Category Archives: General

Forensic Nursing

Forensic Nursing combines nursing science with the investigation of injuries or deaths that involve accidents, abuse, violence or criminal activity. Sexual Assault Nurse Examiners (SANE nurses) are one of the most recognized types of forensic nurses, but they have special training in one type of injury. Forensic nursing programs typically involve a broader set of skills, encompassing some or all of the following:

  • Interpersonal violence, including domestic violence, child and elder abuse/neglect, psychological abuse
  • Forensic mental health
  • Correctional nursing
  • Legal nurse consulting
  • Emergency/trauma services, including auto and pedestrian accidents, traumatic injuries, suicide attempts, work-related injuries, disasters
  • Patient care facility issues, including accidents/injuries/neglect, inappropriate treatments & meds
  • Public health and safety, including environmental hazards, alcohol and drug abuse, food and drug tampering, illegal abortion practices, epidemiology, and organ donation
  • Death investigation, including homicides, suicides, suspicious or accidental deaths, and mass disasters

Forensic nurses find that their additional training improves their basic nursing skills, and allows them to derive greater career satisfaction from helping patient in another rather unique way.

Approximately 37 training programs exist, ranging from certificate programs that require a specific number of hours of training, to degree programs (typically Masters level programs). Many of the certificate programs are available as online training. 

Source: International Association of Forensic Nurses (http://www.iafn.org/)

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High Inspired O2 Is Not An Effective Pneumothorax Treatment

The use of high concentrations of inspired oxygen seems to be a time-honored technique for trying to avoid chest tube insertion for pneumothorax. But does it stand up to scrutiny, or is this just an urban legend?

This recommendation is based upon a single case report involving 8 patients in 1983! Six patients with a pneumothorax of less than 30% showed a decrease in size of 4.2% per day on average. The two patients with pneumothoraces larger than 30% did not respond. A response was only seen with oxygen administered by a partial nonrebreather mask, not by nasal cannula.

What’s the problem? First, this is a very small case report. There were no controls, so it is entirely possible that the resolution rate without treatment was the same as that seen in this report. Furthermore, this study was performed prior to the availability of chest CT. Therefore, the true size of the pneumothoraces is only a guess since volumetric calculations could not be performed. It is not possible to distinguish a 4% change in the size of a pneumothorax by regular chest xray (click here for more details).

The bottom line: If the patient needs supplemental oxygen for management of other pulmonary conditions, then administer it. It is not indicated as an independent treatment for pneumothorax, and its use for this condition should be abandoned!

Related posts:

Reference: Noninvasive treatment of pneumothorax with oxygen inhalation. Chadha TS. Respiration 44(2):147-52, 1983

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Lack of EMS Documentation is Associated With Increased Mortality

EMS policy and the trauma center verification process requires that all trauma patients delivered to a trauma center must have a copy of the EMS run sheet. Two parameters that are commonly used to monitor performance improvement (PI) in EMS are:

  • accurate record of scene physiology (SBP, HR, RR, GCS)
  • request by on-scene BLS for ALS assistance

The study looked at the impact of those criteria on patient survival. A total of 4744 patients from the National Trauma Data Bank were analyzed.

Physiologic data: About 28% had at least one missing physiologic data point, with respiratory rate being most commonly missed. They found that the mortality in the group with missing data was over twice as high (10.3%) as it was in the group with complete date (4.5%).

BLS call for ALS assistance: This assist was called for in 17% of cases. These cases were less likely to involve penetrating injuries and more likely to involve car or motorcycle crashes. Injury Severity Score was the same. Eventual patient mortality was the same for BLS calling ALS and ALS response alone.

So why does failure to record physiologic data translate into higher mortality? The initial response may be that the patient was sicker, and so they needed more intense care during transport with less time to record vitals. However, the researchers controlled for this and found it was not a factor. Other issues that may be a factor are EMS training and proficiency, leadership at the scene and enroute, and available staff and resources, among other things.

The researchers speculate that documentation might be a good global measure of appropriate or inappropriate prehospital care that rolls all of these possible factors into one easily identifiable audit filter. They recommend that this be used to focus performance improvement efforts and hopefully improve survival.

I recommend that the results of this study be taken to heart and used to help persuade EMS programs to get religious about recording complete vital signs and leaving the run sheet at the trauma center every time a patient is delivered. Documentation should be evaluated regularly, and all cases with any missing vital signs should be reviewed closely. Trauma Center PI programs should work with EMS to analyze this data and look for the patterns that increase mortality.

Reference: Lack of Emergency Medical Services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. Journal of the American College of Surgeons, 210(2):220-227, 2010.

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Cardiac Contusion (for Nurses)

Cardiac contusion is an uncommon condition that is too-commonly worried about. It requires extreme blunt force with a significant head-on component. The most common mechanisms are car crashes (steering wheel) and sports injuries.

A true cardiac contusion is very rare. If a patient did not strike their chest hard enough to cause significant and lasting anterior chest pain, they probably do not have one. If the force was enough to cause a sternal fracture, there is some possibility they may have sustained a cardiac contusion. During ED evaluation, if a patient with a significant mechanism does not exhibit any arrhythmias, they do not have a contusion.

Diagnosis is relatively simple: any trauma patient with a likely mechanism who has chest wall pain and a new arrhythmia or cardiac pump failure has a cardiac contusion. Atrial or ventricular arrhythmias are significant, but a ventricular one is significant because it can degenerate into v-tach or worse.Enzyme measurements do not indicate severity of injury or outcome and should not be obtained.

From a nursing standpoint, you should monitor for and report the following:

  • new arrhythmia, especially a ventricular one. Medications or cardioversion may be ordered to treat.
  • Hypotension, pulmonary congestion, or other signs or heart failure. An echocardiogram or vasoactive medications may be ordered.

Remember, true cardiac contusion is rare! If suspected, telemetry is indicated, along with frequent vital signs. Cardiac enzymes should not be ordered, and any indication of cardiac problems (arrhythmia or failure) should be reported and treated promptly.

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The VIP (Very Important Person) Syndrome in Healthcare

The VIP syndrome occurs in healthcare when a celebrity or other well-connected “important” person receives a level of care that the average person does not. This situation was first documented in a paper published in the 1960s which noted that VIP patients have worse outcomes.

VIPs have the expectation that they can get special access to care and that the care will be of higher quality than that provided to others. Healthcare providers often grant this extra access, in the form of returned phone calls and preferential access to their clinic or office. The provider tries to provide a higher quality of care by ordering additional tests and involving more consultants. This idea ignores the fact that we already provide the best care we know how, and money or fame can’t buy any better.

Unfortunately, trying to provide better care sets up the VIP for a higher complication rate and a greater chance of death. Healthcare consists of a number of intertwined systems that, in general, have found their most efficient processes and lowest complication rates. Any disturbance in this equilibrium of tests, consultants, or nursing care moves this equilibrium away from its safety point.

Every test has its own set of possible complications. Each consultant feels compelled to add something to the evaluation, which usually means even more tests, and more possible complications. And once too many consultants are involved, there is no “captain of the ship” and care can become fragmented and even more inefficient and dangerous.

How do we avoid the VIP Syndrome? First, explain these facts to the VIP, making sure to impress upon them that requesting or receiving care that is “different” may be dangerous to their health. Explain the same things to all providers who will be involved in their care. Finally, do not stray from the way you “normally” do things. Order the same tests you usually would, use the same consultants, and take control of all of their recommendations, trying to do things in your usual way. This will provide the VIP with the best care possible, which is actually the same as what everybody else gets.

Reference: “The VIP Syndrome”: A Clinical Study in Hospital Psychiatry. Weintraub, Journal of Mental and Nervious Disease, 138(2): 181-193, 1964.

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