Job Resources

In this double-blind, randomised controlled trial of 59 newborn infants, a heel lance was performed to produce a noxious stimulus. A solution of either saline or sucrose was then placed onto the anterior surface of the tongue as is current practice.
An EEG was used to analyse pain specific brain activity, in addition to noting the infants facial expressions, heart rate and oxygen saturation.

The study found that although the observational assessment of pain relief (based on facial expressions) suggested a decreased response to pain, this was not confirmed by direct EEG readings of neural nociceptive activity.

The authors of the study conclude:

Thus in infants exposed to noxious procedures, sucrose could mediate a brainstem inhibition of behaviour, and inhibit facial motor activity, while strong pain activation still occurs in the forebrain. This notion is especially important in view of the increasing evidence for short-term and long-term adverse effects of infant pain experience on neurodevelopment.
The absence of evidence for an analgesic action of sucrose in this study, together with uncertainty over the long-term benefits of repeated sucrose administration, suggest that sucrose should not be used routinely for procedural pain in infants without further investigation.

Reference:

Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomised controlled trial (pdf) The Lancet

The study relates the results of a series of focus groups conducted on a group of 56 medical students that explored their experiences of cynical or derogatory humour directed towards patients.
These conversations were then analysed sorted into the following categories: objects of humour, locations of humour, the humour game, not-funny humour, and motives for humour.

Object of humour:

By far the largest target of derogatory humour were morbidly obese patients, with the greatest incidence occurring in surgery and obstetrics/gynecology.

Other examples of making fun of obese patients were the circulating stories about objects found in the folds of their bodies, as one student described: There’s lots of stories about larger older women who when you lift up their fat, and you see Oreo cookies, a remote …

Next, patients who’s problems were viewed as ” being their own fault”.
This included patients with conditions related to smoking, excessive alcohol intake, driving under the influence, criminal behaviour, and non compliance with medical treatments.

The third largest was the ‘difficult’ group. That is, patients who were demanding, aggressive, talkative, disrespectful, persistent or periodic.

The students that were interviewed all agreed that certain groups of patients were definitely off limits for cynical humour. These included:

• Terminally ill or dying.
• Patients with a history of recent loss.
• Oncology patients in general.

Location:

According to the students, derogatory or cynical humor generally can be found anywhere in the hospital but most commonly they experienced it in the operating rooms. They observed that despite the widespread use, such humour would never deliberately occur in close proximity to the patients themselves.

Rules

The students reported that humour was often initiated by more senior doctors, which was a flag for lower ranks to initiate their own contributions. However not all junior staff would appreciate or find the humour appropriate, Even so, they often felt pressured to laugh along, or at least not object.

The big thing for me personally is when you go into a room with an attending and they are talking to the patient real empathetic and they are discussing these problems appearing like they really care. As soon as you walk out of the room the attending says that patient is a nut job. [His behavior] wasn’t even real. I am going to be there one day and want to see myself as someone who really cares. But if my role models are like that, I question, Am I going to become like that?

Motives:

Most students believed that those who use such humor do so as a form of coping mechanism, or an outlet to deal with frustrating or depressing situations, particularly when patients do not take care of themselves in spite of the time, care, and resources spent on them.

One student explained how repeat offenders are resented by some medical staff because they’re drains on the resources of the hospital … they come in with problems because they don’t take their medications, and we often say, ‘So and so is in again, who wants to take him, Not me! Not me! Not me!’
Cynical humour was also thought to be used to prevent the patient becoming too familiar or getting too connected to the treating doctor:

The authors of the paper go on to discuss the use of such humor as both a defensive/protective mechanism, as a venting or purging of pent up feelings, and as an expression of (perhaps) hidden feelings of superiority.
Whatever the reason, the authors express concern over the effects of such humour on both those who use it, and those who are looking for role models amongst medical professionals.

The issues raised here go to the heart of professionalism in medicine, yet few of us want to acknowledge them directly. But we suggest that an honest engagement with the realities of clinical training faced by our students, even those realities that make us wince, is necessary.
We must forewarn students early and consistently in their training that contradictions will abound everywhere once they begin their clinical clerkships. We must alert students that they will hear horrible, disrespectful comments about patients’ bodies, about their ability to pay for care, about their addictions. We must impress upon students that there are always choices when these moments arise-to ignore such comments, to laugh or chime in, to talk to a trusted role model about what to do, or perhaps even to risk confrontation with the sources of such humor.

Reference:

Making Fun of Patients: Medical Students’ Perceptions and Use of Derogatory and Cynical Humor in Clinical Settings (Journal of Academic Medicine)

Related:

Inappropriate conversations in the health-care setting.

When the patient becomes the enemy.

In an article from the Journal of Advanced Nursing (2008), May McCreaddie and Sally Wiggins performed a comprehensive literature search and review of the use of humour in the nursing profession.
Their conclusion?

Nursing and nurses, have thus far had a perfunctory, token and somewhat fleeting association with humour research. Somewhat paradoxically, they have failed to take humour seriously, perhaps afraid that, as members of a struggling profession, they may not be taken seriously themselves.
Humour is not about whether we can tell a joke or not: it is complex, challenging, context-dependent and an integral part of who we are and how we interact with others. Current research does not support the humour–health hypothesis directly, but rather indirectly via interpersonal interactions and support. Nursing and nurses can contribute to interdisciplinary research by moving the debate out into the real world, among healthy and unhealthy people. Further, they can challenge the notion that humour is an entirely positive phenomenon and the dangers inherent in such an assertion, particularly when communicating with disempowered patients who may be struggling to cope with illness.

Some of the more interesting points to consider from the paper include:

• Commonly, the use of humour is said to be effective in lowering blood pressure, pulse rate, increasing immune response and decreased pain perception. In fact, there remains very little evidence of such effects but rather, much speculation.
• Humour or laughter may assist in decreasing stress levels and enhancing social competence and support and may be closely linked with traits such as empathy, intimacy and interpersonal trust. However, some forms of humour such as self-depreciating humour may increase loneliness and interpersonal anxiety.
• Quantitate studies support the suggestion that humour is effective as a coping strategy in managing the symptoms of burnout. Particularly in and enviroment posing stressors such as death and dying, excessive workloads and poor working environments. Humour was found to act as a stress moderator and may also confer a positive emotional state, thereby improving interpersonal relations among staff.
• Two notable studies examining the use of humour between nurses and patients with renal failure or in hospice settings concluded that it was primarily used to facilitate communication and avoid conflict. It was found to be present in up to 85% of interactions. Interestingly, 70% of the time it was patient initiated.
• Amongst clinically depressed people, or people with physical or mental illness, an individuals sense of humour may be radically altered. But, even if they do, what exactly does it mean? For example, is self-deprecating humour indicative of (a) poor psychological well-being, physical or mental health and, or maladaptive coping or (b) simply the patient’s ‘normal’ humour use?
• Several studies contend that humour is inappropriate and unethical to use when engaged in ‘serious’ dialogue or dealing with tragedy, or managing patients who are psychologically impaired or emotionally unable to appreciate it.
• However other authors suggest that such studies fail “to recognize that the very tragedy and disease-related symptoms may provide the commonality between patient and nurse and potentially offer the basis for shared understandings and humour use.

Reference:

The purpose and function of humour in health, health care and nursing: a narrative review (pdf):: May McCreaddie and Sally Wiggins ::

Our departments medical emergency team (MET) consists of a senior doctor and nurse who respond to medical emergencies occurring throughout the hospital. We actually call them the MET team, which is kinda like saying: ATM machine.

When their pager goes off they respond by pushing this rather large trolley bristling with advance life support equipment to the scene of the emergency.

But its not like on TV.

We don’t take off running down the corridor with the doctors coat flapping behind him like a Batman cape.
We walk to our emergencies, Its safer that way.

When I was young and stupid. I did run to emergencies. We didn’t have such a large crash cart back then. In one hand you picked up a fishing tackle box full of emergency drugs and cannulation equipment, with the other you grabbed the defibrillator (which was pretty heavy back then) and off you sprinted.

One night I was running to a code, full tilt down a long underground corridor that leads from one hospital building to another.
As my arm carrying the heavy defibrillator swung past my hip it knocked the pager from my waist. The pager bounced off my knee and fell to the ground breaking open… the very instant before I trod on it.

For some reason known only to Motorola, its old pagers were packed with a hundred little small ball bearing springy thingies, and I skidded along on one leg for several meters on the now disintegrating pager, arms flapping out to the sides.
One of the paddles of the defibrillator came loose wrapping around my flailing legs.

I landed heavily on my back.
The defibrillator came crashing down; seriously injuring three of the Tweety-Birds that were now flying around my head. Once I collected myself and sat up on my elbows, I could see that I had broken the pager, the defibrillator and the world record for the slowest response to a medical emergency.

Another time one of my colleagues was on the MET that responded to a man who had jumped through a large window on the ninth floor of the hospitals main building. He landed on the roof directly above the hospital main entrance.
Initially the code was called to the ninth floor, and our intrepid team, thinking it would be far quicker than waiting for our glacial lifts, humped up the stairs (right past the crumpled roof), arriving totally exhausted to find their patient was back down where they had started.

To get to him Chris and the doc had to break a thick window on the first floor and clamber out onto the roof. They were knackered. And they fully expected the man to be dead. The roof had partially collapsed under his impact leaving him laying at the bottom of this human shaped crater.
The crumpling of the roof must of cushioned his fall somewhat, for as they climbed out to him he lifted his arm and said, “I know I just died…but I feel OK.”

Crap. Now what do we do?
Chris was checking the poor guy over and figuring out how the heck they were going to extricate him off the roof whilst maintaining spinal precautions, when an enormous section of glass from the window way up on the ninth floor sliced down like a guillotine just centimeters from where they were crouched.

Chris and the doc looked at each other, MET was trumped by WTF, and without a further word of discussion, they dragged the man unceremoniously by one arm and one leg, out of his crater, across the roof and back through the window.

And then of course there was the time I ran to a code way, way over at the other end of the hospital. I was a young nurse back then and I thought I looked pretty cool yelling at little old ladies on their hopper frames to stand clear as I sprinted past. Yes, this is what being an ED nurse is all about.
By the time I got there, I was so knackered I vomited into the physiotherapy pool.
Nope, you don’t see that on TV.

1. I know, its an oldie…but there is a whole new generation of nurses who probably haven’t heard it yet.

After studiously watching one of our senior staff give an intramuscular (IM) injection, the new-grad informed us that, in fact, she was not taught to give injections into the upper-outer quadrant.
This is were I have been sticking my needles for many years now, and I have given thousands (if not millions) of injections this way.
We were about to re-orient her….but as this student is no dummy,  the senior staff member and I thought we had better get our facts straight before engaging our mouths.
We quickly slipped away under the pretext of ‘going to check for leaks in the pan room’ to find out what exactly is best practice for selecting a site for an adult IM injection in the buttocks.
Turns out she was right.

OUT: The Dorsogluteal IM injection site.

This site been used by nurses for years as the target of choice for IM injections.
It is found in the area of the superior lateral aspect of the gluteal muscles, commonly known as the ‘upper outer quadrant’.
It is located by dividing the buttock into four equal quadrants. This is usually done by drawing an imaginary cross (bisecting it vertically and horizontally).

Problems that have been identified with using this site include:

• Presence of major nerves and blood vessels in this area, including the sciatic nerve and superior gluteal artery.
  It has been taught that you will probably avoid this by further dividing the upper outer quadrant into another quadrant and giving the injection into the upper outer of the upper outer.
  Despite this, there have been reports of injuries to the sciatic nerve leading to problems ranging from foot drop to paralysis of the lower limb.
• Thickness of fat in this area. A number of studies have found that the depth of muscle in the dorsogluteal region is often greater then the length of a standard needle used for IM injections, resulting in a failure to achieve intramuscular deposition of the medication.
  In fact, one study found the success rate of IM injections to be 32% (which fell to 8% in female patients)!
  With the increasing incidence of obesity amongst our patients we are probably going to be delivering subcutaneous injections if we choose this location.
• Pain receptors are located in the subcutaneous layer, not in muscle tissues and so medication delivered into this area may be more painful.
• Dorsogluteal site has a decreased absorption rate increasing the possibility of a depot effect with drug build up and potential for overdose.

IN: The Ventrogluteal IM injection site.

The ventorgluteal (VG) site has less subcutaneous fat and a thicker muscle mass than the dorsogluteal site with an almost certain probability of penetrating muscle with a standard needle.
The VG site is also sparse of any major innervating nerves or blood vessels whilst remaining well perfused from smaller branches.

Locating the VG site.
The ventrogluteal site is located halfway between the hip and the head of the femur. One method to locate the correct site is:

1. First, place the heel of your  hand (use your L hand if injecting into the patients R VG and vice-versa) over the patients greater trochanter, and feel for the anterior superior iliac spine with your index finger.
2. The middle finger then slides across to make a peace-sign pointing up to the iliac crest.
3. The injection site is in the middle of this peace-sign.
4. Wipe site with alco-wipe in a circular motion and allow to dry.
5. Use your peace sign to spread skin taut.
6. Insert needle at 90 degree angle. Take care as you are inserting needle in proximity to your fingers.
7. There is no evidence for the need to aspirate the plunger when using the VG site.
8. Inject medication slowly (around 10 seconds per ml), remove needle quickly, and gently apply pressure to site for 10 seconds.

So, the ventrogluteal site is indeed the best practice location for delivering an adult IM injection.
You live and learn.

References:
Intramuscular injections: a review of best practice for mental health nurses:
COCOMAN A. & MURRAY J. (2008) Journal of Psychiatric and Mental Health Nursing 15, 424–434

Are techniques used for intramuscular injection based on research evidence? (NursingTimes.net)

And for some strange reason, all over the world, student nurses, paramedics, and med students are keen to find out first hand just what all that gagging is about…..

And Leo, wherever you may be……you are the man.

Most nurses have inserted them, and those that have had any experience with the management of trauma patients, know that attempting to insert a NG tube into a patient with a potential base of skull fracture is contraindicated due to the risk of the tube entering the cranium via a fractured cribriform plate¹.

However, here is something that is a little disturbing.

From the British Medical Journal comes a 1996 report on a NG tube that was accidentally passed into the brain of 59 yo female patient who had no history of trauma.
The lady ( a poorly controlled epileptic) presented with a 6 hour history of seizures following a prodrome of several hours vomiting.
The seizures were terminated following IV diazepam on arrival at the ED.

To decrease the risk of aspiration, the staff then attempted to insert a NG tube:

Three attempts at insertion were made,each of them producing blood stained fluid. When the fluid was aspirated and tested using litmus paper there was no colour change.
The tube was left in position after the third insertion as the fluid was assumed to be blood stained nasal secretions resulting from traumatic intubation.
Although the resuscitation was successful in terminating the fit, the patient remained deeply unconscious.
In view of this, and the past history of meningitis, computerised tomography was undertaken.

The patient subsequently had the tube surgically removed… but eventually died from an overwhelming sepsis.
Postmortem examination identified a small defect, a ‘congenital anomaly’ known as a nasal glioma just lateral to the cribriform plate.

This is an extremely rare occurrence, with only one or two cases ever documented.
But things like this serve to remind us never to get too complacent, even  with our ‘routine’ procedures.

You just do not want to see a CT scan like that on your shift.

Reference: Inadvertent intracranial insertion of a nasogastric tube in a non-trauma patient (BMJ)

1. The cribriform plate is a sieve-like region of the ethmoid bone (which separates the nasal cavity from the brain). When base of skull fractures are suspected an oro-gastric tube is placed instead

There are plenty of reasons for why people cause car accidents.

And we get to hear excuses for them all.
Most seem to begin with “I was just driving along minding my own business….”

Here is a list of some of the most common reasons why people actually do cause car accidents.

Of everything listed 1 and 2 are by far the most common, with 13 running close for 3rd place.)

1. Speed
2. Sloshed
3. Substance abuse
4. Sleepy
5. SMS (texting on mobile)
6. Seizure
7. Sex
8. Sneeze.
9. Spider.
10. Singing (distracted).
11. Suicide.
12. Sinister.
13. Stupidity.
14. Somewhere they shouldn’t have been.