Archive for December, 2008

Forensic Cases in the Emergency Department

December 30, 2008

As a long time employee of the ED, this chapter really perked me up. This entire Forensic Nursing course taught by Dr. J Johnson has made a tremendous impact, I think, as I tend to turn a jaundiced eye toward an ever-increasing number of cases that before might have slipped under the wire. Of particular interest was the list of potentialities in Box 53-1: a. Domestic violence, abuse, or neglect (child, spouse, partner, elder abuse) b. Trauma (nonaccidental or suspicious, and accidental injuries with third-party payer implications) c. Vehicular and automobile versus pedestrian accidents d. Substance abuse e. Attempted suicide or homicide f. Occupational injuries g. Environmental hazard incidents (fire, smoke inhalation, toxic chemical exposures, etc.) h. Victims of terrorism or violent crime i. Illegal abortion practices j. Supervised care injuries k. Public health hazards l. Involvement of firearms or other weapons m. Prominent individuals or celebrities n. Unidentified individuals o. Damaged or improperly used equipment p. Poisoning, illegal drugs, or overdose q. Anyone in police custody for any reason r. Sudden, unexpected, or suspicious deaths s. Sexual assault and abuse. References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby

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JACHO Regulation

December 30, 2008

JACHO has developed a checklist to prevent sentinel events from occurring in the hospital setting. I have not encountered these before and found them particularly noteworthy: a. Screening tools are available for personnel in clinics, the ED, inpatient, geriatric, or critical care units to identify patients who have been abused or neglected. b. All personnel are trained in the use of specified criteria for detecting abuse or neglect using objective assessments, not allegations alone, to identify cases for further management by appropriate authorities. c. Orientation and annual training programs include information and procedures useful in detecting forensic cases and referring them to appropriate individuals or services for treatments, reacted space for examining forensic patients which is equipped with locked units for storage of forensic evidence. d. Forensic reference resources are available to providers who may need guidance in identifying signs and symptoms of human abuse and neglect. e. The communication and reporting system within the facility is designed to maintain a high degree of patient privacy and discretion when forensic cases are being managed (short chain of reporting, dedicated phone lines, record security, release of information, etc.) e. Personnel are skilled in the appropriate techniques required for identification, collection, preservation and safeguarding of evidentiary items outlined in the facility’s policy and procedure manual. f. Patient standards of care include the recognition of forensic patients. g. Policy and procedures outline management of sudden, unexpected deaths, sexual assault and human abuse and neglect. h. Personal training folders incorporate required training and skills validation associated with the management of human abuse and neglect i. The facility has a clear plan for managing victims of sexual assault of all ages and both genders. j. Mechanisms are in place to accomplish various types of photo documentation and to manage these photos with high level of security and flawless chain of custody. References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby

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Forensic nursing in Correctional Facilities

December 30, 2008

This chapter started with a wonderful summary of some of the issues that forensic nurses had to contend with in correctional facilities. These nurses are not concerned about the crime that was committed because that has nothing to do with how the patient is to be treated. The same holds true for a psychiatric patient. The ED seems to be the only area where the entire story of the person is portrayed; for better or for worse. The text succinctly summarized the tasks of the correctional nurse: a. Consult and advocate on human rights issues b. Perform medicolegal examinations (not where employed) c. Teach and perform detailed, unbiased documentation d. Provide nursing care that is free of bias and judgment e. Advocate for healthcare and healthcare education f. Inspire health-care for offenders g. Assist nursing and other professionals in creating protocols with the highest ethical standards h. Assist in providing an impartial and secure environment for offenders and staff i. Develop and implement initiatives that decrease the roots of violence. References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby

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Critical Stress

December 30, 2008

I personally feel this is an important issue that is frequently swept aside in many critical incident situations. I have been both an EMT and an RN for many years, but have had very few debriefing sessions. Several occasions were warranted, such as a when an entire family perished in an MVC on Christmas Day, co-workers who were killed on their way into work, a colleague who successfully overdosed; to name just a few. The emotional and behavioral keynotes were especially noteworthy. It is no wonder that so many of my colleagues have turned to substance abuse and psychotropics to seek refuge. As for myself and a few others, we have turned to a higher power; after all there has to be more and a “better place.” I pray that is not a hollow promise. I and my co-workers have experienced many of the emotional stress responses: a. Agitation b. Anger c. Anxiety d. Apprehension e. Depression f. Fear g. Feeling abandoned h. Feeling isolated i. Feeling lost j. Feeling numb k. Feeling overwhelmed l. Greif m. Guilt n. Irritability o. Limiting contact with others (I found I withdrew and cuddled up with my Lab and quilting) p. Panic (what if I can’t make it through this shift?) q. Sadness r. Shock s. Startled t. Suspiciousness u. Uncertainty (constantly checking and rechecking your work, documentation, etc.) v. Wanting to hide (that never happened to me) w. Worry about others (BIG TIME!!). References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby

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Handling Bodies after Violent Death

December 30, 2008

For some reason, I found this section to be rather poignant, as I had not given it much thought. Perhaps as a care provider, I had naturally assumed that I was just supposed to take on the responsibilities and not flinch. After reading the text, however, I feel vindicated and actually relieved that it is “alright” to grieve. During my career, I have actually been chastised by my supervisor for sharing the grief of family members over their loss and actually ridiculed. The following excerpts from the text give credence to the opposite belief: a. Stressors and coping strategies have been reported at 3 different points; before, during and after the exposure to corpses b. Profound memory stimulation, the shock of unexpected death, identification of emotional involvement with the dead and the handling of children’s bodies are all profound stressors. c. Even nonhuman bodies can produce discomfort. These feelings should also be respected. d. The handling of personal effects can lead to identification with the deceased. References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby

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Role of the Expert Witness

December 30, 2008

a. A fact witness testifies to direct observations made. b. He or she does not offer expert opinions or draw conclusions from reports but may offer opinion and certainly clarify information. c. In order to become an expert witness, the nurses has to answer questions regarding training, experience and specialized knowledge. A curriculum vita is helpful. d. The nurse specialist must have expertise, trustworthiness and presentational style to have credibility. e. Expertise is established by one’s credentials, including academic background, professional training, experience, and professional association. f. Trustworthiness as perceived by the judge or jury is the degree of honesty in one’s demeanor and opinion. The jury perceives the witness as trustworthy if he or she remains calm, unruffled and cooperative. g. Presentational style includes dress, demeanor and the ability to communicate. h. The presentation should be forth succinctly, clearly, thoughtfully and professionally. i. Dress should be conservative. References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby

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Automotive Improvements that have lessened MVCs

December 30, 2008

Despite the high number of MVCs occurring regularly daily on our roads, the auto industry has made remarkable improvements to lessen fatalities and decrease the risk and extent of some of the injuries seen. a. Seat belts – Seat belts stretch giving a “longer ride down” thus easing impact with the inside compartment of the vehicle – They prevent ejection from the vehicle which are almost always associated with fatal injuries – Cause predictable injuries such as lacerations or injury to liver, spleen, omentum, mesentery, fractured spine, clavicle, sternum and rib cage b. Air bags – Provide gradual deceleration of the head and neck preventing whiplash motion of frontal impact – Cause predictable injuries due to force of ejection of deployment and can dislocate, fracture, and amputate thumbs. Side air bags can cause rib fractures. c. Auto safety glass – Windshield made like a sandwich which shatters but basically “hangs” together instead of separating into distinct shards as do side windows – Lacerations tend to be less serious d. Dashboards – These are contoured and impact with the lower extremities may have less of a deleterious effects – Steering columns on some vehicles collapse under pressure thereby sparing the driver serious injury. References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby

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Lowering the Risk in Suicide

December 30, 2008

Much has been said about assessment for suicidal tendencies. However, there is an upside in all the chaos. During the evaluation, one must also consider positive enforcements that actually help lower the risk of suicide. They are as follows: a. Family and friend support system b. Significant relationships (marital and non-marital) c. Children under the age of 18 living at home d. Employment e. Religious beliefs, culture, ethnicity f. Physical health g. Hopefulness, problem-solving, coping skills, cognitive flexibility h. Plans for the future i. Constructive use of leisure time j. Treatment and medication possibilities k. The propensity to seek treatment and maintain it when needed; the stigma of mental health help is not as great now as it was ten years ago. References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby

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Strange Sleeping Behavior Blamed on Sleeping Pills, comment

December 29, 2008

It is a shame that a prescription drug such as Ambien can have such a downside. More and more prescription drugs are being pulled off the market for safety reasons. This is after they have been approved by the FDA. It is true that the warning label for Ambien states that it might cause sleepwalking and hallucinations. It can also cause worsening depression, suicidal ideations, amnesia, aggressive behavior, back pain, diarrhea, and more. Why not try a natural treatment such as melatonin, valerian root, kava kava, passionflower, skullcap, 5-HTP, or Sleepy-time tea. Taking a hot bath a couple of hours before bedtime is relaxing. These are just some of the natural ways to get a good nights rest. I think they are a much safer alternative than prescription drugs.

Original Post:
April 1, 2006
A number of recent news stories on the side effects of Ambien. I read an article in our metro newspaper, and listened to a women speak on a national news program, about a variety of strange behaviors that were experienced during sleep.

There were even a large percentage of people arrested in the state of Wisconsin for DUI, who it was later detected had no BAL but were instead under the influence of Ambien.

Another one of the frequently reported behaviors is “sleep-eating”. Sleep researchers at Mayo Clinic in Rochester, MN first reported such cases in 2002.

Recently a physician who specializes in sleep disorders at the Minnesota Regional Sleep Disorders Center in Minneapolis, MN said he and his colleagues have documented 32 cases of sleep-eating in patients taking Ambien.

Sanofi-Aventis, the maker of Ambien say it’s safe when taken as directed. The warning label does caution it might cause sleepwalking and hallucinations.

According to the National Institute of Health, about a third of all adults say they have insomnia at least sometimes. Last year, there were an estimated 26.5 million prescriptions for Ambien sold in the US, making it the leading sleep medication on the market.

Researchers say that Ambien somehow increases the amount of time in the stage of sleep that promotes sleepwalking in people who have no history of it. It seems to me that if assessing a patient with a sleep disorder such as insomnia, it would be wise to caution them about the findings in persons taking Ambien, and also to provide them with some guidance if it is decided to be the drug of choice.

Some of the suggestions I would make would be to:
1.)try non-drug remedies to solve their insomnia before trying a sleeping pill,
2.)take the lowest dose necessary to fall asleep if it is decided a sleeping pill is necessary,
3.) to try putting chimes or some other type of noise maker on their bedroom door (to wake them if up sleepwalking).

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Benadryl, comment

December 29, 2008

It is a tragedy when a child is injured or killed secondary to a pharmaceutical drug. Children are given prescription and OTC medications too often. There are many herbal and homeopathic remedies available to treat everyday complaints. This tragedy not only impacted the mother of the child, but the siblings as well. In the instance presented here, perhaps the natural herb valerian would have been a safer choice over benadryl.

Original Post:
December 1, 2008
Benadryl, comment
I agree that Benadryl, an antihistamine often used for its sedation effect in adults, can cause paradoxical central nervous stimulation in children with effects ranging from excitation to seizures and death. Many young parents have used Benadryl to give their children to calm them down when they travel. I was working the emergency room one night when a mother with 3 small children came running into the emergency room with her youngest who was 12 months old. She said they were traveling to Iowa and she stopped at a road side park to change the baby’s diaper. She started screaming her baby was cold and not breathing. She tried to do CPR and drive at the same time. She did not have a cell phone and no other cars were at the park. We assessed the baby and did a tox screen which also showed nothing. I asked the mother if she ever gave her kids any over the counter medicine for colds or coughs. She said sometimes. The 6 year old sister said, “mommy gave us some pink medicine”. The mother then told us she gave them Benadryl liquid. We tried to revive the baby, but after 45 minutes of CPR she died. The death was ruled accidental and no charges were made. But I am sure the mother was emotionally blaming herself for what she did and will have to live with that the rest of her life. I think there needs to be an education program for parents that over-the-counter medications can be lethal at any age.

Original Post:
November 21, 2008
Benadryl, comment
How do we combat the abuse of drugs that are unable to be detected through any toxicology tests? The fact remains that people, especially young teenagers, will try almost anything to attempt to get high. It becomes almost impossible for law enforcement to prevent such actions and therefore lies solely on the parents. It is definitely time to be involved in the lives of your kids and know what they are doing.

Original Post: November 12, 2008 Benadryl, comment I have a response for the blog entry from November 10, 2008 entitled Benadryl. In the emergency department I work in we had an adolescent arrive in a psychotic state. He was hallucinating, was manic, combative and then would calm down and become very docile. He was slightly tachycardic and at times tachapneic and his blood pressure wavered between normo to slightly hypertensive. He didn’t have a diagnosed mental disorder. Our toxicology screens all came back negative and so we were getting ready to transfer him to an inpatient mental hospital when one of his relatives came in with Benadryl wrappers and opened capsules of Benadryl found in his waste basket in his room (they think he may have smoked it on a cigarette or joint). The kid overdosed on Benadryl. Not because he wanted to die, because he wanted to get high. Benadryl doesn’t show up in a tox screen and all his other labs were pretty normal. He ended up going to our ICU for a day and was discharged.

Original Post November 10, 2008 Benadryl, an antihistamine often used for its sedation effect in adults, can cause paradoxical central nervous stimulation in children with effects ranging from excitation to seizures and death. Teenagers have discovered Benadryl, an over-the-counter medication, which is easily obtainable and affordable. The effects of Benadryl produce a “High.” Benadryl in this population is also taken with alcohol and high energy drinks. Parents also give their infants Benadryl to produce sleep and the outcome has been fatal intoxication. I have been made aware of Benadryl and its deadly side effects when a 10-year-old child was told by his mom to take a Benadryl tablet for his allergies. The child unfortunately took an overdose and was placed in the hospital for 2 days to withdraw from medication.

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