the General Assembly to order for 2010 here in Baltimore MD.
Many new and interesting things were on tap for starters.

One of the first "improvements" was the installation of a new method for registering keypads for the delegates to vote with. Previous years had seen difficulties with delegate registration, missing keypads, DUPLICATE keypads, keypads being "swapped" etc. So it was with a bit of trepidation that we installed a new vendor/service for this and a new process for registering keypads. Overall it seems to be like a good system and some inefficiencies since last year have been improved upon... so far. ...we'll see!

The second part of the morning session saw some emotional debate and speaking regarding one of the new proposed bylaws which is going to effectively "cap" the number of delegates to the general assembly.

This had been proposed by ENA leadership for several reasons, one of which was a financial concern in that larger and larger delegate assemblies was becoming a logistical chore, as well as expenses to the organization were increasing as well. The ENA leadership had proposed a fixed number of delegates and each state would be awarded a respective percentage based upon their annual membership.

Good --- Bad???

Much discourse was had throughout the assembly, many people voiced their opinions both for and against. Some of the larger states voiced concerns that their representation might be diluted by the smaller states getting their "guaranteed" delegates based on small ENA member rolls. Other speakers voiced concerns about the principles of "grassroots", "membership driven" as their speaking points and they advocated for the current method using arbitrary ratios, such as is the current case.

The discussion went on and nearly ran into lunch time and discussion had to be halted temporarily.

As for this author, I am not completely convinced on my own stance on this. I understand the need to limit some of the expenses and the ever increasing logistical burden, however I also understand that, as a "pure" representative organization that is growing, a stable delegate:member ratio, despite increasing numbers, has it's benefits also.

Will be interesting to see how this one pans out.