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..."

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.

Seasonal Flu Myths

In the spirit of the upcoming flu season I decided to share with my followers this list of common misunderstandings and misperceptions of the seasonal flu vaccine. An alarming 50% of healthcare workers do not get the flu vaccine annually and some of these myths are the reasons I've heard of before...

Flu Myth #1: The seasonal flu vaccine protects against swine flu. Unfortunately, it doesn’t. The swine flu virus that first appeared in Mexico during April 2009 is a different strain of influenza virus. There is no vaccine for it. So even if you got a flu vaccine earlier this season, it won’t offer any protection against swine influenza.

Flu Myth #2: The seasonal flu is annoying but harmless. There has been a lot of focus on swine flu, but it’s important to remember that the run-of-the-mill seasonal flu can be a serious condition itself. “A lot of people just think of the flu as a very bad cold,” says Curtis Allen, a spokesman for the CDC in Atlanta. But it’s much worse than that. For one, you usually feel terrible. In addition to the congest ion and cough, you’re apt to have nasty body aches and fever, which are less likely with a garden-variety cold. “When you get the flu, you know it,” says Christine Hay, MD, assistant professor at the University of Rochester Medical Center. “You feel like you’ve been hit by a Mack truck.” Aside from the short-term misery and lost workdays, flu can have more serious implications. Sure, most people who get the seasonal flu recover just fine. But the seasonal flu also hospitalizes 200,000 people in the U.S. each year. It kills about 36,000. That’s close to the number of women killed by breast cancer each year, and more than twice the number of people killed by AIDS.

Flu Myth #3: Swine flu is transmitted by pork products. Lots of people have reacted to the swine flu outbreaks by swearing off bacon – just as some countries reacted by banning pork or slaughtering pigs. But experts say that despite the name, there’s no reason to worry about pork products spreading swine flu. Though the virus did originate in pigs, it’s now jumped to people. Since then, the spread has been from person to person, not from pork to person.

Flu Myth #4: The flu vaccine can give you the flu. This is the flu myth most likely to drive experts bonkers. “There is simply no way that the flu vaccine can give you the flu,” says Hay. “It’s impossible.” Why? For one, injected flu vaccines only contain dead virus, and a dead virus is, well, dead: it can’t infect you. There is one type of live virus flu vaccine, the nasal vaccine, FluMist. But in this case, the virus is specially engineered to remove the parts of the virus that make people sick.

Flu Myth #5: There is no treatment for the flu. If you can get to the doctor quickly -- within 48 hours of having flu symptoms-- there are antiviral medications that can help. These drugs, such as Tamiflu and Relenza, won’t cure the flu. But they can reduce the amount of time you’re sick by one or two days and make you less contagious to others. These drugs work with both the typical strains of seasonal flu as well as swine flu.

Flu Myth #6: Antibiotics can fight the flu. Antibiotics only fight bacterial infections. Flu – whether it’s seasonal flu or swine flu -- is not caused by bacteria, but by a virus. So antibiotics have absolutely no effect on any kind of flu. But this message just won’t sink in for some people. “We still have oodles of patients coming into the doctors, or bringing their children to the doctors, who want antibiotics for influenza,” says Schaffner.

Flu Myth #7: The flu is only dangerous for the elderly. It’s true that the people most likely to become seriously ill or die from the seasonal flu are over age 65. But flu can become risky for anyone, even healthy young adults. Some of the most susceptible people to seasonal influenza are young children. Experts don’t have enough evidence yet to say whether young children are at increased risk from swine flu. However, based on past experience with the seasonal flu and previous flu pandemics, it’s possible. “Children under 2 years have some of the highest rates of hospitalization from [seasonal] flu,” says Hay. Children under 6 months are at the most risk from the seasonal flu because they’re too young to get the vaccine.

Flu Myth #8: “Stomach flu” is a form of influenza. The word “flu” is so overused that it’s lost much of its actual meaning. Gastrointestinal viruses are called the “stomach flu,” but they have no connection to the actual influenza virus. If you suffer vomiting and diarrhea, but no fever or body ache, you probably do not have the flu.

Flu Myth #9: If you get the flu, you can’t get it again during that flu season. Many people assume that if they’ve had the flu recently, they can’t get it again -- and thus don’t need to get the vaccine, Perl says. That’s not the case because the flu isn’t a single virus. “In any flu season, there’s usually both Type A and Type B influenza in circulation,” Perl tells WebMD. Both can cause the flu. It’s quite possible that you could get infected with one type and then the other.

Flu Myth #10: If you’re young and healthy, you don’t need to worry about getting the vaccine. First of all, we should all get the seasonal flu vaccine. Sure, if you’re in good health, you’ll probably recover from the seasonal flu just fine. But why suffer through the flu if you can avoid it? Second, protecting yourself isn’t the only reason to get vaccinated. “Healthy adults forget that while they themselves might be at low risk for getting serious flu complications, other people in their family might not,” says Hay. If you have a small child at home, or an older parent, your failure to get yourself vaccinated could endanger them. And that’s true on a larger, societal level. People with the weakest defenses, like children under 6 months, can’t get the flu vaccine. Their safety depends on the rest of us getting immunized.

Flu Myth #11: You can skip years between flu vaccinations. Experts say that some of us don’t understand that we need a new seasonal flu vaccine every year. “It’s confusing, since the flu vaccine is different from most vaccines, which offer longer-lasting protection,” says Schaffner. “With the measles vaccine, you get two injections and then you don’t have to worry about it for the rest of your life.” The flu vaccine isn’t like that.

Flu Myth #12: Vaccines are dangerous. In recent years, there’s been growing mistrust of vaccines, including the flu vaccine. Some believe that there could be a link between vaccines -- specifically the ingredient thimerosal -- and developmental disorders in children, like autism. However, there is no evidence that vaccines cause autism, and experts say that we’re losing sight of how important vaccines are. “Vaccines are, arguably, the greatest medical advance in history,” says Perl. They’ve prevented more illness and death than any treatment.

Flu Myth #13: Cold weather causes the flu. No matter what your grandmother may have said, going outside in the winter hatless does not increase your risk of flu. While there might seem to be a connection -- since flu season coincides with colder months in the U.S. -- there isn’t. After all, flu season is the same throughout the whole country: even if it’s frigid in Minnesota, it’s still warm in Florida. The rise and fall of flu season each year has more to do with the natural cycle of the virus, although experts aren’t exactly sure how it works.

Flu Myth #14: If you haven’t gotten the seasonal flu vaccine by November, there’s no point getting vaccinated. While supplies of vaccine used to run out by November, that’s not the case anymore, says Allen. Nowadays, there should be enough vaccine for anyone who wants it, and you should be able to get it as late as December or January. Besides, the flu often doesn’t hit its peak until February or sometimes as late as March.

(Original source article: http://www.webmd.com/cold-and-flu/features/top-14-flu-myths)

"A 98.8% passing rate...?"

While promoting and publishing my own CEN review course and CEN Review Manual, I have been keeping abreast of what others are doing out there.

One "competitior" company is Med-Ed. On their website they boldy proclaim a "98.8%" passing rate.
While they do not specific which exam that refers to, they do print it on their flyer for their CEN classes.

I found this passing rate pretty high and had some questions as to how they calculated it so on 9/12 I called them. I called their office in Charlotte and spoke with the lady who answered the phone. She was nice and pleasant. I introduced myself and stated that I was wondering about their quoted passing rate. I asked her how they knew who did and did not pass the exam. (I do not have her permission to use her name publicly, so I will honor that).

She politely told me that they know the pass rate based on the number of people who have requested a refund based on not passing their exam.

Okay, I can buy that, I guess. But, what if someone doesn't even take the exam? I asked her this, and she said, "well, why wouldn't they take it?".

So I clarified by saying to her that she was telling me that they calculate their pass rate based on how many attendees request a refund for not passing; she said "Yes"....

Seems to me this isn't very scientific at all.
Just because someone doesn't pass the exam, does NOT mean they will contact Med-Ed for a refund.

I can think of several scenarios where someone would NOT be contacting them for a refund....

1) If the attendee is taking the class merely for CEU (continuing education) purposes and they are already certified as a CEN - they have NO NEED to take the exam! (I've had a few of these people in my own classes)

2) If the attendee does not take their exam within the 60 day window, then they do not qualify for a refund; there is the potential for many delays in this 60 day time frame. It takes at LEAST 3-4 weeks to get the "permission to test" letter from the BCEN, then you still have to make an appointment to take the exam. Some exam centers have very limited openings.

3) Another person who would not qualify for a refund is an attendee who has had their registration paid for by the hosting institution in a "flat fee" pricing structure.

There are other permutations of similar scenarios here but I believe the point is clear, there is ABSOLUTELY no sure way to know who has not passed their CEN exam.

The opposite is true however, you can find out who HAS passed their exam by checking the BCEN website and looking at the names of those who have passed their CEN. However, that still would not account for those who have NOT taken it yet.

I'll be doing my own research and study from an upcoming Med-Ed CEN review class and seeing just who is and who isn't passing their exam and running my own numbers.

In the meantime, feel free to check out MY CEN revivew book which is 10% off through the end of September!

10% OFF Thru September 30, 2009

Use code "LULUBOOK" at checkout.

(Click on the Book to Preview or Purchase!)

Primary Care in the ER?

Original article at: http://tinyurl.com/washpost071309 See my points/comments in bold/blue

A Critical Situation For Area Hospitals
Primary-Care Needs Spill Over Into ERs

This title is inaccurate: it implies patients are seeking "primary care" in the ED. This is false. Primary care (pap smears/breast exams, colonoscopies, diabetes managment etc) is not done in the ED, rather it's people who no longer have a PCP coming to the ED for their acute problems that would otherwise have gone to their PCP's office.

By Yamiche Alcindor

Washington Post Staff Writer Monday, July 13, 2009

Hospital emergency departments across the region are overflowing with patients who have been battered by the recession and are increasingly using hospitals as their primary source of health care, according to local and national health officials.

What national officals? This article mentions none.

At the District's Providence Hospital, emergency room visits increased by 13 percent in the past year. In Montgomery County, the number of patients seeking free care at community clinics designed to divert people from emergency rooms rose by 43 percent, many of them referred by hospitals.

The community clinics are not focused on providing ACUTE care, they are there for chronic, preventative and primary care purposes. They provide a different service line than the ED. That 43% increase are the people that have no PCP and are going there for their ongoing, primary medical services.

... A national debate is underway about how to reduce health-care costs and provide medical coverage to everyone. Diverting people from emergency rooms -- which are an inefficient and expensive way of delivering basic health care -- is a central issue, said Larry Gage, president of the National Association of Public Hospitals and Health Systems.

Don't forget dwindling reimbursements for emergency care are also to blame. Trauma funding is often inadequate as well. Lack of on call specialists, lack of qualified attending MD's and Nurses as well. Also patient "boarding" and psychiatric/mental health patient "holds" ....ALL these things are contributing in addition to people merely lacking a primary MD.

"The absolute number of people using emergency rooms has gone up as much as 20 to 30 percent in the last six to eight months due to the recession and people losing their jobs," he said. "The only option in their minds is going to the hospital."

...also, it's the only thing they KNOW. In my personal experience, quite a few of the folks I've had to refer to community clinics or free clinics had no idea they even existed. (Now here's an opportunity for public education!)

Last year, Providence and the D.C. Primary Care Association launched the ED Diversion Project, which places community health workers in waiting areas to help patients obtain primary-care doctors and sign up for Medicaid and Medicare coverage.

Now this is a GREAT idea! However, don't the hospitals have social workers and medicare/medicaid workers already? Can't the ED care team give these people the information to make a phone call the next day or give them directions to these people's offices? Why do the taxpayers (again!) have to fund this "diversion project" when we already have health care workers who can make the referrals?

Zoila Alvarez, who arrived in the United States three years ago from El Salvador, has been a patient at Mary's Center for a year. Before she found the clinic, she sought prenatal care and treatment for depression at hospital emergency rooms, she said.

Interesting, here is a lady (I'll assume a legal immigrant) who comes to the US (no mention of husband or family) to have her baby who "becomes" a US citizen upon birth....

...Albertha Boone, 55, of Southeast Washington, can relate. Her last visit to a primary-care doctor was in 1989, she said, even though she has asthma and high blood pressure and needs to have major knee surgery.

She said she has a monthly income of $1,400: $1,000 from a disability check and $400 from a part-time job as a clerical assistant. After she pays rent -- $800 -- she uses the remaining $600 to pay for utilities and buy groceries. She said that she has Medicare coverage but that it won't pay for regular doctor visits or for the knee surgery a doctor has told her she should have. So when she needs care, she will continue to go to an emergency room for treatment.

WHAT????? Medicare not paying for doctor visits? I don't believe this statement. However, if you tell me that she can't find a PCP who will TAKE medicare, then I can swallow that a bit more. We need more information here because this doesn't make sense to me.

"Moving forward, we need to do more so that people are aware of clinics in their neighborhoods," said Pierre Vigilance, director of the D.C. Department of Health. "We have to make sure that these clinics are available to people when they need them."

I agree, get the word out, run a campaign or a public education incentive. However, I postulate that the root cause of a lot of this (economy aside) from the provider's standpoint is the whole EMTALA (http://tinyurl.com/emtala) issue. Those of you in the "biz" you know what I'm talking about...the whole legislated principle of ED's not "turning" people away as well as ED's doing WAY MORE than they were designed to do beyond providing the legally mandated "Emergency Medical Screening" assessment/exam.

Tasers in the ER...

(This blog refers to a post by "Impactednurse.com" which can be found here)

Dr Donald Dawes, from the University of Louisville, Kentucky, reported that
Tasers were used 27 times at one Minneapolis medical center over a one year
period and found the number of injuries to both patients and medical staff were
reduced with the introduction of Tasers to the hospital.

(For more information on Taser devices: http://en.wikipedia.org/wiki/Taser)

It is an interesting sign of the times when we even have to be discussing use of Tasers in the E.D. However, it is a sign of today's times indeed. I can speak from my personal reference including my personal observations and viewings of Taser use in the ED.

A local ED is staffed by at least 2-3 "off duty" local law enforcement officers 24/7, they carry the usual fare of lethal as well as non-lethal force weapons (Tasers). I have seen them 'displayed' to a perp twice and seen them used to drop a pt. twice. I have "heard" them out of eye sight being used 3-4 times.

While not considered "firearms", Tasers do present a new venue of consideration which requires application of standards, codes and interpretation of the law and consequences.

There are even safety claims as to the liability for Taser weapons to cause permanent and or fatal damage. This is an ongoing debate and struggle to get these tools accepted more widely.

However, when I consider all the times I've seen the Taser "deployed", it was situations, which, in my opinion, had it not been deployed, it would have escalated into a situation in which deadly force would have been likely to have been used and/or warranted.

-KMG-365

Taxi vs. Ambulance

Any chance they are "Transformers"????

CEN Review Questions 5/19/09

Sorry for the delay folks!

Here's some more CEN Exam Review Questions for practice/review...

Here's some sample CEN like review questions. Try to answer them and write out a rationale. Try to justify why the answer you choose is correct and why the others are wrong.....

The link to the answers is at the Bottom of this page...

Category: Psychiatric/Mental Health
(1) When caring for a delusional patient, the ED RN knows that it is important to:

A) Allow the patient to freely verbalize his thoughts.
B) Provide distraction activities for this patient.
C) Acknowledge the thought disorder and orient the patient to reality.
D) Place the patient on a suicide precautions.

Category: Cardiac

(2) Which of the following is an INAPPROPRIATE route to give epinephrine by:

A) Intravenous
B) Endotracheal
C) Intraosseous
D) Epidural

Category: OB/GYN

(3) At what point during pregnancy is the fetus at most risk of injury due to trauma?

A) In the first week of pregnancy
B) In the second trimester
C) In the third trimester
D) In the first trimester

Category: Professional/Legal

(4) Which of the following sources of evidence is the BEST to establish the standard of care in a legal case?

A) The defendant's testimony
B) Nurse Practice Act
C) The plaintiff's attorney
D) An expert witness

Category: Professional/Legal

(5) A prior ED patient is suing after having complications from an IV access while in the ED previously. During that visit the pt became agitated and ripped the IV out. This went unnoticed for 3 hours as the primary RN did not do any assessment or documentation of the IV site. Based on this information, which principle of negligence is being described.?

A) Duty
B) Breach of duty
C) Causation
D) Damages

GOOD LUCK!

CLICK HERE TO CHECK YOUR ANSWERS

Too Many Cooks in the Kitchen?

A recent discussion over at Jems.com was started in which the original poster (OP) threw out the question about what drives EMS staffing, Cardiac Arrests (ALS) or Medical Care, and what the mix of EMT's to EMT-P's should be utilized. (http://connect.jems.com/forum/topics/cardiac-arrest-or-medical-care)

An interesting discussion ensued with many people voicing their opinions and experiences. After reading through a majority of the posts I could pick up on a couple of themes which seem to predominate...

One of the strongest themes is that if we are basing our EMS staffing on ALS calls, then increased EMT-P's are needed, sometimes even dual EMT-P crews. This is further facilitated by the growing use of and demand for EMT-P qualified "first responders" as part of the fire service and a responding engine or rescue company. Unfortunately, with this increased use of EMT-P's by the fire service, it has mandated or "encouarged" many who would not otherwise consider going to EMT-P school to go to get the increased education and medical credentials. Many men/women entering the fire service are now being called up on to change/alter their career paths to incorporate this EMS training to meet the demands/desires of their municipality public safety administrators.

So the thought process goes that we need more medics (EMT-P's) to be able to effectively cover more ALS calls, more readily.

While this sounds good in principle the numbers don't pan out as well.

Having more medics on duty means each medic gets less calls. Huh you say? What's that got to do with the price of diesel?

Of those ALS calls that require medic level skills (IE: non-BLS), each medic will have less opportunities to "play" and get the ongoing job/real-life experiences which add to and build upon their experience repertoire'. When one considers critical ALS skills, like, er, uh, lets say "INTUBATION", you see where lack of "practice" can lead to lack of success.

Ultimately this leads to an EMS/Fire Service with lots of medics who each SELDOM get intubations on live (er, uh, "barely alive") patients. So when it REALLY counts, they lack the field experience and have to base their skill set on those manikins and OR rotations for recalling the psychomotor skills.

Add to this the current recommendations by the American Heart Association and the EMS/Pre-hospital system as a whole; to forego intubation if BVM will suffice. So now you have even less opportunities for intubations amongst and increasing number of medics.

It's not uncommon to read about medics in some systems these days who are lucky to get even just ONE opportunity to intubate annually - that's OPPORTUNITY, we're not even talking successful intubation yet!

So now to explore this we respectfully have to look at the other side of the equation or assume the other possible outcome - to DECREASE the number of employed medics and increase the number of EMT's (basics) out there.

Well, up front the numbers would support this. Overall, a majority of all EMS calls are BLS in nature and don't require ALS skills at all. So it would make sense to have an EMS system that is heavy on the EMT-B side of providers. This would, however, beg the question: what to do with all those medics?

Some proponents have suggested staffing with medics where they are needed, or centralized or via the QRV scheme.

Looking at demographics, transport times, distances, a service could strategically look at where to maximally staff their medics. Maybe they would put them in areas that were longer transport, higher acuity traumas or more rural where experienced providers were limited in availability.

One could conceive of even putting more EMT-B's in some of the urban areas where even with a "trauma" a load-n-go might only be 2-3 minutes from a trauma center.

Some systems have already incorporated the medic QRV concept. Contemporary implementations of this usually have a shift supervisor (medic) readily available to respond to a wider area quickly to "back up" the EMT-B's on scene and bring that higher level ALS skill set when necessary. Most systems that are using this however are using their supervisors; the new evolution of this position would consider merely a street level paramedic who is unencumbered to respond as needed to scene calls and not tie up a supervisor. If no ALS needed on a particular scene, then the medic could get back "in service" and "available" for the next one.

These are only limited solutions to bigger system problems. In an era of increasing cost containment, decreasing reimbursements, increased operating costs and increased litigation risks the overall principle is COST. The costs of labor, training and effective resource utilization all add up. New and novel ways to staff and provide effective community level EMS services continues to be a challenge even for the most experienced administrations.

It is interesting however to note that we spend way too much time focusing on "the big one" when the "big one" occurs a whole less often than previously considered. But....would anyone want to tell THEIR community that they are cutting back on Advanced Life Support (IE: Paramedic) level care???? Political suicide for sure!






~"KMG-365, Clear..."

NBC TV "Trauma" - ER Replacement?

New NBC TV Series "Trauma" trailer/preview....

I'll probably watch this just for pure entertainment purposes nothing more.

Interesting - they included HEMS in this "Emergency meets Third Watch" trauma
show. Now the public will see more mis-information and mis-use of HEMS I'm
SURE!!!

I guess that's why the guy playing the flight medic/nurse ("The rebel") is
flying cause he says "I can't die".....!!!!

Emergency Department Overuse - Austin Tx

In a recent article posted in the online version of the Austin American Statesman Newspaper, Ms. Mary Roser (a staff writer) comments on a recent release of information that shows that one ED in Austin Texas log over 2678 patient visits from just nine individual patients. These astounding numbers were released by a nonprofit group in central Texas which provides care for uninsured and low income patients.

The author goes on to discuss some specific numbers in situations which paralleled that of the current state of our EDs nationwide. The problem of ED overcrowding is not new, nor is the problem of overuse of our nations emergency departments.

In her article Ms. Roser reports that between the years 2003 in 2008 there were 9 patients who accounted for 2678 merged department visits in that time. In particular, one of these patients spent 145 days in the ED during the last year alone.

Ms.Roser further discusses in her article, some considerations for possible causes of these apparently excessive uses of the emergency department. From her article it seems that one of the main causes is that these patients have no place else to receive their health care. Which, interestingly, echoes back former Pres. George W. Bush's statement about our nation's health care. Mr. Bush, when asked about the lack of primary health care in America, stated that people do have access to health care through the emergency department.

The article also attempts to explain some things are being done to appropriately manage these recurring patients. One of the doctors interviewed for the article stated that their primary focus is to assess and stabilize any medical emergencies but the problem becomes when they must decide where and how inappropriate discharge plan would be undertaken for the patient. The problem becomes that some patients still don't have access to basic health care needs, and they find that they have nowhere to turn other than emergency departments for their care.

In particular I have seen similar problems firsthand during my times working in the ER. The problem, as Ms. Roser discusses in her article, is not unique nor inherent to any one particular region, community, or facility. That being said, the solution to this ever growing problem is not an easy one to solve. A situation such as this, would require cooperation and collaboration between the health care facility, community organizations, local, state, and federal legislators.

Several readers of this article have left their comments on the newspaper website. I would like to take a few minutes and reply to some of those comments directly on this blog.

One poster (chukalukabus): seems to have the opinion that the overuse of their ED is mostly due to a problem with illegal aliens. As we are talking about a hospital in Austin Texas, I can understand this posters position and concern. It stands to good reason that in this person's region, there are many undocumented illegals residing. These same people, again I would logically assume, do not have a third-party health-insurance, and, are for the most part unfamiliar with public or free community resources for health care needs. I also believe that this poster does not realize that the problem of ED overuse is not a regional one but of national scope. Because it is a bigger problem than just locally, more than likely there are other factors at play here than just illegal aliens using the ED for healthcare.

Another poster (dterbush): remarks that if there were more affordable primary or urgent care type clinics that the emergency departments would not be as affected as much with overuse. This is a good thought. And this may be a potential solution which we are currently watching unfold. There is a growing trend nationwide towards establishing retail health care clinics to meet some primary care needs. Some of the largest venues for these are found in places such as Wal-Mart and the CVS pharmacies. These walk-in clinics, while not a substitute for primary care, are quite capable of treating a large host of maladies which typically bring people to the ED. However, the retail health clinic system, is in its early stages of establishing itself in building its unique niche in the health care industry.

Other posters who have applied to this article have indicated that "Universal Health care" might be the answer as well. We don't know this yet, if it would be beneficial or not. Additionally, as we hear more about universal health care daily, our understanding of just what universal health care is might become different than what we perceive it to be.

I suggest that any solution for this problem is still years away, multifaceted, and will have profound political and social implications to strictly address.


You can refer to the original article here:

CEN Review Questions 3-30-09

(ANSWERS POSTED 4/3/09 - Scroll to bottom of this article for link)

Sorry for the delay folks!
Here's some more CEN Exam Review Questions for practice/review...

Here's some sample CEN like review questions. Try to answer them and write out a rationale. Try to justify why the answer you choose is correct and why the others are wrong.....

Category: Orthopedic/Trauma
(1) Your patient is complaining of a painful right hand. She states it got hit one day ago, and now the hand is painful and swollen. On exam, the hand and fingers are swollen and there is a wound with dried blood over the third knuckle. You anticipate an order to:

A) Perform an iodine scrub to the finger
B) Administer oral antibiotics
C) Obtain an x-ray
D) Soak in cool saline

Category: Environmental
(2) A geriatric man arrives by EMS with reports of marked lethargy. The pt has been having a steady decline for approx 4 months. The pt appears lethargic but responsive with slow speech. Skin is pale, cool and dry. Rectal temperature is 94°F, pulse 52, resp 16, BP = 82/40. IV access is accomplished. Which is the most appropriate method for gradual re-warming of this patient?

A) Heated bladder irrigation via urinary catheter
B) Passive rewarming with warm blankets
C) Warmed IV fluids
D) Peritoneal lavage with warmed fluids

Category: Psychological
(3) A female is brought by her spouse for evaluation after she made several self-inflicted lacerations on her forearm which appear to be superficial. The spouse states that the pt has been very depressed and withdrawn for over a month since the death of their only child. The spouse also indicates the patient has taken to drinking heavily and not sleeping. What is the priority intervention for this patient:

A) Ask her if she has a plan to harm herself.
B) Bandage her wrists
C) Ask her what her usual coping mechanisms have been in the past
D) Take her to the registrar so you can get a chart started

Category: Professional/Legal Issues
(4) A 52-year-old man with a subarachnoid hemorrhage is identified as a potential organ donor. The patient’s family consists of his estranged wife, geriatric parents, a 20-year-old daughter, and 40-year-old sister. Who is the legal next of kin that can give permission?

A) His daughter
B) His sister
C) His parents
D) His wife

Category: Special Populations/Pediatrics

(5) A 4-month-old female comes in with: low-grade fever, rhinorrhea, tachypnea, and poor feeding. You suspect which of the following?

A) Epiglottitis
B) Bronchiolitis
C) Croup
D) Pneumonia

GOOD LUCK!

CLICK HERE TO CHECK YOUR ANSWERS

I Got My EM training during 'Prime Time'....

In the article "Young Doctors Learn Bad Habits From TV Medical Dramas", in the NATIONAL POST, (Mar 23, 2009) author Tom Blackwell talks about how more and more young physicians are becoming a product of the entertainment industry rather than the medical education establishment.The original article published in the "Journal of Resuscitation" looked at data gathered by a survey in which evaluation of young MDs (YMD) ability to perform endotracheal intubation (ETI) was influenced by television medical dramas.

When YMDs were asked where they "learned" their skills (when they were noted to have performed them incorrectly) some responded by indicating that they saw it "on TV". Further information showed that the most often cited TV medical drama for this was NBC TV's "ER".

Researchers then backtracked to investigate this more and find out just how mis-leading some TV medical dramas are.


The researchers (Dr Brindley and Needham) looked at an entire season of ER episodes. They specifically looked at scenes depicting ETI; and more specifically, ones where they could clearly see the entire procedure to critique it.

Their research showed that 22 observed ETIs that met criteria, had at least one step done incorrectly.

INTERESTING SIDE NOTE:
There were 22 ETIs that met criteria, I can only assume that some did not; but they do not say how many were excluded. A typical North American TV "season" averages from 22-26 episodes. This means that on the average, nearly one person received ETI each episode! Unfortunately, without data from the other seasons of ER, it's hard to compare if this particular season had more or less ETIs than their "season-average" (???)

The researchers went on to explain that "traditionally" topics such as ETI are taught in a lecture-classroom setting first, and then reinforced in the clinical (IE: hands on) setting. So when those YMDs attributed their performance failures, it is interesting to note that they recalled their more influential experience watching ETI to have come from the TV medical dramas.

So why the disparity? Why did some of the YMDs remember their ETI "training" more from the TV rather than their didactic and practical instruction? Is there something different the establishment needs to do to drive home the education and experience? Is there something to be learned from TV medical dramas?

When we look at what is "entertainment" things like: story line, special effects, continuity, contemporary issues, hi-profile actors/actresses and plot intrigue factor into play. If you look at NBC TV's successful ER drama, it is no wonder that it was successful. This was an adrenaline pumping, fast paced, on the seat of your pants show. ER was one of the innovators in using the first-person-continuous-scene filming style. This greatly enhanced the "realism" of the show. As well ER frequently dealt with issues of such impact and significance as: resuscitation, trauma, life-death -- it lends itself easily to a hi-powered drama.

All these factors that go into making ER a great show (as well as a much recognized and rewarded show), make it also form more of an impression on the viewer. You remember, more...You contemplate it more... You analyze and think about it more.

Now back to our traditional model of education; that dry, stuffy, formal lecture hall or classroom. Do you really think the classroom can lend itself to as much as an entertaining-learning experience as prime time TV?

Probably not.

Even if we step forward out of the lecture hall and into the clinical arena, it still fails to compare. The "real world" business of treating patients and learning by hands-on, does not compare to the pulse-pounding world of shows like ER. Although one would argue that once you apply learning to the psycho motor (IE: hands on) phase in the clinical setting, you should get higher reinforcement and retention - but apparently not.

I'm guessing that prime time medical dramas like ER, are just hard acts to follow when it comes to teaching and learning.

In the end, I think the lesson we can learn here is to look at what we (as educators) can do to make our teaching and our student's respective learning experiences more "high powered", engaging and compelling.

With our currently expanding use of life-like simulators, skills labs and technical advances - eventually we will reach a cross-roads where life meets technology. At that point we can start to see how a new "technical-altered-reality" would evolve.

I think there is something that we can take from all this, and see the future of education and how we can apply it to the learner's skill sets.


NEXT UP: Now I'm going to pick a season of ER and do my OWN study - I want to look at of all the ACLS scenarios, how they adhered to the AHA guidelines of the day!!!

"KMG-365, Clear..."

CCC Class Wake Med - Day 1 Report

What a day!
Just finished day 1 of a 2 day CFRN/FP-C course here in Raleigh NC at Wake Med. This was a 2-day certification review course produced by Critical Care Concepts and Rick Patterson. I was assisting Rick in teaching for his company during this class.

Their conference facility was THE BOMB. Rick even compared it to some conference hall. He said "man this is like JEMS" the EMS today national conference. Wake Med (WM) has this AWESOME conference center across from the main hospital. It's got several multi-size rooms with sweet A/V setups in each. Nice central lobby, reception areas and a juice/soda/coffe bar (self serve)....it's freakin sweet! Just being in such a nice place, made us feel like some special guest speakers and such!

Class went pretty well on day 1. We ran long and didn't cover as much as we wanted. We hit most of the big topics, but probably ran a little long winded for most of the audience.

After course introductions and "settng the stage". We kicked it off with me doing the cardio lecture. This cardio lecture is always a tiring one. The one we do for Rick's classes is a bit longer (about 80-90 minutes) than the stand alone one I do for my "CEN-only" classes. I think it's a good starting point however, and it DOES lend itself to some minor alterations depending on class prior expeience and knowledge level. Today's version we cut a bit short due to time and we dropped off the 15 or so, ACLS review slides. Instead of slides we closed out the ACLS with a 20 minute "core" ACLS review and Rick went impromptu as he finished the cardiovascular by hitting on the main ACLS bullet points. And, as always, reminded the students that if they hadn't attended an ACLS provider class within the last 6-8 months, that it's probably a good idea to hit that before taking the cert exams (CEN, CFRN, FP-C).

Then we jumped over to the flight portion of the class. Rick jumped right in and ran through the flight principles and concepts (gas laws, stressors of flight etc)..and as always, while I was sitting back watching/listening - I once again was quite engaged when Rick "does his thing"! Shortly later, we went to aircrew safety, survival and regulation to complete most of the dedicated flight content. And once again, Rick gets right into his "zone" and runs through this, lecturing effectively while inserting his anecdotes and war-stories as appropriate. Pretty cool this time working through the survival/shelter part using the big graphics on the LARGE screen; cool to see the "big picture".

Due to time concerns we carried the neuro lecture on into and through lunch this time. I was giving this one and probably where we started to see the early signs of the diverse audience starting to loose their learning thread. You start to see it when we start talking about some more "general" neuro stuff like Multiple Sclerosis or Lyme disease -- the people there for flight certifications are probably starting to think like "why do I need to know this"... So it's always a challenge to try to deliver it and at least make some relevancy to the entire audience. Interesting, at the beginning of the neuro lecture we review the cranial nerves (Nursing 101 right?)....well when I threw up the "Old Olympus Towering Tops" slide, I got so many blank stares...? Kind of made me stop and think. However as this was not a "teaching class" but rather a "review class" - I just referenced it and pointed out that some people may want to spend some time reviewing this on their own before sitting for their exams. So I knocked out the neuro lecture and then we took a break for fresh air and a leg stretch.

We proceeded to head across the parking lot to the helipad. We all posed around the Wake Med hel0; a beautiful machine -- the EC 135 with their appealing crimson and white paint scheme. It really is an appealing piece of equipment - I hope the class photos came out okay!

Afterwards we headed back in for another lecture. This time it was back to Rick for his ABG lecture. Now since I've known Rick, and since the first time I've seen him do this lecture; I am continually amazed and blown away how he does this. The first 15 min or so arethe groundwork for the topic; looking at some basic ABG concepts, pulmonary function/gas laws etc. Once that's done, the "show" begins. Rick starts to run through these ABG "problems" on the board. He starts off like a kindergarten teacher, holding the student's hand through the first few examples, prompting them along the way. Then he backs off a bit and starts letting the class work through the problems more independently.

Towards the end, the students are engaged and interacting. There were a few people however that just "didn't get it" completly and a few who were aking the time honored "calculus question: but what will I do with this in the real world?"... We had to try to explain to them that it's not so much that you'll be doing calculations like this bedside or stretcher side, rather it was a learning curve to start to drive home the relationships between the components and the principles there which lent themselves to overally pt management.

There wasn't a person who told us they had looked at the whole ABG/respiratory function like we just did here - I'm sure there were SEVERAL seasoned people who left that room feeling like they actually LEARNED something!

That pretty much wound it up for the day, it was close to 5pm and people were tired.

We'll be back hitting it early Sunday morning...bright and early at 0800!
Gonna have to step it up and get in our "zone" to keep this puppy on track.

Full day tomorrow, topics include...
1)Airway/respiratory/vents
2)Toxicology
3)Burns
4)Thoracic/abdominal trauma
5)OB/Neonatal
6)Peds
7)General medical

Gonna sign off for now, it's late and I gotta review some notes!
http://www.bemetweb.com
"...KMG-365, Clear..."