Sunday, September 30, 2012

Winner!!-- And Up and Coming


I'm pleased to announce that Ira won Sarah Sundin's book With Every Letter. Ira, I've sent you an e-mail so be sure to send me your address so we can get you this wonderful book.

A big thanks to Sarah Sundin and her readers for participating in my blog contest. It was great to see all the comments and I was happy to learn about Cherry Ames! Have to check those books out.

It was a pleasure having all of you.

For you this week:

Monday: JoAnn Spears is back! Her posts are super popular and she will be at Redwood's the next four Monday's discussing Queen Anne's obstetrical history which I found truly fascinating.

Wednesday and Friday: Author Question! Love to do these posts. This week, Amy stops by with an involved question about car accidents. Dianna will give her thoughts on Wednesday and I'll add mine on Friday.

Hope everyone has a fantastic week!!

Jordyn

Friday, September 28, 2012

Medical Air Evacuation in World War II—Part 3

I am so so pleased to host amazing author and fellow research hound, Sarah Sundin, back to Redwood's this week. Sarah is a fabulous historical author whose novels highlight the WWII era. This week she is discussing her research into medical air evacuation and flight nursing.

Sarah has also graciously agreed to give away one copy of her newest release, With Every Letter, to once commentor on any of this weeks posts. Simply leave a comment with your e-mail address. Must live in the USA. Drawing will be midnight, Saturday September 29th. Winner anounced here at Redwood's Sunday, September 30th.

Welcome back, Sarah!



The broad grin on the private’s face didn’t reveal how serious his condition was. “Hiya, nursey.”
“Lieutenant,” Mellie said, but she smiled back. “How are you feeling?”

“Depends. How many girls you got at that hospital in Algiers?”


“Oh, not one of them is good enough for you.”


“She wears a skirt, she’s good enough.”


Mellie clucked her tongue. “Too bad. All the women wear trousers.”


In my novel With Every Letter, the heroine serves as a flight nurse. If you’re writing a novel set during World War II, a soldier character may get sick or wounded, and you might need to understand medical air evacuation.


On September 24th I discussed general principles of air evacuation, on September 26th we followed one patient in his flight experience, and today we’ll meet the flight nurse.


Training

The profession of flight nursing began in World War II. The US Army Air Force started the first training program at Bowman Field in Louisville, Kentucky in the fall of 1942. Training was haphazard at this point, and the first two squadrons (the 801st and 802nd) were sent overseas before training was complete. The formal program ran six to nine weeks, changing throughout the war. The first class of flight nurses graduated in February 1943.

The program was named the School of Air Evacuation in June 1943 and moved from Bowman Field to Randolph Field, Texas in October 1944. The US Navy started a flight nursing program in December 1944 in Alameda, California.


In training, the nurses studied academic subjects such as aeromedical physiology. They also learned field survival, map-reading, camouflage, ditching and crash procedures, and the use of the parachute. The program included calisthenics, physical conditioning, and a bivouac in the field with simulated enemy attack.


Organization


Each Medical Air Evacuation Transport Squadron (MAETS) was headed by a flight surgeon and chief nurse. The MAETS was divided into four flights, each led by a flight surgeon and composed of six teams of flight nurses and surgical technicians. A Headquarters section included clerks, cooks, and drivers.


Uniform

The typical Army Nurse Corps uniform of white dress or a skirted suit uniform did not work in flight. Although some resisted—including in ANC leadership—the women were allowed to wear trousers. The first few squadrons improvised uniforms, often cutting down the dark blue ANC service jacket and purchasing trousers. Eventually an official flight nurse uniform was authorized—a waist-length gray-blue jacket and matching trousers and skirt, with a light blue or white blouse. Depending on the climate, nurses also wore the combat airman’s heavy flight gear.

The official insignia of the flight nurse was a pair of golden wings with a maroon N superimposed. These wings were changed to silver later in the war.


Duties


The role of the flight nurse was revolutionary. No physician accompanied her on the flight, and she outranked the male surgical technician, who worked under her authority. She was trained to start IVs and oxygen, tasks reserved for physicians at the time. In addition, she was trained to deal with medical emergencies including shock, hemorrhage, and sedation. One flight nurse even performed an emergency tracheotomy using improvised equipment.


Dangers

The primary responsibility for the lives of the patients rested on the shoulders of the flight nurses. Their emergency training was put into use in many cases throughout the war. Flight nurses and technicians successfully evacuated patients into life rafts after a ditching in the Pacific, unloaded patients from a burning plane after crash landing in North Africa, and loaded patients under enemy fire in the jungles of Burma.

One flight nurse was taken prisoner briefly by the Germans after crashing behind enemy lines, and another parachuted to safety in the mountains of China. In one dramatic incident, a plane carrying a dozen nurses from Sicily to Italy was blown off course and crash landed in Nazi-occupied Albania. With the help of their survival training and Albanian partisans, the crew and nurses all evaded capture and crossed snowy mountains to be rescued at the coast—a two-month ordeal.


Seventeen flight nurses lost their lives during the war. Lt. Ruth Gardiner, 805th MAETS (pictured), was the first flight nurse killed, in a plane crash in Alaska.


Through professionalism and courage, the five hundred women who served as flight nurses in World War II saved many hundreds of lives and comforted over a million sick and wounded servicemen.


***********************************************************************

Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist.

Wednesday, September 26, 2012

Medical Air Evacuation in World War II—Part 2

I am so so pleased to host amazing author and fellow research hound, Sarah Sundin, back to Redwood's this week. Sarah is a fabulous historical author whose novels highlight the WWII era. This week she is discussing her research into medical air evacuation and flight nursing.

Sarah has also graciously agreed to give away one copy of her newest release, With Every Letter, to once commentor on any of this weeks posts. Simply leave a comment with your e-mail address. Must live in the USA. Drawing will be midnight, Saturday September 29th. Winner anounced here at Redwood's Sunday, September 30th.

Welcome back, Sarah!


Mellie smiled at her patient. “Are you enjoying the flight?”

“Sure.” Corporal Fordyce stared at the fuselage curving over his head. Mud from the battlefield speckled his hair, and dark stubble covered his cheeks.


Mellie settled her hand on his blanketed arm. “How does your leg feel?”


“It’s gone,” he said through clenched teeth.


“I know,” she said softly. Now was no time for platitudes.


In my novel, With Every Letter, the heroine serves as a flight nurse. If you’re writing a novel set during World War II, a soldier character may get sick or wounded, and you might need to understand medical air evacuation.


On September 24th I discussed general principles of air evacuation, today we’ll follow one patient in his flight experience, and on September 28th we’ll meet the flight nurse.


Pre-Flight

Let’s follow my fictional patient, Corporal John Fordyce. While retaking Sbeïtla, Tunisia from the Germans in March 1943, Fordyce steps on a landmine. Medics perform first aid and take him from the battlefield to the battalion aid station, where he’s stabilized. An ambulance carries him to a field or evacuation hospital, where his right leg is amputated below the knee. Since the corporal will receive a medical discharge, he will return stateside. An ambulance will take him to the airfield at Youks-les-Bains, Algeria. A C-47 will fly him to Algiers. Later he’ll fly to Casablanca in French Morocco, where he’ll take a hospital ship home for convalescence.

At Youks-les-Bains he arrives at a tent hospital at the airfield. The flight surgeon evaluates the patients to decide which are good candidates for air evacuation. Due to high altitude, the doctors prefer not to send patients with serious head injuries, sucking chest wounds, or severe anemia. Each combat theater has different policies on “neuropsychiatric” patients, but if they’re allowed, an extra technician will attend these patients.


At the airfield holding unit, the physician briefs flight nurse Lt. Mellie Blake on each patient. Mellie in turn orients the patients—most of whom have never flown—on what to expect. Corporal Fordyce wears an Emergency Medical Tag (EMT) which summarizes his condition and treatment. A large envelope with his medical records and X-rays rests beside him on the litter.


Loading the Plane


The surgical technician and medics from the holding unit carry the litter patients onto the plane. At the cargo door, Mellie checks the EMT against the list of patients on her flight manifest and directs the tech where to place each patient based on his medical needs.


The litters are clamped into aluminum racks along each side of the fuselage, stacked three litters high. Later versions of the C-47 will come equipped with lightweight web-strapping systems to hold litters. Fordyce is placed in the top tier with his bandaged stump facing the aisle for easier access. Lower tiers are reserved for patients with heavy casts or needing more intense care.


Flight


After the patients are secured, the C-47 glides down the runway. When the plane levels off, the flight nurse and technician see to the patients’ needs. They record Fordyce’s “TPR” (temperature, pulse, and respiration) on the flight manifest, and check for signs of bleeding and infection. Mellie is trained to treat shock, hemorrhage, pain, air sickness, and other medical emergencies, but Fordyce is stable and needs little care.

The flight team also provides water and food if needed. They converse with the patients, a voice of calm for the anxious and of encouragement for the depressed. If no patients are on oxygen, the men are allowed to smoke.


The interior of the C-47 is poorly ventilated and heated, and becomes stifling in hot weather and frigid in colder climates or higher altitudes. Smells can become overwhelming, especially when burn patients are aboard or someone becomes airsick. Surprisingly, air sickness occurs in less than 1 percent of flights. Corporal Fordyce is thankful his flight is in the 99 percent.


Unloading

After an uneventful two-hour flight, the C-47 lands at Maison Blanche Airfield in Algiers, Algeria. Mellie and the technician unload the plane with the help of men on the ground. A trained flight team can unload a full plane in 5-10 minutes, which is crucial in case of crash landing, ditching in water, or landing at a field under enemy fire.

An ambulance ferries Corporal Fordyce to a hospital in the Algiers area while he waits for the next step in his journey home.


**********************************************************************






Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist.



Monday, September 24, 2012

Medical Air Evacuation in World War II—Part 1

I am so so pleased to host amazing author and fellow research hound, Sarah Sundin, back to Redwood's this week. Sarah is a fabulous historical author whose novels highlight the WWII era. This week she is discussing her research into medical air evacuation and flight nursing.

Sarah has also graciously agreed to give away one copy of her newest release, With Every Letter, to once commentor on any of this weeks posts. Simply leave a comment with your e-mail address. Must live in the USA. Drawing will be midnight, Saturday September 29th. Winner anounced here at Redwood's Sunday, September 30th.

Welcome back, Sarah!

“Do you have room for one more litter case?” the doctor asked. “Private Jenkins fell headlong on a landmine. The nearest hospital’s in Cefalù, a long ambulance ride over rough roads. By air he’ll be in Mateur in two hours. He needs a thoracic surgeon.”

Mellie stared at the unconscious patient. He lay on a litter, his torso swaddled in white gauze.
Bloody streaks painted his face, arms, and khaki pants. “We’re his only hope.”

In my novel With Every Letter, the heroine serves as a flight nurse. If you’re writing a novel set during World War II, a soldier character may get sick or wounded, and you might need to understand medical air evacuation.


Today I’ll discuss general principles of air evacuation and share resources, on September 26th we’ll follow one patient’s flight experience, and on September 28th we’ll meet the flight nurse.


History of Air Evacuation

As soon as the Wright brothers took to the air, clever minds thought of ways to use the new contraption. In 1910 two Army officers constructed the first ambulance plane, and during World War I the Army experimented with transporting patients by air.

The advent of large multi-engine cargo planes in the interwar years made these dreams realistic. In November 1941, the US Army Air Force authorized the Medical Air Ambulance Squadron. Air evacuation was first performed informally early in 1942 during the construction of the Alcan Highway and in Burma and New Guinea. The first official air evacuation with flight nurses was flown on March 12, 1943 in Algeria.


Advantages of Air Evacuation


Speed is the primary benefit of air evacuation. Planes can also traverse inhospitable terrain or dangerous seas. The military came to see that air evacuation required less equipment than ambulance transport, aided recovery, and increased morale on the front.

However, planes were unable to fly in bad weather, and planes were not reserved for ambulance use. Since top priorities for transport planes were airborne missions and carrying supplies, medical air evacuation depended on availability. Also, dangers existed from crashes and enemy planes. Since transports carried cargo and troops, they were not allowed to be marked with the Red Cross and were legitimate military targets. Fighter coverage was provided in some combat theaters.


Use of Air Evacuation in World War II


Thirty Medical Air Evacuation Transport Squadrons served in World War II in every combat theater. In all, 1,172,000 patients were transported by air. About half were ambulatory patients (the “walking wounded”) and half were litter patients. Only 46 patients died in flight, although several hundred died in crashes. By 1944, 18 percent of all Army casualties were evacuated by air.


Planes


The C-47 was the workhorse of air evacuation. This dependable two-engine plane was used for shorter flights within a combat theater and could fly into forward landing strips close to the battlefield. A C-47 carried 18-24 patients, depending on how many were on litters.

For transoceanic flights, the four-engine C-54 Skymaster was used. The preferred load for a C-54 was 18 litter patients and 24 ambulatory. These flights carried patients from the combat theater stateside when the patient required 90-180 days of recovery or was eligible for medical discharge.

The C-46 Commando was used less frequently. Although it could carry 33 patients, the cargo door made loading difficult, and the plane had an unsavory habit of exploding when the cabin heater was used.


Medical air evacuation revolutionized the care of the wounded. Gen. Dwight Eisenhower credited air evacuation, sulfa drugs, penicillin, and the use of plasma and whole blood as key factors in the significant drop in the mortality rate among the wounded from World War I to World War II.


Resources:


Sarnecky, Mary T. A History of the U.S. Army Nurse Corps. University of Pennsylvania Press, Philadelphia. 1999.


Links, Mae Mills & Coleman, Hubert A. Medical Support of the Army Air Forces in World War II. Office of the Surgeon General, USAF. Washington, DC. 1955.


“Winged Angels: USAAF Flight Nurses in World War II.” On National Museum of the US Air Force website.
http://www.nationalmuseum.af.mil/factsheets/factsheet.asp?id=15457

The World War II Flight Nurses Association. The Story of Air Evacuation: 1942-1989. Taylor Publishing Co., Dallas TX, 1989. [Source of most of the photos used in this article]


Website of the World War II Flight Nurse Association.
http://www.legendsofflightnurses.org/ Contains photos, news clippings, and PDF of The Story of Air Evacuation.

Futrell, Robert F. Development of Aeromedical Evacuation in the USAF: 1909-1960. USAF Historical Division, Research Studies Institute, Air University, 1960. Available free online at
http://www.ibiblio.org/hyperwar/AAF/AAFHS/AAFHS-23.pdf


***********************************************************************
Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist.

Sunday, September 23, 2012

Up and Coming


Hey Redwood's Fans!!

This will be short and sweet as I'm just getting back from Dallas, Texas and the amazing ACFW conference. I'll share some about that next week.


For you this week:

Sarah Sundin is BACK!! I truly adore Sarah and her posts. Sarah writes novels surrounding the WWII era and her latest book, With Every Letter, just released. Sarah will be posting all this week on her flight nursing research and is even giving away a copy of her book so be sure to comment on her posts.

Blessings to you this week.

Jordyn

Friday, September 21, 2012

The Secrets Nurses Keep: 2/2

In the November, 2011 issue of Reader's Digest-- there was an article entitled 50 Secrets Nurses Won't Tell You. I mean, of course, I am going to read this. As a nurse, as an author, and as a blog editor-- I'm going to see what it has to say. Please, take some time to check out the full article.

I thought I'd give my thoughts here on whether or not I agree with the trueness of these statements. I'm not sure that's truly a word-- so don't use it in Scrabble or anything. The items are taken directly from the article-- so credit is given to Reader's Digest for these.

You can read about my first post here.


Item Four: "When a patient is terminally ill, sometimes the doctor won't order enough pain medication. If the patient is suffering, we'll sometimes give more than what the doctor said and ask him later to change the order. People will probably howl now that I've said it out loud, but you have to take care of your patient." A longtime nurse in Texas.

Hmmm.... this one is painful-- no pun intended. First, let me say that I understand where this nurse is coming from. I've been in situations where the patient has needed more pain medication than the physician is willing to order and it is really frustrating because you're the one whom the patient is staring at, begging for relief.

However, the nurse is right about the howling part. Put simply, this is illegal. A nurse who chooses to do this is operating outside her scope of practice. She would be giving a narcotic without an order. An uber-big no-no. She is at risk for losing her license.

Personally, I would not choose to do this. I've never done it nor has it even crossed my mind. What I have done is called the doctor relentlessly and summoned the physician to do a bedside exam so they can SEE exactly what I'm talking about.

Item Five: "Every nurse has had a doctor blame her in front of a patient for something that is not her fault. They're basically telling the patient, 'You can't trust your nurse.'" Theresa Brown, RN.

Sadly true. I've had this happen. I spoke a little bit about this in the last post. A nurse would get in a lot of trouble for doing the same of a physician so there is a double standard. All corrective conversation should never be done in front of a patient, at the nurse's station, etc--- only a private room with reasonable discussion.

Item Six: "Never talk to a nurse while she's getting your medications ready. The more conversation there is, the more potential there is for error." Linda Bell, RN

True...true...true. In fact, this is becoming part of training videos for fellow staff-- to not talk to your co-workers when they are calculating and drawing up meds. It is fine to ask medication questions-- in fact, you should. But wait until you have your nurse's undivided attention.

What do you think of these items?

 

Wednesday, September 19, 2012

The Secrets Nurses Keep: 1/2

In the November, 2011 issue of Reader's Digest-- there was an article entitled 50 Secrets Nurses Won't Tell You. I mean, of course, I am going to read this. As a nurse, as an author, and as a blog editor-- I'm going to see what it has to say. Please, take some time to check out the full article.

I thought I'd give my thoughts here on whether or not I agree with the trueness of these statements. I'm not sure that's truly a word-- so don't use it in Scrabble or anything. The items are taken directly from the article-- so credit is given to Reader's Digest for these.

Item One: "When you tell me how much you drink or smoke or how often you do drugs, I automatically double or triple it." A longtime nurse in Texas.

Jordyn Says: Absolutely TRUE. A person over the legal limit has surprisingly only EVER had 1-2 beers. Always. What I will add to this statement is a teen driver who comes in involved in a minor traffic accident. I always add at least 20mph over the limit they state because they are likely not going to be truthful in front of a parent about how fast they were really going.

Item Two: "We're not going to tell you your doctor is incompetent, but if I say, 'You have the right to a second opinion,' that can be code for 'I don't like your doctor' or 'I don't trust your doctor.'" Linda Bell, RN.

Jordyn Says: This is a tough one for sure. What is the nurse to do? Primarily, we are an advocate for the patient and NOT the doctor. I have been in this situation. Not necessarily with a diagnosis but more with the emergency treatment provided for the patient. I had a sick asthmatic once at a hospital where I worked previously and the doctor was ready to discharge the patient after one treatment when really the patient needed a barrage of treatments and steroids to control the asthma attack. The child was still in obvious respiratory distress. I had the doctor reassess. They didn't agree with my assessment (and clearly-- I'm always right.) At discharge, I told the family, "Look for these respiratory signs that your child should be seen in the ER." The mother says--"Well, she has all those right now." My response, "Exactly." Wink, wink. "I know this ER is open."

A nurse puts herself and the hospital in a bad position and will never outright say a physician has made a poor decision or is incompetent but be mindful of language and if a nurse says-- "do such and such" like get a second opinion or seek out this course of action-- do it.

A nurse can also approach another physician on duty to see if they'll assess the patient and/or they can call a medical director for intervention. I've done this as well when I thought the treatment/or lack of-- would result in a patient's death.

Item Three: "If you're happily texting and laughing with your friends until the second you spot me walking into your room, I'm not going to believe that your pain is a ten out of ten." A nurse in New York City.

Jordyn Says: True. True. True. Amen, brethren in New York!

From the time a nurse goes through nursing school, we're taught that pain is subjective and the only person who can truly assess how significant pain is is the patient themselves. In many situations, the patient overestimates their pain.

The general scale used is 0-10. Zero being no pain and 10 being the worst. I've started to say, even to pediatric patients, "a 10 is like someone took an ax and chopped of your arm." A 10 means you cannot sit still in a chair. A 10 means if I don't do something about the pain, you'd rather die than live with it any longer. You cannot text. You're not laughing and joking. Do we still treat the pain-- yes, but a nurse will report to the physician your demeanor and that does influence the amount of the narcotic you'll get.

A nurse will also advocate for a patient who should get more pain medication or in instances where the patient or family refuses pain meds. I had a girl with an obviously broken arm and her father refused to let her have Ibuprofen. I'm guessing he had a religious objection but wouldn't say it out loud. Normally, I'm all for a parent's right to have a say in their child's treatment but this time I'm practically begging to give this child Ibuprofen. He says--"shouldn't I be able to decide her treatment"-- oh, that's a whole other post for sure. I said, "Well, perhaps if it was your arm that was broken, you might think differently." One of the few times I actually said what I really wanted to say.

What do you think of these situations?

Monday, September 17, 2012

The Universal Language of Parenthood

I'm pleased to welcome back Dr. David Carnahan as he writes about a personal experience caring for an Iraqi youngster during his military service.

Welcome back, David.

It was easy to hate the people who had produced the martyrs of 9/11. Maybe hate was too strong a word, but I certainly had no compassion for them, even though I’d taken an oath to do so. That was until one night in Iraq, when the squawk box relayed a trauma on its way in.
“Trauma call, Trauma call, Trauma call, times one, pediatric,” a voice cried over the hospital speakers. A collective moan echoed in the emergency room as physicians, nurses, and technicians streamed in to take their positions.

The squawk box sounded again in staccato sentences. “Vitals stable. Patient fell off roof. Fall distance: twenty feet. Seven year old boy trying to fly his kite. Significant head injuries. Would call the Neurosurgeon. Over.”

Trauma Tahoe arrived listless and unresponsive with a bluish hue. Orders reverberated off the walls as the Trauma Czar, Dr. Garrett, directed Tahoe’s initial resuscitation, stabilizing him for his eventual surgical care. Within an hour, he was taken to surgery and  then placed in the Intensive Care Unit on the ventilator.

The next morning I got up early to check on him. His physical examination had degenerated, and now showed signs of herniation, a condition incompatible with life. The ominous signs on the initial CT scan suggested that Tahoe had suffered severe damage akin to having major strokes on both sides of the brain, and had little chance of recovery, but we all were praying he would be the outlier. The neurosurgeon leaned against the door of the “doc box,” the room where the doctors stay overnight to care for the ICU patients. “There’s nothing more we can do,” he said. All gazes cast downward, and the room remained quiet. We had all arrived at the same conclusion, but saying it had cast the reality into the universe with finality.
The pediatrician, ICU director, neurosurgeon and I walked into the room, and looked at the silent, unconscious patient. His head was wrapped in white bandages. His long, dark eyelashes curled up hinting of his former handsome features, but his swollen face now cast a shadow over his angelic appearance. The ICU staff worked all around me as I watched them perform as professionals: removing tubes, shutting down machines, gradually causing the room to grow still. Dr. Williams, the pediatrician, asked the nurse to bring in the nicest blanket we had. She returned with a hand-quilted blanket sent from a family in Wisconsin.

The beautiful design contrasted against the hideousness of the moment. Then, we waited.
The little boy’s father approached the door, his face somber and eyes heavy. The mother was close behind. She was dressed in a black robed dress, shawl and shoes. She held a handkerchief to her face as the tears streamed down her face. Her voice filled the room with an Arabic phrase uttered repetitiously and mournfully. I imagined what I would say, how I would react, and my mind began to whirl as I pictured my own seven-year old daughter in the bed. The father pulled the blanket off and leaned over the bed to kiss his boy’s feet. His tears washed his son’s toes as he slumped over his feet, rocking back and forth in grief.

His mother kissed his lips, brooded over him as she continued to chant the doleful phrase trying to bring her boy back to her. Then as if she suddenly realized we were in the room, she looked up at Dr. Williams and with begging eyes asked him the question in Arabic. The translator in the room knew that he need not explain, Dr. Williams had been asked the question that all doctors despise, the question that raises the issue of the limitations of medicine and the injustice of harm that befalls innocent children. He shook his head and said, “I’m sorry, there’s nothing we can do.”

In that moment, I stood with tear-brimmed eyes, struggling with the sorrow and grief that losing a child will bring.

**********************************************************************
Dr. David Carnahan is a Board Certified Internist, who fell in love with writing while getting his Masters Degree in Epidemiology at the University of Pennsylvania. He has served in the Air Force for the past 14 years as an academic clinician/educator and now works in the area of Healthcare Informatics. He has a wonderful wife and two beautiful daughters, and invites you to read about his life (www.dhcarnahan.blogspot.com), and weekly installments of his current work in progress, The Perfect Flaw (www.theperfectflaw.com).


Sunday, September 16, 2012

Up and Coming

First, I want to thank everyone who downloaded Proof when it was free Monday-Friday last week for Kindle! It stayed in the top 100 free books for Kindle for most of the week. You are all AmAzIng. It is still inexpensive at $5.00 so download and give this book a try. See if Library Journal knows what they're talking about!

For you this week:

Monday: Dr. David Carnahan is back posting about a heart wrenching experience of caring for a young Iraqi boy.

Wednesday and Friday: The secrets nurses keep. These two posts piggy-back off of a Nov, 2011 Reader's Digest piece entitled 50 Secrets Nurses Won't Tell You. I'll give you a behind the scenes look at some of the items.

I'll be at the American Christian Fiction Writer's conference this week! Looking forward to seeing a lot of my friends and fellow authors. Be sure to say "hi" if you're there.

Jordyn

Friday, September 14, 2012

Strangulation: Care of the Victim 3/3

I'm concluding my series on strangulation today. You can find Part I and Part II by clicking the links.

Victims of strangulation/hanging require emergent evaluation due to the structures in the neck that could have obtained injury (trachia, hyoid bone, vocal cords, blood vessels, and brain from lack of blood flow).


image by thetombstonesnake courtesy of Flickr via baratunde.com
If the victim was hanged, it is important to know the height from which they dropped. If if was equal to or greater than their height, there is a high probability of C-spine injury. Therefore, these patients need to be placed in a C-collar until such injury is ruled out.

Remember, there may few external signs of injury. This doesn't rule out significant damage. However, there may be signs of bruising around the neck and petechia above the point of the ligature. There may also be bleeding in the eye, changes to the voice. Symptoms may range from general soreness to difficulty breathing.

Other signs and symptoms include:

1. Difficulty swallowing.
2. Mental Status Changes: may indicate a period where the brain has gone without oxygen.
3. Miscarriage
4. Swelling of the neck
5. Lung Injury: if the patient vomited during strangulation.
6. Chin Abrasions: from the victim trying to protect their neck.
7. Defensive wounds to the neck from the victim tryng to break free.

How do we care for this patient? History of the event will be paramount in helping the physician determine what tests to run. Hopefully the patient will be able to supply pertinant information.

1. Baseline vital signs including continuous monitoring of the patient's oxygen level.

2. Assessment of neurological (did the patient lose consciousness, are they neurologically intact?), respiratory (are they having difficulty breathing) and cardiovascular systems.

3. If the patient was hanged-- they will need X-rays of the spine to rule out fracture as well as soft tissue films of that area. If they were strangled, soft tissue films of the neck are still warranted.

4. Direct Laryngoscopy: Visualizing the vocal cords to look for damage.

5. CT of the brain: if the patient was unconcious at any point.

6. CT/MRI scan of the neck: to look for soft tissue/vascular injury.

7. Chest x-ray: aid in diagnosis of aspiration.

8. Carotid Doppler: Looking at the neck vessels with ultrasound to look for injury and clots as a result of the attack.

This patient, depending on their severity of injury, could be observed in the emergency department for several hours and sent home or intubated out of concern for further airway compromise and admitted into the ICU. There is a lot of lattitude for the writer here.

Resources:

General Overview: http://emedicine.medscape.com/article/826704-overview

Wisconsin Medical Journal: Strangulation Injuries http://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/102/3/41.pdf

Emergency Medicine Reports: Strangulation Injuries. http://www.ahcmedia.com/public/samples/emr.pdf:

How to Improve Your Investigation and Prosecution of Strangulation Cases. http://www.ncdsv.org/images/strangulation_article.pdf:

Wednesday, September 12, 2012

Strangulation: Facts 2/3

I'm continuing my series on strangulation injuries. Here is Part I.

I once worked with a physician who was having a baby. Her father handmade her a crib. Sadly, his grandchild was strangled in that crib.

Vintage crib where slats are too wide.
I often think about that family-- how he must feel to have constructed the tool of this infant's demise. How was the relationship of that woman with her father after that? Definitely enough conflict in just that scenario to carry a novel.

While researching this series of posts on strangulation for a reader, I came upon a lot of interesting facts I didn't know myself. This is one reason why I'm such a research hound-- I love learning these things to add extra detail for the reader.



There are four types of strangulation:

1. Hanging
2. Manual: The use of bare hands.
3. Chokehold: Elbow bend compression
4. Ligature

Strangulation injury is not as uncommon as I thought-- it accounts for 10% of all violent deaths in the US. Perhaps because the hands are such a ready weapon-- the criminal doesn't have to think about bringing them to the crime scene.

Infants are likely to be strangled by falling between something (like slats in a crib that are too wide), or entangling themselves in something (like cords that dangle down from blinds).

Teens and pre-teens can suffer strangulation injury by playing the "choking" game or engaging in autoerotic hanging. These are not so uncommon activities in the pediatric population and we should discuss their danger with our children.

Women are increasingly using hanging as a means of suicide whereas in the past it was more common among men.

Prisoners will often kill themselves by hanging as it is the means of suicide that is most available to them.

When treating the victim of a hanging-- it is important to know the height they dropped from. A height equal to or greater than their height brings forth large concerns for C-spine injury. When a prisoner is hanged, they essentially die from decapitation. The C-spine is fractured between C1-C2 and thus severs the spinal cord(also called a Hangman's Fracture) so the head will free float. If done right, death is instantaneous.

When a person is strangled, there may be no signs of injury to the neck or very minimal signs. There may be only a single bruise present which is caused by the imprint of the thumb.

Resources:

General Overview: http://emedicine.medscape.com/article/826704-overview

Wisconsin Medical Journal: Strangulation Injuries http://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/102/3/41.pdf

Emergency Medicine Reports: Strangulation Injuries. http://www.ahcmedia.com/public/samples/emr.pdf:

How to Improve Your Investigation and Prosecution of Strangulation Cases. http://www.ncdsv.org/images/strangulation_article.pdf:

Monday, September 10, 2012

Strangulation: What Really Kills the Victim 1/3

I got a message from a new blog reader with this comment:

Finding this blog is so timely for me, as my protagonist witnesses a strangulation in the first scene of my WIP, and I haven't been able to find out the precise observable symptoms.  I wanted to ask if you'd done a posting on strangulation.  I've looked back a bit in the blog archives, but haven't seen that topic yet.

Well, let's just fix that for Colleen.

I'm sure many of you, particularly if you're an avid crime show TV watcher, have seen the scene with the medical examiner and the victim splayed open on the table talking about damage to the "hyoid" bone. Though this is true, damage to this bone or the trachea itself is not what ultimately kills a victim who is strangled to death, though it can complicate their care if they live.

For instance, there have been instances of individuals with tracheotomies hanging themselves and the ligatures were above the level of the trach-- which means the person would still be able to breathe.

So the following theories are proposed as explanations for the cause of death related to strangling.

Venous obstruction, leading to cerebral stagnation, hypoxia, and unconsciousness, which, in turn, produces loss of muscle tone and final arterial and airway obstruction.

Arterial spasm due to carotid pressure, leading to low cerebral blood flow and collapse.

Vagal collapse, caused by pressure to the carotid sinuses and increased parasympathetic tone.

Which is a lot of scientific language to say "death ultimately occurs from cerebral hypoxia and ischemic neuronal death".


Which means-- when a person is strangled, they die because their brain is no longer getting blood flow from the carotid arteries, which leads to brain cells dying from lack of oxygen.
As you can see from this photo, the major blood vessels that drain blood from the brain but also, more importantly, feed it with oxygen-- are in very close proximety to the trachea or windpipe.

It is the vital oxygen these vessels carry to the brain that upon slowing or stopping-- is the biggest problem for the victim.

Next post we'll discuss some strangulation facts. Third part of this series will include treatment of the strangulation victim.

Source:  http://emedicine.medscape.com/article/826704-overview

Other Resources:

Wisconsin Medical Journal: Strangulation Injuries http://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/102/3/41.pdf

Emergency Medicine Reports: Strangulation Injuries. http://www.ahcmedia.com/public/samples/emr.pdf:

How to Improve Your Investigation and Prosecution of Strangulation Cases. http://www.ncdsv.org/images/strangulation_article.pdf:

Sunday, September 9, 2012

Up and Coming


What a great group of posts last week on quality of life issues. If you missed them-- go back and take a look. A lot of great comments and stories. Thank you to everyone who shared them.

For you this week, we're focusing on strangulation injuries. These posts were prompted by a reader comment that I began to research and I actually learned a lot of interesting stuff that I thought would be beneficial to pass onto you.


Also-- my debut novel, Proof, is being offered free this week for Kindle through Amazon. Specifically, Sept 10th-15th, so help spread the word. Even if you have bought the print version (which I greatly appreciate!) please download the e-book. Helps to increase the sales rankings.

May you all have a blessed week!

Jordyn

Friday, September 7, 2012

As I Am: A Quality of Life Issue

I'm pleased to welcome Dr. Karen Pirnot as she talks about an amazing patient of hers, Garret Frey.

Welcome, Karen!

Imagine yourself totally paralyzed just below your chin.  You can move nothing but your head.  And then imagine a ventilator attached to your throat to help you breathe.  This is not a temporary “nuisance” condition.  This is the life of Garret Frey of Cedar Rapids, Iowa.

Injured in a motor vehicle accident at the age of four, Garret was rendered quadriplegic and ventilator-dependent for life.  After the accident, Garret was immediately placed on artificial, mechanical breathing while his parents rushed to the hospital.  It would be months before they would know that Garret’s paralysis and inability to breathe on his own would be permanent.


After nearly a year in various intensive care units and a children’s rehabilitation hospital, Garret was discharged to his home, along with supplies which would fill the ordinary person’s closet.  Garret’s parents were trained to care for him but as they both worked, a full-time nurse had to be with Garret, severely depleting the medical insurance benefits.  For some time, Garret remained confused and depressed.

While others speculated about a vegetative, non-productive existence for the child, Garret, his mother and a Clinical Psychologist went about trying to develop the best quality of life possible, within the permanent medical parameters.  Over a period of seven years, Garret was taught to use his brain in order to have an entirely cognitive experience of life in which his remaining senses would become highly and acutely developed.  As Garret’s brain matured and he became emotionally prepared for his life as it was, his relationship with his psychologist was terminated.

Garret’s mother and the psychologist fought for a free, public education for Garret.  When the school board in Garret’s community resisted, the matter was adjudicated and Garret was allowed entrance into school.  The decision was appealed several times and eventually ended up in the United States Supreme Court where the Judges ruled in Garret’s favor.  The ruling has set precedence for thousands of handicapped children across the nation.
While the court battles went on, Garret learned to participate in a full public school life.  He was eventually placed in an accelerated academic program and he thrived both academically and socially.  In high school, his friends were trained in the operation of the ventilator and Garret was then free to attend concerts, restaurants and school functions.


In daily life, Garret continues to require 24/7 supervision for the care of his body and the functioning of his ventilator.  Garret considers his care and equipment simply a part of his daily life.  He sleeps through most of the personal care essential to keep his body functioning.

And so, we might just ask how the quality of life is determined for any one individual?  In all probability, we never know our own limits until faced with our own worst fears.  For some, it may be the loss of a limb and for others, the loss of speech, sight or hearing.  For some, quality of life is determined by athletic or intellectual skills; for others, by the accumulation of wealth.

For Garret, quality of life as a child meant that he was able to get a free, public education in the least restrictive environment.  As an adult, quality of life for Garret means he is able to be out with friends and that he has people who love and support him while he takes college courses and ponders the various mysteries of life.  Garret maintains a steadfast belief in God as well as an optimistic attitude about each and every day of life granted to him.

Finally, we might ask who should determine what the quality of life is for any one individual.  More and more, health issues are legislated rather than left to personal decision-making.  There are pros and cons to each side of the coin but for Garret:  “I do not remember the day I was born and I do not remember the day that I died.  I only remember myself AS I AM.”  (This is the first sentence of the book AS IAM by Garret Frey and Dr. Karen Hutchins Pirnot.)
***********************************************************************
Dr. Karen Hutchins Pirnot has worked with children and families in various capacities for the past forty years.  She is a Clinical Psychologist who practiced in Cedar Rapids, Iowa and later, in Sarasota, Florida.  For years, she worked extensively in the human services and juvenile justice systems as well as various school and hospital settings.  Dr. Pirnot worked with special needs children as well as children and families experiencing transitions and tragedies. Dr. Pirnot’s books are written to empower children and their families.  The books may be found on Amazon, Barnes and Noble and www.drpirnotbooks.com  

Wednesday, September 5, 2012

What are Life Saving Measures?

To say there is some confusion among authors as to what constitutes lifesaving measures really should not be a surprise. After all, most people not involved in medicine can have a difficult time with the concept.

Lifesaving measures is a broad term. It can be used to describe any futile care to a patient that is likely not to live. However, often times these same lifesaving measures are really a bridge to get a patient through a critical illness that they can fully recover from and still lead a long life but will certainly die if they are withheld.

What you should do is examine each of these areas and think through the possibilities of what situations you would be okay receiving these and which you wouldn't and make that decision clear to your family.

So-- what are some of these lifesaving measures.


1. CPR: This is chest compressions. Generally, when people are a DNR (Do Not Resusitate), this is its basic definition. If your heart stops and you're a DNR-- we won't do compressions. You can delineate this further by also saying I don't want drugs or electricity. Some patients are fine getting the medications but they don't want their chest to be pounded on. However, CPR is the one mechanism that will MOST LIKELY bring you back in conjunction with these other therapies.
 

2. A ventilator: This is a breathing machine where a tube is inserted into your mouth, through your vocal cords, and into your trachea to assist with breathing. Being on a ventilator is hard. It is not anything like the natural way we breathe. A patient can say-- I don't want to be intubated. However, this can also be short term. Say a healthy, young male has a severe pneumonia. He's just not able to maintain his oxygen levels and his breathing worsens. In most circumstances-- as a nurse-- I would not expect the patient to die but he NEEDS that breathing machine to buy him some time for the antibiotics to kick in...etc.

3. Vasopressors: These are drugs that help support blood pressure. Many shock states will cause lower blood pressure which is bad. You need normal blood pressure to heal. This is another area that might be short-term to buy the patient the time they need to get better.

4. Nutrition: I'm going to lump this all into one category. It can include everything from IV fluids, to TPN (which is IV nutrition) to a feeding tube. If this is withheld, what you die from is dehydration and starvation. This is what the Terry Schiavo case centered on. Some people believe withholding food and fluid is unethical as it is a basic requirement to live. How about you?

5. Oxygen: You can get oxygen many ways without being on a ventilator. Through nasal prongs, through a mask, and sometimes via a machine called CPAP or BiPAP. Again, this may be a short term measure to help a patient through an illness and most often is used for that very reason. But, if you take them of their oxygen-- they will die.

Patients and families need to be well-educated in what these terms actually mean well before they are sick enough to be forced to make a decision during a crisis.

Lifesaving measures and End-of-Life Care are not really interchangeable. Have these conversations with your family now.

What about you? What would you want and not want? Under what kind of circumstance?

Monday, September 3, 2012

Do Nurses Ever Stop Caring? End of Life Issues...

There is nothing that distresses me more than watching a television show, seeing a movie or reading a book that says something akin to the following..."He's going into hospice. They're not going to care for him anymore."

Honestly, boils my blood.

When I was in nursing school, I spent six weeks caring for a hospice patient. Our community health instructor first asked for volunteers. I remember her saying, "It's for six weeks but he is expected to live several more months."-- implying that we wouldn't have to deal with his death.

Let me first say no human can put an expiration date on you.


It came down to a lottery and my name was drawn.

He was in his mid 60s and was diagnosed with multiple myeloma-- which is a type of bone cancer. I would visit he and his wife at their mobile home to make sure his needs were met. They had a feisty, young golden retriever that was one huge, butterball of energy that greeted me at the door every visit.

My non-care (yes-- that is dripping with sarcasm) included pain management (helping the family choose a PCA pump, instructing them in how to use it, etc) and discussion of end of life issues. This includes a lot of talk about where you think you're going to end up. Heavy, spiritual issues.

I was just twenty-one.

As we were talking one day, he said he'd really like to go up to the mountains. Unfortunately, he was bedridden. The previous summer, I spent a camping trip in Rocky Mountain National Forest and had some pictures.

I brought him this huge pile of photos. I said, "I'm really sorry you can't go to the mountains but perhaps you could pick one of these photos and put it by your bed to help you visualize being there."

And that's just what he did. Took a red, push-pin and shoved one of those photos right into the wall.

A visit shortly after that and the normally exuberant golden retriever was inconsolable. He would not leave this gentleman's side and in my heart I knew that was the last time I would ever see my patient alive. He died within a few days.

I went to the funeral, with some other members of my nursing class, and I still can hear the bagpipes play in that church and how my soul just ripped apart at the grief of his widow. He truly touched my life in those short few weeks I was with him.

After the funeral, my class went to a Chinese restaurant for lunch. My fortune cookie said, "Your kindness to another will not be forgotten."

I don't know... call it what you will, but I think that was a God wink.

His wife gave me that picture back and told me how often she would find her husband just staring at it. I still have that photo and that fortune in a frame some twenty years later.

Please, do not make the mistake of EVER saying that medical personnel stop caring for patients when they have made the choice to forgo further lifesaving measures.

There is much care that is done, very humbling, straight-at-the-heart moments and hospice nurses are truly angels on this earth.

Sunday, September 2, 2012

Winner!! And... Up and Coming


 
 




Congratulations to Debbie Curto who won a copy of Wedded to War by Jocelyn Green. I'll be sending you an e-mail on how to claim your prize.

For Redwood's fans this week.








Monday: Do Nurses Ever Stop Caring? My take on the phrase..."they've stopped caring for him" after a patient chooses to forgo medical care.

Wednesday: Life Saving Measures. You hear this term a lot in novels and television but what exactly does it mean?


Friday: Dr. Karen Pirnot shares the inspiring story of her patient Garret Frey.

Hope you guys have a fantastic week!