By Dina Fine Maron on February 15, 2017
By the time the pregnant woman arrived at the nearest hospital with a maternity ward—90 minutes after leaving her home in Winfield, Ala.—she was ready to deliver her baby. She made it just in time, recalls Dan Avery, an obstetrician–gynecologist who tended to patients in rural Alabama and elsewhere until his recent retirement. Too often, he says, patients are not so lucky. Some have ended up delivering on the side of the road. Winfield, located in the northwestern part of the state, does have its own hospital—but, like many rural hospitals, it no longer offers obstetrical services, Avery says, so women in labor must travel about 60 miles to Tuscaloosa. When hospital budgets get tight, Avery explains, obstetrical wards are often one of the first things to go.
The problem has metastasized across the state and the nation. In 1980, 45 of Alabama’s 54 rural counties had hospitals providing obstetrical services. Today only 16 of them offer such care, and doctors say that means many, many women need to drive an hour or more to deliver their babies or even get basic prenatal care from an ob–gyn. Too many women cannot make such a long monthly trek, so they simply do without. Others seek care from their family physicians.
Such extreme access problems lead to difficult decisions. Some women in Alabama preemptively choose caesarean section births because they fear they will not make it to the hospital in time, says Dale Quinney, executive director of the Alabama Rural Health Association. Although there have been no studies proving it, Quinney believes the access issue helps explain why his state has one of the country’s highest caesarean rates—35.4 percent of its births in 2015. (The national average was 32 percent that year).
The disappearing maternal care problem is common across rural America. Only about 6 percent of the nation’s ob–gyns work in rural areas, according to the latest survey numbers from the American Congress of Obstetricians and Gynecologists (ACOG). Yet 15 percent of the country’s population, or 46 million people, live in rural America. As a result, fewer than half of rural women live within a 30-minute drive of the nearest hospital offering obstetric services. Only about 88 percent of women in rural towns live within a 60-minute drive, and in the most isolated areas that number is 79 percent.
Maternal mortality is also significantly higher in rural areas. Scientific American analyzed public mortality data from the U.S. Centers for Disease Control and Prevention, and found that in 2015 the maternal mortality rate in large central metropolitan areas was 18.2 per 100,000 live births—but in the most rural areas it was 29.4. Exactly why this happens is unclear. Underlying health conditions such as hypertension or diabetes could be factors, alongside poor prenatal care and geographic access. But the numbers are troubling, and the same trend holds true for infant mortality rates, according to the analysis of CDC figures.
Credit: Amanda Montañez; Source: CDC
New analysis from the University of Minnesota Rural Health Research Center puts the situation in dire terms: “More than two thirds of rural counties in Florida, Nevada and South Dakota have no in-county obstetrical services,” says one of the study’s authors, Carrie Henning-Smith, a research associate at the center. The analysis, which has not yet been published, finds that this was true from 2004 through 2014 (the latest year analyzed). That means these counties had absolutely no hospitals providing obstetrical care—forcing women to travel to other counties.
Unfortunately, family physicians are not moving in to fill these care gaps in high enough numbers. And the number of family physicians offering obstetrical services has dropped by half in recent years, although many still offer basic prenatal care: In the year 2000, 23 percent of family physicians offered obstetrics—but when they were surveyed in 2010 it was only about 10 percent.
Some women manage to cobble together a workaround. Maren Webb, who lives just outside Grand Marais, Minn. (population about 1,350) lives two hours from the nearest hospital that does planned deliveries (in Duluth, Minn.). In the five years that she lived and worked in the area before giving birth to her daughter in October, she had heard countless horror stories about women in labor in the back of ambulances on the way to Duluth or those who had to deliver in the emergency room at a local hospital. To avoid those fates she says she decided to “camp out” at her parent’s house—about half an hour from the hospital in Duluth—in the days ahead of her due date. Webb and her husband ended up staying with her parents for a week before she finally went into labor. “We were thankful that we had the option,” she says, but they wished they could have been at home, preparing for their newborn. Still, they were grateful she had not gone into labor early while they were still at home. Her family has a history of fast deliveries—two or three hours—she says, so she might not have made it to the hospital in time.
Searching for More Answers
To understand how the U.S. got here is not a simple task. Rural health care in general has taken a hit in the past few decades as hospitals have closed and fewer doctors have sought to practice in rural areas. Eighty rural hospitals have been shuttered nationwide since 2010, and about a third of the country’s remaining rural facilities are vulnerable to closure as they continue to operate under tight margins, according to findings from the latest annual Rural Relevance Study. Half of Mississippi’s rural providers operate at a loss, for example, according to the report, which was presented last week at the annual National Rural Health Association (NRHA) conference in Washington, D.C. Rural communities, however, are in desperate need of care: They tend to be poorer, older and less healthy than their urban counterparts.
But obstetrics–gynecology care is particularly vulnerable because delivering a baby is such a pricey business, accounting for more than 5 percent of hospital costs . Why is it so expensive? Unlike a hip replacement, it is hard to anticipate exactly how long it will take to deliver a baby, so the number of nurses, doctors, surgeons and anesthesiologists that must be available throughout delivery adds up. Rural Americans are also less likely to be insured, and more likely to pay for their care using Medicaid—which reimburses doctors at lower rates than private insurance, making it difficult for doctors and hospitals to recover costs and make profits. Low birth volumes make the economics of obstetrical units harder still: Rural communities are generally graying, a demographic fact that reduces the number of births and makes it difficult for hospitals to financially justify having maternity wards at all. And when those wards cannot make adequate money, it leads to their shutdown.
The problem also has a multiplier effect. “It’s a quality of life issue. You don’t want to be the only ob–gyn in a 150-mile radius. You’d never sleep!” Michael Kennedy, associate dean for rural health education at the University of Kansas Medical Center said at the NRHA conference.
The blueprint for addressing the situation remains obtuse at best. Some medical schools think part of the solution is to train more doctors for rural work. The University of Wisconsin School of Medicine and Public Health is launching the nation’s first official obstetrics–gynecology residency program for “very rural” areas, with the first resident slated to be selected next month. “Increasing the physician workforce is important,” says Ellen Hartenbach, residency program director for the school’s Department of Obstetrics and Gynecology. “A large percentage of people practice in the same area after residency, so the theory behind our new training track is to get people training in the smaller communities and increase their exposure,” she says. (ACOG says about half of all residents practice in the state where they trained.)
There are already other ob–gyn residency programs in rural areas, Hartenbach says, and there are rural tracks in family medicine for doctors in other specialties. But official definitions of rural often just mean “not urban,” she says, and the Wisconsin residency program will make sure that communities considered “very rural”—those serving fewer than 20,000 people—will be the focus. “You would be hard-pressed to find that elsewhere,” she says.
Yet this is only one program, with only one resident expected for 2017. Rural health care advocates are also pushing for policy action to help fuel further changes and to incentivize work in rural America. The Improving Access to Maternity Care Act, which has already passed the House but has not yet been introduced in the Senate, would require further data collection by the Department of Health and Human Services about which geographical areas need these maternity care professionals and provide student loan forgiveness for ob-gyn work there—a benefit that is currently offered for dentists and primary care physicians in some underserved communities.
Telemedicine—offering online video call access to patients—for prenatal care could also be part of the solution, rural health experts say. But a lack of broadband internet access continues to keep that from becoming a reality in many rural areas in Alabama, says Hillary Beard, a legislative assistant for Rep. Terri Sewell (D–Ala.). “I don’t think this is unique to Alabama,” she says. “This is a problem for many rural areas.” And too often, she says, people in Sewell’s district report that they had to deliver on the side of the road because they could not make it to the hospital in time, she says.
Changing state laws to let certified nurse–midwives and nurse practitioners perform more clinical tasks might help, too, Henning-Smith says. But other cultural changes may be needed to really lure more clinicians to move to rural areas, she adds. One analysis she conducted found that rural areas—at least in the state she studied, Wisconsin—were less likely to offer child care services than their urban counterparts. That matters, of course, for working parents and their quality of life.
Yet, despite these widespread ob–gyn shortages, there is still little hard data on the long-term effects of these health access gaps. “We know a lot about the closures and about the workforce challenges, but we don’t really know how these things impact women and the health of their infants,” says Britta Anderson, a senior research scientist at NORC’s Walsh Center for Rural Health Analysis at the University of Chicago. “We need more data on if women who travel longer distances to get care suffer more negative outcomes—emotionally and physically.”
Webb, the new mother from Minnesota, says knowing about this potential harm—and reducing the burden of these distances—is essential. “No one has done this research about if these distances are increasing bad outcomes,” she says. The emotional burden, however, is apparent. “If the roads aren’t clear and there’s a blizzard, it could take a lot longer than two hours from my house—and that, too, adds to the stress,” she says. “You don’t want to have this extra stress when you are in labor! You want things to flow.”
June 7, 2016 Brit Long Leave a comment
Author: Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Erica Simon, DO (@E_M_Simon)
You’re wading through your third shift in a row in the pediatric area of your emergency department. The last two shifts have been full of coughs and colds. However, today is shaping up to be a completely different story.
Your first patient is five year-old male who presents after a fall with an obvious right forearm deformity. You order an Xray, expecting to sedate him for adequate reduction. Your second patient: a two year-old female who lost her battle with the corner of a table, suffering a four centimeter laceration to her cheek, presents with a Mom who is adamant that the repair is perfect.
What are your options for procedurally sedating these patients? This post will review sedation medications, and discuss their employment in varying ED clinical scenarios.
Procedural sedation is the administration of a sedative or dissociative agent to produce a depressed level of consciousness, while maintaining cardiorespiratory function. When performed adequately, patients exhibit little or no response to, or memory of, the procedure undertaken.
Principles of Sedation
Pediatric sedations are commonly performed by the emergency physician, however, patient factors including obesity, psychiatric disorders, sleep apnea, recent upper respiratory infection, and ASA class 3 or greater (such as cardiac disease) predict the need for sedation in the OR due to increased risk of complications.
For procedural sedations to be performed in the ED, providers should obtain informed consent, anticipate a required level of sedation, and ensure adequate monitoring and rescue equipment (bag/valve mask, suction, airway equipment including intubation setup, cardiovascular monitoring, oximetry, capnography, and intubation medications) are available. As the rule goes, if you’re prepared for the worst, you won’t need it. If you don’t prepare, you can pretty much guarantee that something bad will happen.
The following chart offers a review of the differing levels of sedation. As emergency physicians, general anesthesia is what we try to avoid unless intubating.
||Normal response to verbal
||Purposeful response to verbal or tactile stimulation
||Purposeful response following repeated or painful stimulation
||Unarousable even with painful stimulus
||No intervention required
||Intervention may be required
||Intervention often required
||May be adequate
||May be impaired
From the American Society of Anesthesiologists, 2014.
As an aside: Dissociative sedation is particular to ketamine. Patients appear in a trancelike state of profound analgesia and amnesia. Airway reflexes are generally protected.
Remember…Child life services can be department-savers in any sedation, procedure, or imaging examination. A little Dora the Explorer or SpongeBob on a tablet device can often times preclude the need for medications. If a caregiver’s presence comforts the patient, request that the caregiver remain in place for frightening aspects of the imaging exam or procedure. On the other hand, if the caregiver’s demeanor or appearance are worsening the child’s anxiety, respectfully request that he/she step out.
If there will be any pain involved, do not hesitate to give acetaminophen or ibuprofen PO shortly after arrival. If pain is severe, intranasal fentanyl at 1-3mcg/kg is a fast-acting option (onset within 2-3 minutes). What’s this intranasal route, you ask?
The Benefits of the Intranasal Route…
The intranasal route (IN) is relatively painless and has rapid onset. The blood supply to the nose is robust; the nares provide a large surface area for absorption, and the venous drainage of the nose ends in the SVC thereby avoiding the liver’s first pass metabolism. Volumes of 0.3mL per nostril are easily tolerated (the ideal medication for intranasal administration being highly concentrated).
Intranasal medications can allow you to complete a procedure or obtain an IV (which may be the procedure itself). Commonly utilized IN medications include midazolam and fentanyl.
When using intranasal medications:
- A higher concentration of medication formulation is advised (decreases the volume to be administered).
- Utilize both nostrils to increase the absorptive surface area.
Avoid intranasal medications in a patient with URI symptoms as nasal congestion and rhinorrhea may alter absorption.
A vast array of medications and delivery routes exist for sedation (Table 1). No one agent is perfect, as multiple options and combinations can be employed. The provider must choose an agent with consideration of the clinical scenario, his/her personal comfort level with the medication, and resources available to him/her.
Table 1 – From EBmedicine.net, Elikashvili I, Vella AD. An Evidence-Based Approach to Pediatric Procedural Sedation. Emergency Medicine Practice 2012 Aug;9(8):1-16.
How do you choose an agent based on the clinical scenario?
The patient’s age and maturity should factor into your decision-making, and the following questions can help guide your choice of medication cocktail:
1. Goal(s) of procedure:
Do you want anxiolysis? Do you want sedation? Do you want sedation deep enough to prevent patient movement? Do you want analgesia? Do you want amnesia?
2. Type of procedure:
Not painful? Minimally painful? Painful?
- Time of procedure
Short versus long?
- What route for medication will you use?
IV, IN, IM, PO?
From EBmedicine.net, Elikashvili I, Vella AD. An Evidence-Based Approach to Pediatric Procedural Sedation. Emergency Medicine Practice 2012 Aug;9(8):1-16.
These procedures will likely involve an attempt to obtain diagnostic imaging in the uncooperative child. Ultimately, you will need sedation to control patient motion. This can be completed through several options:
Oral (PO): Midazolam at 0.2-0.5mg/kg/dose or pentobarbital at 3.5mg/kg/dose.
Intranasal (IN): As seen in Table 1, midazolam at 0.2-0.5mg/kg per dose has an onset of 10-20 minutes and lasts 45-60 minutes and can provide adequate anxiolysis.
Intravenous (IV): Propofol (1mg/kg), ketamine (1-2mg/kg), pentobarbital (2.5mg/kg initial bolus, followed by 1.25mg/kg dosing delivered twice to achieve sedation), and benzodiazepines such as lorazepam and midazolam are options.
A newer agent is dexmedetomidine, provided as an IV drip. This alpha-2 agonist protects airway reflexes, dissociates the patient, and allows for motion control. It provides analgesia, anxiolysis, and sedation. Dosing by textbook is 0.5-1 microgram/kg IV bolus, followed by 0.5 micrograms/kg/hr IV drip, however, caution should be observed as a bolus dose may result in hypotension and bradycardia.
Intramuscular (IM): Ketamine (3-5mg/kg) or midazolam (0.05-0.2mg/kg/dose) are options, however given the increased time to onset, IV administration is often preferred.
Of note, knowledge of the time of onset of these agents is paramount in obtaining desired sedation outcomes.
Maia Rutman discusses in-depth medications for sedation in her 2009 Pediatrics publication. She includes chloral hydrate, pentobarbital, methohexital, and thiopental (not addressed in detail here):
From Rutman MS. Sedation for emergent diagnostic imaging studies in pediatric patients. Curr Opin Pediatr 2009;21:306–312.
Short, Painful Procedure
Then there’s the short, painful procedure, such as a simple laceration repair. Here, the most important factors are anxiolysis and pain control, but patient age is vital in determining which agent to use. In an older child, procedural sedation is often unnecessary as the patient is able to understand the procedure, and can likely be treated with a topical anesthetic such as LET and/or lidocaine injection into the wound, followed by repair.
Contrast this patient to a three year-old who is virtually incapable of sitting still. In this circumstance, you will need sedation, motion control, analgesia, and amnesia. Intravenous ketamine or nebulized nitrous oxide (see below) will allow pain and motion control, as well as sedation and amnesia. Intranasal medications including fentanyl and midazolam are other options if the procedure can be completed within minutes. The downside is determining the optimal time for repair and managing additional dosing, if required.
What about NO?
Nitrous oxide (NO) is a weak dissociative agent that provides significant anxiolysis and moderate pain control with rapid recovery. NO can work well when used to facilitate laceration repairs or orthopedic procedures such as a forearm reduction requiring minimal manipulation. NO is delivered as nebulized, pre-mixed 50% NO, 50% oxygen blend, with an onset of action of 3-5 minutes and a recovery time of 3-5 min post discontinuation of the nebulization. The fast onset and recovery times make this agent extremely useful in a busy ED (assuming the necessary equipment for administration is on hand). NO can also be combined with other medications such as midazolam or fentanyl.
Unknown Procedure Time; Painful Condition
Procedures that are painful and may take an unknown time to complete often require sedation, amnesia, analgesia, and patient motion control.
- Reduction of complex fracture/dislocations
- Complex laceration repairs
- Lumbar punctures
- Central line placement/arterial line placement
Similar to the above section on painless procedures, many of the same medications can be utilized. PO or intranasal routes are optimal to initiate the road to sedation, but obtaining IV access is highly recommend given the ease of administration and ability to perform directed dosing according to observed patient response.
- Ketamine is one of the most frequently utilized medications for sedation in the ED. It is dosed at 1-2 mg/kg IV initial bolus with a duration of action of 30-60 minutes. Ketamine functions well as an analgesic, and is safe for use in patients suffering from head trauma or exhibiting signs of elevated ICP/IOP. Ketamine may cause emergence reactions and emesis, however, the prevalence of these side effects is very low. Many providers will offer pre-medication with ondansetron prior to ketamine administration in an attempt to reduce post-sedation emesis. Current literature does not support pre-treating with a benzodiazepine to reduce the risk of emergence reactions in pediatric patients.
- Combination therapy includes an analgesic and sedative. Remember, propofol, phenobarbital/pentobarbital, benzos, and etomidate are not analgesics, thus, you are sedating, but not treating the patient’s pain. A combination benzodiazepine and analgesic was the staple for sedation years ago, however, as compared to the options of today, this cocktail has greater risk of cardiorespiratory depression, and should only be utilized if other alternatives do not exist.
- Analgesia with fentanyl or newer fentanyl-like medications are key if not using a dissociative agent. Remifentanil is an ultra-short opioid analgesic with potency equal to fentanyl. It is commonly utilized as a continuous infusion, as its short half-life makes bolus dosing difficult. Dosing ranges from 0.1-0.15 micrograms/kg/min.
- Propofol is the fastest acting sedation medication, with an almost immediate time of onset, and recovery time of 8-10 minutes. Initial dosages range from 0.5-1.0 mg/kg IV. Propofol functions only as a sedative and anti-emetic, not an analgesic. Providing an analgesic, such as fentanyl, 15-20 minutes prior to propofol sedation is a commonly utilized technique. (Care should be taken as to avoid the co-administration of propofol and analgesics as significant respiratory depression may occur).
- Etomidate is dosed at 0.1 mg/kg IV and has no intrinsic analgesic properties. Etomidate reduces the rate of cerebral metabolic oxygen consumption, making it ideal in settings of increased ICP and reduced myocardial function. Etomidate is not ideal, however, in settings in which the absence of patient movement is desired, as its administration may result in myoclonus. Etomidate has a rapid onset and last approximately 10 minutes after administration of the first dose. Similar to propofol, pre-treatment with an analgesic is recommended.
- Benzodiazepines such as midazolam (0.05-0.2 mg/kg IV) and lorazepam (0.05-0.1mg/kg IV) are often used in combination with remifentanil, as benzo’s do not treat pain. Unfortunately, in the young these medications may result in cardiorespiratory depression and paradoxical excitation.
- Pentobarbital has a rapid onset (1-2 minutes) but a prolonged duration of action of 2-4 hours (2.5mg/kg IV initial bolus). If the bolus dose is ineffective, a 1.25mg/kg IV dose may subsequently be given.
What about Ketofol?
Ketofol, administered by IV, is a combination of propofol and ketamine. Given alone, ketamine may cause vomiting, hypersalivation, and agitation during the recovery period, and as previously mentioned, administered alone, propofol may cause respiratory depression/apnea and hypotension. Current studies demonstrate these side effects as dose-dependent, therefore it is thought that combining the two agents decreases side-effect occurence. Ketofol can be prepared in varying ratios (ketamine to propofol 1:1, 1:4, 1:2, 2:1, etc.). All regimens are safe, however, a 2015 study by Miner, et al. found an increased propofol ratio (1:4 ketamine to propofol) to be associated with improved anesthesia, anxiolysis, and patient satisfaction. There was, however, an increase in respiratory depression (treated with jaw thrust, and stimulation of the patient). Increases in the ketamine component (1:1 ratio) resulted in fewer respiratory events, but increased agitation during recovery. Ultimately, similar to identifying an appropriate sedation agent for the clinical scenario, the ketamine-to-propofol ratio is at the user’s discretion.
Many providers may not provide analgesia prior to performing a lumbar puncture, as it’s a common myth that neonates do not feel pain. Nociception develops around 30 weeks of gestation, and adequate pain control will maximize your success in this often-important procedure. Topical lidocaine such as LMX 4%, is recommended and has an onset of 30 minutes, so it is important to apply this anesthetic to the potential site while completing the history, physical examination, and orders if feasible.
For young infants, oral sucrose is an effective agent. For patients > 6 months of age, IN or PO midazolam can assist with anxiolysis and amnesia.
After utilizing the above medications, remember that local lidocaine injection is useful.
Rapid Control for Behavior/Psychiatric Complaint
This situation produces a great deal of anxiety amongst providers. Unlike an agitated adult patient, an unruly pediatric patient requiring sedation so as to avoid harm to self or others, is a rare occurence in the ED. If the disruptive patient was previously diagnosed with an anxiety or behavioral disorder, and prescribed PO pharmacotherapy, it is important to utilize the medication that he/she is taking to treat acute symptomatology, in order to limit side effects and drug-drug interactions.
For patients without previously prescribed medications, use lorazepam 0.05mg/kg/dose PO/IV/IM, diazepam 0.04-0.2mg/kg/dose PO/IV/IM, or diphenhydramine 1mg/kg/dose PO/IM/IV to control anxiety.
For psychosis, aggression, or loss of impulse control, use risperidone 0.25 mg PO, olanzapine 2.5mg PO, ziprasidone 10mg IM (for teenagers), or haloperidol 0.025-0.075 mg/kg/dose IM.
Finally, ketamine is a great option for rapid control of all behavioral issues and is dosed at 1 mg/kg IV or 4-5 mg/kg IM. A prior emDocs post provides a succinct summary of adult, pediatric, and geriatric medications for acute behavior control: http://www.emdocs.net/the-art-of-the-ed-takedown/.
Adverse Side Effects/Contraindications:
Here’s a quick run down and recap of the side effects and contraindications of the sedation medications highlighted:
Procedural sedation for pediatric patients is common in the ED setting. Treating pain and utilizing distraction techniques are vital to success. Ultimately, medications employed should be chosen based upon: the patient’s age, the duration of the procedure, the desired patient response to sedation, the determined need for analgesia, the patient’s co-morbidities (see contraindications), medication availability, and your own personal comfort level with the agent.
*Note: We did not discuss rectal forms of medications, though they are listed in the tables above.
-Ali S, Mcgrath T, Drendel AL. An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond. Pediatr Emerg Care. 2016;32(1):36-42.
-Del Pizzo J1, Callahan JM. Intranasal medications in pediatric emergency medicine. Pediatr Emerg Care. 2014 Jul;30(7):496-501; quiz 502-4.
-Elikashvili I, Vella AD. An Evidence-Based Approach to Pediatric Procedural Sedation. Emergency Medicine Practice 2012 Aug;9(8):1-16.
-Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014;63(2):247-58.e18.
-Grunwell JR, Mccracken C, Fortenberry J, Stockwell J, Kamat P. Risk factors leading to failed procedural sedation in children outside the operating room. Pediatr Emerg Care. 2014;30(6):381-7.
-Migita RT, Klein EJ, Garrison MM. Sedation and analgesia for pediatric fracture reduction in the emergency department: a systematic review. Arch Pediatr Adolesc Med. 2006;160(1):46-51.
-Miner, JR et al. Randomized, double-blinded, clinical trial of propofol, 1:1 propofol/ketamine, and 4:1 propofol/ketamine for deep procedural sedation in the emergency department. Ann Emerg Med. 2015 May;65(5)479-488.
-Roback MG, Wathen JE, Bajaj L, Bothner JP. Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs. Acad Emerg Med. 2005;12(6):508-13.
-Rutman MS. Sedation for emergent diagnostic imaging studies in pediatric patients. Curr Opin Pediatr 2009;21:306–312.
-Stevens B, Yamada J, Lee GY, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2013;1:CD001069.
-Tobias J and Leder M. Procedural sedations: a review of sedative agents, monitoring, and management of complications. Saudi J Anaesth. 2011; 5(4):395-410.
-Quality Management and Departmental Administration. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. American Society of Anesthesiologists. 2014. Available at http://www.asahq.org/~/ media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedation-analgesia.pdf
-Zier JL, Liu M. Safety of high-concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases. Pediatr Emerg Care. 2011;27(12):1107-12.
John Murphy, MDLinx, 08/06/2015
When in doubt, administer epinephrine. In other words, you don’t need to be 100% certain that a patient is having a severe allergic reaction to administer epinephrine in an emergency setting. That’s the recommendation from a panel of allergists and emergency physicians convened by the American College of Allergy, Asthma and Immunology (ACAAI).
Using epinephrine for anaphylaxis outweighs the risks of withholding it, allergy experts said.
The panel’s conclusions were published in an August 6 article in Annals of Allergy, Asthma and Immunology. The panel determined that anaphylaxis is underdiagnosed, and epinephrine is underused, in emergency departments.
“Our emergency medicine colleagues told us that if patients don’t fit established guidelines for anaphylaxis, there may be a reluctance in the emergency room to treat with epinephrine,” said allergist and chair of the panel Stanley Fineman, MD, MBA, ACAAI past president and adjunct associate professor in the Department of Pediatrics, Allergy Division, at Emory University School of Medicine, Atlanta, GA. “Because epinephrine is the first line of defense in treating anaphylaxis, the panel agreed it should be used—even if a patient’s reaction may not meet all the established criteria. The consequences for not using epinephrine when it’s needed are much more severe than using it when it might not be necessary.”
Intramuscular administration of epinephrine at proper doses is safe and there are no absolute contraindications for its use in treating anaphylaxis, the panel agreed. In fact, delay in administering epinephrine may lead to more severe and treatment resistant anaphylaxis.
Indeed, epinephrine should be given to patients at risk of an anaphylactic reaction if they have had a previous severe reaction or had a known or suspected exposure to their allergic trigger with or without the development of symptoms, the panel concluded.
“We want emergency medical personnel, as well as people who have had or are at risk for having severe allergic reactions, to know there is no substitute for epinephrine as the most important tool for combatting anaphylaxis,” said panelist Paul Dowling, MD,director of the Allergy/Immunology Training Program at Children’s Mercy Hospital, Kansas City, MO. “Antihistamines and corticosteroids should not be given instead of epinephrine because they don’t work fast enough.”
The other crucial message highlighted by the panel is that anyone seen for anaphylaxis in the emergency department needs to be referred to an allergist to schedule a follow up visit to assist with diagnosis confirmation, trigger identification, and continued outpatient management with a goal of preventing anaphylactic reactions in the future.
This research was supported by an educational grant from Mylan Specialty, maker of EpiPen®.
April 18–Hospital emergency rooms across Minnesota are reporting a surge in mental health patients that has turned many ERs into “holding pens” for troubled and sometimes violent adults, often at the expense of other patients needing urgent care.
The crowding has become so acute in some smaller, rural hospitals that patients are forced to wait on stretchers in public hallways, often for hours, or even turned away and sent to hospitals hundreds of miles away.
While most psychiatric patients are not violent, the anxiety of long waits and long stays in emergency wards is causing more patients to lash out at medical staff not trained for violent behavior.
“This is supposed to be a place of peace and security,” said Dr. Peter Neifert, a psychiatrist at St. Joseph’s Medical Center in Brainerd. “Instead, we have acute [psychiatric] patients banging on windows, throwing feces, and assaulting people … It’s deeply unsettling to other patients on the ER.”
With more psychiatric patients, often occupying ER beds longer, hospitals have been forced into a number of measures:
— Two of Minnesota’s largest hospital systems, Allina Health and Essentia Health, said they are increasingly turning away ambulances because so many of their emergency ward beds are occupied by mental health patients.
— Hospitals are sending ER patients as far away as Fargo and Sioux Falls because psychiatric beds in Minnesota are full.
— St. Mary’s Hospital in Detroit Lakes is preparing to build its second “safe room,” stripped of all furnishings but a narrow stretcher bolted to the floor, to hold growing numbers of ER patients in danger of hurting themselves.
The challenge of providing care for patients with mental illnesses has become “the single most significant issue” facing private hospitals across the state, said Matt Anderson, a senior vice president at the Minnesota Hospital Association. It has supplanted the cost of caring for the uninsured, now that tens of thousands of Minnesotans have gained coverage through the Affordable Care Act, he said.
Patient rips out sprinkler
Emergency rooms, generally designed to treat trauma victims for a few hours until their conditions stabilize, are now holding mental-health patients for days or even weeks for lack of inpatient beds. This practice, known as “psychiatric boarding,” was banned by the Supreme Court of Washington state two years ago because of concerns that ERs did not provide adequate mental health treatment.
Once a rare occurrence in Minnesota, “boarding” in ERs is now a common practice. From 2007 to 2015, Minnesota hospitals saw a 65 percent increase in mental health visits to emergency rooms, nearly three times the increase for ER visits overall. And these patients are staying far longer. Last year, 20 percent of all ER visits by mental-health patients lasted longer than a day, up from 10 percent in 2006, according to the state hospital association.
But unlike jails, hospital emergency rooms are not equipped to deal with violence.
Last month, the emergency psychiatric unit at HCMC was evacuated after a patient ripped a sprinkler head from the ceiling, flooding the unit with hundreds of gallons of water. At St. Joseph’s in Brainerd, all six voluntary patients in the hospital’s 15-bed psychiatric unit requested discharge the morning after a patient threw a chair at a nurse and screamed obscenities.
“This affects everyone, not just people with mental illness,” said Dr. Christopher Delp, an ER doctor at St. Luke’s Hospital in Duluth. “If we are boarding people in the ER … then I can’t get to the grandmother with the broken hip, and people wait longer because we just don’t have the room.”
Full-time security guard
A young man with fetal alcohol syndrome and a severe anxiety disorder, Matthew Johnson reflects the challenges that many hospitals face.
A sheriff’s deputy brought Johnson, 19, in restraints to the United Hospital’s emergency department in St. Paul, after he ran away from his group home in Apple Valley and threatened to hurt staff. It was the sixth time he was brought to a hospital ER, often in restraints, since his best friend moved out of his group home in February, an event that aggravated his wild mood swings.
However, within hours, the group home called his family to say it would no longer take Johnson back as a resident. It was then up to a county social worker and his adoptive parents to scramble and find him a new place to live while he waited in a hospital emergency room.
As the days passed with little to do, Johnson paced the hallways anxiously. At one point, he grabbed a nurse by the hair and pulled her to the floor. The assault prompted the hospital to place Johnson in a secure room on its surgical unit, with a full-time security guard stationed outside.
Days turned to weeks. “It was heartbreaking,” said his mother, Beth Johnson, of Apple Valley. “The doctors kept saying, ‘He doesn’t need treatment, so why is he here?’ ”
On a recent night, Johnson’s second-floor hospital room bore the cluttered remains of his three-week stay. Empty soda cans, board games and a stuffed animal were strewn about his bed, and piles of movie and video game DVDs lined the windowsill. Dressed in a brown hospital gown, Johnson kept pounding a handheld call button, causing a nurse to rush in with a security-guard.
Sitting patiently by his side, Johnson’s father, Ken, tried to calm his son by showing him photos of a new group home that had agreed to accept him temporarily as a client. “They hated me at the old place,” Matthew said angrily. “Nobody wants me.”
Earlier this month, Johnson was finally discharged from United. With two security guards watching, he was wheeled out and into a nearby ambulance with restraint straps across his wrists, ankles and chest. But less than a day later he was sent to an emergency room, this time at Abbott Northwestern Hospital in Minneapolis, after he attacked another group home employee.
When Beth Johnson visited her son last week at Abbott, she was surprised to discover him curled up and asleep on a chair in the waiting room while a security guard watched over him.
“I was shocked that he was not even given a stretcher to sleep on,” she said. “He seemed really uncomfortable.”
David Schmoyer, director of United’s emergency department, said Johnson’s case is not unusual. In recent months, there have been days when as many as 17 of the hospital’s 32 emergency rooms were occupied by mental health patients. The number of mental health patients and their length of stay have increased 10 percent annually for the past four years, he said.
To handle the influx, emergency staff members are now trained how to strip a room of all tubing, sharp objects and other dangerous devices. The stripping takes about 15 minutes, and the equipment must be reinstalled once the patient leaves. On a recent afternoon, plastic bins full of gear stripped from rooms lined the emergency room corridor.
“We’ve been forced to adapt creatively, like everyone else,” Schmoyer said. “Still, from a human perspective, this isn’t right. People were not meant to stay here day after day after day.”
Copyright 2016 – Star Tribune (Minneapolis)