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JOURNAL OF EMERGENCYNURSING/Pyles,Pringte, and Hawkins so by the pilot. Only approach the helicopter from the side, in full view of the pilot. As you approach the he- licopter, maintain eye contact with the pilot at all times so that you are able to observe warning signals to move away or to stop your approach. The tail-rotor guard The tail-rotor guard position may vary, depending on the aircraft and the policy of the program. Some pro- grams may not use a tail-rotor guard. Because many programs do use a tail-rotor guard, responsibilities of the person in this position are reviewed here. Respon- sibilities of the tail-rotor guard are as follows: 1. Once the aircraft has landed and the pilot has sig- naled, the tail-rotor guard should position him/her- self on the left side of the landing zone in view of the pilot. 2. The tail-rotor guard must maintain this position the entire time the rotor blades of the helicopter are turning. 3. THE TAIL ROTOR GUARD MUST NOT ALLOW ANYONE TO APPROACH THE TAIL AREA OF THE HELICOPTER. 4. The tail-rotor guard should stand by for instructions from the flight crew. 5. Once the patient is placed in the aircraft and the pilot has signaled, the tail-rotor guard should move toward the front of the helicopter and leave the LZ. 6. The tail-rotor guard should always wear hearing and eye protection. Approach the helicopter on foot. No vehicles, in- cluding emergency vehicles, should be within 75 feet of the aircraft. This prevents the possibility of the he- licopter rotor striking antennas, lights, or other pro- truding obstacles. Always approach the helicopter in a crouched position. Hands, arms, and equipment should not be raised above your head. Do not use IV poles around the aircraft. Remember to protect the patient and rescu- ers from rotor wash. As a ground support person, you are as much a part of the team as the helicopter crew. Their safety, as well as the safety of the patient, bystanders, rescu- ers, and yourself are dependent on your adherence to safe helicopter landing procedures. Contributions to this column should be sent to Susan Budassi Sheehy, RN, MSN, CEN, FAAN, 6 Martin Ln., Hanover, NH 03755; phone (603) 650- 6699. I ~ T he screaming in the background confirmed the paramedic's report of chaos at the scene. The pa- tient's husband had called 911 and stated that his wife had had a seizure and was not breathing. Paramedics Carol Cramer is a staff nurse, Emergency Department, Pioneer Val- ley Hospital, West Valley City, Utah. For reprints, write Carol Cramer, RN, 401 East 1000 North, Center- ville, UT 84010. J Emerg Nurs 1996;22:236-8. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/9/73510 transported the woman by ambulance and raced her to the hospital. The patient was in cardiac arrest, without IV ac- cess or a patent airway. We immediately inserted an endotracheal tube and a central venous access line and began administering epinephrine and atropine. Our resuscitation efforts continued for 30 minutes without any improvement in the patient's condition. Convinced she was beyond the point of recovery, we were preparing to stop advanced cardiac life support measures. We were shocked when she regained a cardiac rhythm and pulse. 236 Volume 22, Number 3
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Page 1: Unanswered questions

JOURNAL OF EMERGENCY NURSING/Pyles, Pringte, and Hawkins

so b y the pilot. Only a p p r o a c h the he l i cop te r from the side, in full v i ew of t he pilot. As you a p p r o a c h the he- l icopter , m a i n t a i n eye c o n t a c t w i th the pi lot a t all t i m e s so tha t you are able to observe w a r n i n g s ignals to move a w a y or to s top your approach .

The tail-rotor guard The tail-rotor g u a r d pos i t ion m a y vary, d e p e n d i n g on the aircraf t and the pol icy of t he program. Some pro- g r a m s m a y not u se a tai l-rotor guard. B e c a u s e m a n y p r o g r a m s do use a tai l-rotor guard , respons ib i l i t i es of the pe r son in th is pos i t ion are r e v i e w e d here. Respon- s ib i l i t ies of the tai l -rotor gua rd are as follows: 1. Once the aircraf t has l a n d e d and the pi lot has s ig-

naled, the tai l -rotor gua rd should pos i t ion h im/her - self on the left s ide of t he l and ing zone in v i ew of t he pilot.

2. The tai l-rotor gua rd m u s t m a i n t a i n th is pos i t ion the ent i re t ime the rotor b l ades of the he l icop te r are turning.

3. THE TAIL ROTOR GUARD MUST NOT ALLOW ANYONE TO APPROACH THE TAIL AREA OF THE HELICOPTER.

4. The tai l-rotor g u a r d should s t a n d by for ins t ruc t ions from the flight crew.

5. Once the p a t i e n t is p l a c e d in the aircraf t and the

pilot has s ignaled , the tai l-rotor guard should move t oward the front of the he l i cop te r and leave the LZ.

6. The tai l-rotor guard should a lways wea r hea r ing and eye protec t ion .

A p p r o a c h the he l i cop te r on foot. No vehicles , in- c lud ing e m e r g e n c y vehicles , should be wi th in 75 feet of the aircraft . This p r even t s the poss ib i l i ty of the he- l icopter rotor s t r ik ing an tennas , l ights, or o ther pro- t rud ing obs tac les .

A lways a p p r o a c h the he l i cop te r in a c rouched posi t ion. Hands , arms, and e q u i p m e n t should not be ra i sed above your head . Do not u se IV poles a round the aircraft. R e m e m b e r to p ro t ec t the pa t i en t and rescu- ers from rotor wash .

As a g round suppor t person, you are as m u c h a par t of the t e a m as the he l i cop te r crew. Their safety, as well as the sa fe ty of the pa t ien t , bys t ande r s , rescu- ers, and yoursel f a re d e p e n d e n t on your a d h e r e n c e to safe he l i cop te r l and ing p rocedures .

Cont r ibu t ions to this co lumn should be sen t to Susan Budass i Sheehy, RN, MSN, CEN, FAAN, 6 Mar t in Ln., Hanover , NH 03755; p h o n e (603) 650- 6699.

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T he s c r e a m i n g in the b a c k g r o u n d conf i rmed the p a r a m e d i c ' s repor t of chaos at the scene . The pa-

t i en t ' s h u s b a n d h a d cal led 911 and s t a t ed t ha t his wife h a d had a se izure and was not b rea th ing . P a r a m e d i c s

Carol Cramer is a staff nurse, Emergency Department, Pioneer Val- ley Hospital, West Valley City, Utah. For reprints, write Carol Cramer, RN, 401 East 1000 North, Center- ville, UT 84010. J Emerg Nurs 1996;22:236-8. Copyright �9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 1 8 / 9 / 7 3 5 1 0

t r a n s p o r t e d the w o m a n by a m b u l a n c e and raced her to the hospi ta l .

The pa t i en t w a s in ca rd iac arrest , w i thou t IV ac- c e s s or a p a t e n t a i rway. We i m m e d i a t e l y inse r t ed an endo t r achea l t u b e and a cent ra l venous a c c e s s l ine a n d b e g a n a d m i n i s t e r i n g e p i n e p h r i n e and atropine.

Our r e susc i t a t i on efforts c o n t i n u e d for 30 m i n u t e s w i thou t any i m p r o v e m e n t in the p a t i e n t ' s condi t ion. Conv inced she w a s b e y o n d the po in t of recovery, w e were p r e p a r i n g to s top a d v a n c e d ca rd iac life suppor t measu re s . We were s h o c k e d w h e n she r ega ined a ca rd i ac r h y t h m a n d pulse.

2 3 6 Volume 22, Number 3

Page 2: Unanswered questions

Cramer/JOURNAL OF EMERGENCY NURSING

Dur ing the frenzy of the code w e never cons id- e red w h a t c a m e after w e s a v e d this life. The p a t i e n t ' s pupi l s we re f ixed a n d di la ted. She h a d no s p o n t a n e - ous r e sp i ra t ions and no r e sponse to pain. We had re- s to red a pulse , b u t the re w a s no bra in act ivi ty. We h a d m a d e her d e a t h slow ra ther than quick. An as t ronom- ical bill would now be a d d e d to the cos ts of funeral ex- penses . Our heroic " s ave" no longer s e e m e d so heroic.

Blood s a m p l e s we re o b t a i n e d for labora tory tes t s and d e t e r m i n a t i o n of b lood gas values; w e also s t a r t ed an IV d o p a m i n e infusion. Her blood p re s su re was not pa lpable . She had p i t t i ng e d e m a th roughou t her body. She h a d no ur ine output , and her a b d o m e n w a s dis- t ended . I i n se r t ed a n a s o g a s t r i c tube. While a t t a c h i n g the n a s o g a s t r i c t ube to t he wall suc t ion appara tus , s o m e c o n t e n t s spi l led on the floor. I obse rved abou t 10 g reen pill f ragments . I t hough t abou t k e e p i n g them, bu t d id not.

The family u n d e r s t o o d the re was no hope tha t she would b r e a t h e s p o n t a n e o u s l y aga in or have any h igher b ra in funct ion. Her s i s te rs w a n t e d life suppor t m e a s u r e s s t o p p e d and her mothe r agreed . They left t he room sobbing , " I t ' s really over; s h e ' s gone . " How- ever, t he h u s b a n d w a s a d a m a n t tha t eve ry th ing be done to " s a v e " her.

I spoke pr iva te ly wi th the sis ters . They s e e m e d unusua l ly a n g r y wi th thei r brother- in- law. "We' l l m a k e sure he pays for w h a t he d id ." One s i s te r sa id our p a t i e n t h a d b e g g e d h im to br ing her to the hos- p i ta l earl ier in the day. He had refused. I found their s t a t e m e n t s odd, bu t d i s m i s s e d t h e m as words spoken out of a n g e r and grief.

Later, the s i s te rs b rough t in a b a g of he r pre- sc r ip t ion bot t les . A m o n g t h e m w a s an e m p t y bot t le of amit r ip ty l ine . The ami t r ip ty l ine p resc r ip t ion of 30 pills h a d b e e n filled only 10 days earlier, wi th ins t ruc t ions to t ake one pill daily. The doc tor d i s c u s s e d wi th the family the poss ib i l i ty tha t she m a y have t aken an overdose to c o m m i t su ic ide . They ins i s t ed t ha t this w a s not poss ib le . Our pa t ien t , now in a pe r s i s t en t v e g e t a t i v e s ta te , had s ickle cell anemia , had h a d two strokes, and had b e e n b e d r i d d e n for more than a year. She h a d no a c c e s s to her m e d i c a t i o n s and w a s phys - ically unab le to t ake them. My ins t inc t s aga in told m e s o m e t h i n g w a s terr ibly wrong.

My 12-hour shift w a s comple te , bu t m y ques t ions still were u n a n s w e r e d . I took m y pa t i en t to the cri t ical ca re uni t and left. I h a d difficulty s leeping. P ieces of conver sa t ions r a c e d th rough m y mind. How d id all t hose pills ge t in her s t o m a c h ? Was this an a s s i s t e d su i c ide? Was it an a c c i d e n t a l overdose? Was it a m e r c y kil l ing? Or was i t s o m e t h i n g more s in is te r?

Twelve res t l ess hours later, I r e tu rned to t he crit- ical ca re unit. M y pa t i en t had d i ed 2 hours earl ier and her b o d y h a d b e e n s en t to the mortuary. Alarmed, I

d i s c u s s e d m y obse rva t ions a n d conce rns wi th t he uni t nurse . She e x p r e s s e d s imilar susp ic ions . She sa id t he h u s b a n d h a d told the p h y s i c i a n in the cri t ical care uni t t ha t he h a d g iven his wife a handful of pills.

I hurr ied ly r e v i e w e d her chart. Her ami t r ip ty l ine level w a s g rea te r t han 500 ng/ml, clearly a toxic level. Wha t should I do? Wha t we re m y legal and moral re- spons ib i l i t i e s? I t r ied to call t he e m e r g e n c y p h y s i c i a n I had worked with the night before. He was out of town. The doctor in the critical care unit was unavailable.

If I v o i c e d m y s u s p i c i o n s , w o u l d I b e c o m e i n v o l v e d in a m u r d e r trial? W a s I o v e r r e a c t i n g ? W h a t if s h e h a d d i e d of n a t u r a l c a u s e s ? W a s I a c c u s i n g t h e h u s b a n d of m u r d e r i n g t h e w o m a n h e l o v e d ? W h a t if s h e h a d a s k e d h i m to g i v e her t h e pi l l s? Did s h e w a n t to die?

S a t u r d a y morning. M y pa t i en t w a s dead. Her b o d y w a s a t the funeral home. If I vo iced m y susp i - cions, would I b e c o m e involved in a murde r trial? Was I ove r reac t ing? What if she h a d d ied of natura l c a us e s? Was I a c c u s i n g the h u s b a n d of murde r ing the w o m a n he loved? W h a t if she had a s k e d h im to give her the pills? Did she w a n t to d ie?

I d i s c u s s e d m y conce rns wi th the phys i c i an on du ty in the e m e r g e n c y d e p a r t m e n t . She s a w no d i lemma. "Call the pol ice and repor t th is r ight now!" she said. "You have no choice. Your respons ib i l i ty is to report your observat ions." I called the police depar t - ment. W]~en the officer arrived, I told her the story.

Wi th in m i n u t e s a h o m i c i d e officer was a s s i g n e d to t he case. The pol ice i m m e d i a t e l y had the body p i c k e d up from the funeral h o m e and taken to the med ica l examiner . A n a u t o p s y was per formed tha t af- ternoon. The h o m i c i d e officer a sked if I had saved the gas t r ic conten ts . In d i smay, I r e m e m b e r e d the con- t en t s on the floor and the r e m a i n d e r in the garbage . The w o m a n h a d left our e m e r g e n c y d e p a r t m e n t as a pa t ien t , not a body. I d id not th ink of p re se rv ing ev- idence . Unfortunately, only after her d e a t h were m y susp ic ions voiced.

June 1996 2 3 7

Page 3: Unanswered questions

JOURNAL OF EMERGENCY NURSING/Cramer

The d e t e c t i v e r epo r t ed the s i tua t ion in t he home w a s "no t r ight . " The pol ice we re familiar w i th the home, hav ing b e e n cal led the re n u m e r o u s t i m e s on violent d o m e s t i c d i spu tes . As expec t ed , the h u s b a n d empha t i c a l l y d e n i e d any respons ib i l i ty for his wi fe ' s dea th . The h o m i c i d e d e t e c t i v e exp la ined to us tha t t he med i ca l examine r would have to prove foul p lay to c h a r g e the husband .

I w a s g iven the m e d i c a l e x a m i n e r ' s ini t ial repor t w i th in hours. The w o m a n ' s liver, heart , and k idneys were all in end s t a g e s of failure. Her organs we re not ab le to me tabo l i ze the ami t r ip ty l ine , w h i c h could have c a u s e d the h igh d rug levels. If t he med ica l e x a m i n e r could have e x a m i n e d the gas t r i c contents , he would have k n o w n h o w m a n y pills h a d b e e n i n g e s t e d at

once. But t he e v i d e n c e w a s gone. No legal ac t ion w a s ever pursued . All t ha t r e m a i n e d were t he a c c u s a t i o n s from the family and m y own feel ing of frustrat ion. I still have the n a g g i n g s ensa t i on tha t if any of us h a d fol- lowed our ins t inc t s more aggress ive ly , w e m i g h t know w h a t really h a p p e n e d . This c a se e m p h a s i z e d the im- po r t ance of fulfilling the role of forensic nurse and m a i n t a i n i n g ev idence .

Cont r ibu t ions to th is co lumn should be sen t to Gaff P isarc ik Lenehan , RN, EdD(c), CS, c /o M a n a g i n g Editor, ENA, 216 Higg ins Rd., Park Ridge, IL 60068-5736; p h o n e (847) 698-9400.

A l though a large a m o u n t of d a t a is col lec ted dur- ing an ED encounte r , t he re a re no nat ional ly ac-

c e p t e d s t a n d a r d s for t he col lect ion and d o c u m e n t a - t ion of t h e s e data . Even for f requent ly col lec ted data , the re are different def ini t ions. A major ob jec t ive of de f in ing an ED d a t a se t is the abi l i ty to analyze d a t a to d e t e r m i n e p a t t e r n s a n d re la t ionships . De te rmin ing w h a t to inc lude and def in ing each d a t a e l emen t for c o m p a r i s o n b e t w e e n e m e r g e n c y d e p a r t m e n t s is a major chal lenge. For example , mos t e m e r g e n c y de- p a r t m e n t s d o c u m e n t the p a t i e n t arrival t ime; how- ever, the def in i t ion of arrival t i m e s var ies widely. It m a y b e r eco rded in one e m e r g e n c y d e p a r t m e n t as the

Vicky Bradley is systems coordinator, Emergency Department and Operating Room Services, University of Kentucky Hospital, Lexing- ton, Kentucky. Reprints not available from author. J Emerg Nurs 1996;22:238-40. Copyright �9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/62/73367

t ime the pa t i en t en t e r ed the e m e r g e n c y d e p a r t m e n t , in ano the r e m e r g e n c y d e p a r t m e n t as the t ime t r iage began , or in a th i rd e m e r g e n c y d e p a r t m e n t as t he t ime reg i s t ra t ion occurred. If e m e r g e n c y d e p a r t m e n t s are u s i n g l eng th of s tay as a benchmark , a c o m m o n def- in i t ion of arrival t ime n e e d s to be a c c e p t e d to p r o d u c e rel iable l eng th of s t ay t i m e s for compar i son a m o n g e m e r g e n c y depa r tmen t s . A l though the re are benef i t s to col lect ion and d a t a ana lys i s wi th in t he ind iv idua l facility, t he sha r ing of d a t a b e t w e e n faci l i t ies and a g e n c i e s will p romote g rea te r benef i t s in the effort to improve the e m e r g e n c y ca re de l ivery s y s t e m and the pub l i c ' s health.

ENA's role in data set development The d e v e l o p m e n t of a d a t a se t is an a rduous and complex process . ENA is s u p p o r t i n g efforts to deve lop a uniform ED d a t a se t t h rough the ac t iv i t ies of the E m e r g e n c y Nurs ing Uniform Data Set (ENUDS) t a sk force and b y pa r t i c ipa t i ng in the d e v e l o p m e n t of the p r o p o s e d Uniform E m e r g e n c y D e p a r t m e n t Data Set

238 Volume 22, Number 3


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