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.

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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.

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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

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