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What Do You Do When

Kathi Ayers, Trauma Program Manager, MSN, FNP


Cedar Sinai Trauma Nursing Conference
Cedar Sinai Medical Center
Los Angeles, CA
June 12, 2017
Objectives

Differentiate between debrief and


diffuse or critical incident stress debrief

Define compassion fatigue

List two resources that can assist in a


disaster situation to provide emotional
support
Its Pre-hospital

Its a matter of time


Its about critical thinking
Its about protocols
Its about life vs. death
Two Patients

Patient A
Patient B
Who Lives?
When Found By Paramedics

Pt A Pt B
PEA rate 78 PEA rate 48
Unconscious Unconscious
No pulse No pulse
SW Left GSW Left
Anterior Chest Anterior Chest
Drive Time to Trauma Center

Pt A Pt B
3 minutes 6 minutes
Same Trauma Surgeon
Early Evening Hours

Young Males 19 and 21 yo


Resuscitation Room Assessment
Pt A Pt B
No Cardiac Activity No Cardiac Activity
500 cc HTX 2,500 HTX
Tense Tamponade No Tamponade
RV (2cm SWs) LV (2 cm dia GSWs)
Transected distal Transected OM
(75%) posterior GSW Mult lung lobes
descending artery chest wall,
Other Injury Ant diaphragm, colon
Chest Wall
SO WHO LIVED?
OUTCOME
Pt A Pt B
Transient Ischemic No organ Ischemic
Hepatic and Renal Complications
Injury Survived Completely
No ARDS, Bowel or Neuro Intact
Cardiac Ischemia Home Day 12
DEATH Due To
Cerebral Anoxia
WHY?
PreHospital RX

Pt A Pt B
No intubation Endotracheal
I/O Intubation
IV
PreHospital Response
Pt A Pt B
Call to Dispatch -1 min Call to Dispatch 1 min
Dispatch to scene Dispatch to scene arrival
arrival 8 min - 4 min
Scene Time 18 min Scene Time - 4 min
Call to Base at scene to Call Base Enroute
pronounce Drive to hospital - 6 min
Drive to hospital - 3 min
Its Political

Its about whos in charge


Its about the evidence
Its about HIPPA
Its about the media
Its about the guns
Its about after-action
Its Political
Sheriff arrived to private residence to
serve an arrest warrant for possible
sexual assault of a child
Suspect opened fire on officers as they
entered the complex
Injured two officers who were wearing
bullet proof vests
Officers transported to the trauma
center & taken to the OR
Its Political

Whos in charge
County Sheriff ?
Hospital Administration?
Trauma Surgeon?
Its Political

Its about the evidence


Both patients to the OR
Both with AKA names
Both with GSWs
Who is allowed in the OR to maintain
chain of custody
Its Political

Its about HIPPA


Two families
Multiple officers (75)
Multiple physicians
Everyone wanted information
Patients with AKA Names
Its Political

Its about media


High profile case
Camera crews on scene when medics
arrived & wanting access
PIO officer involved
Its Political

Its about the guns


Armed officers refusing to stand down to
hospital staff or relinquish their piece
Difficult to contain the officers in one
place
Officers present at the bedside 24/7
throughout the hospital stay
What about HIPPA?
Its Political
Its about after action?
Debriefed with medical & law enforcement
teams
Addressed rapid response to high profile or
complex incidents
Hospital policy is always followed
Identify point persons & briefing times
Established areas to contain large groups
of people
Established family identification process
Its Political

Celebrate!
Its Prevention

Its about pregnancy


Its about prevention measures
Its about substance abuse
Its about domestic violence
Its about resuscitation
Its about the outcome
Its Prevention

Its about pregnancy


27 y/o female 34 weeks pregnant
Its Prevention

Its about prevention


Unrestrained front seat passenger
High speed motor vehicle rollover crash
Ejected
Its Prevention

Its about substance abuse


Methamphetamine
Prenatal care
Screening for ETOH & substance use
Its Prevention

Its about domestic violence


Report that there was a restraining order
against significant other
Its Prevention

Its about resuscitation


CPR on scene
Aeromedical transport 20 minutes
Trauma team activation
OB trauma activation
Its Prevention

Its about the outcome


Both mother & baby expired in
resuscitation room
Father treated & released
Trauma M&M discussion with both
Trauma Surgeons & Obstetricians
OB Trauma Stat page
Its Philosophical

Its about resuscitation


Its about ethics
Its about clinical reassignment
Its about the outcome
Its Philosophical

Its about resuscitation


45 y/o Male
Restraining order by wife
Homicidal & suicidal via shotgun
Transported to trauma center
Taken to the OR
Trauma surgeon performed heroic
measures to save the patient
Its Philosophical

Its about ethics


Son was a sheriff
Bioethics consultation
Remained hospitalized for 7 months
Multiples surgeries & amputations
Its Philosophical
Its about clinical reassignment
Staff member can refuse identified
specific clinical procedures based on
philosophies, conflicts with teachings or
doctrines held by a member of the
religion or culture
Discussion with manager & staff
State Law addresses abandonment
Its Philosophical

Its about the outcome


Hospitalized for 6.5 months
Transferred to skilled nursing facility
Died 3 weeks after transfer
Its About Psychiatric

Its about discharge and resource


allocation
Its about recognizing emotional
instability
Its about critical incident stress
debriefing
Its About Psychiatric

Its about discharge and resource


allocation
65 y/o M seen in the emergency dept
with c/o chronic pain
Recently (kicked out) homeless
Discharged from ED but waiting in lobby
to see social worker
Its About Psychiatric

Its about recognizing emotional


instability
Remained in ED lobby a few hours
Left the lobby without seeing the social
worker
Jumped from the 6th floor of the parking
structure outside the ED
Its About Psychiatric

Its about critical incident stress


debriefing
Occurred at 0645 while staff was
arriving to work
ED dept staff observed the event
ED dept staff began CPR & transported
him into the trauma room
Patient expired
Its About Psychiatric

Its about critical incident stress


debriefing (cont.)
Leadership team called in
Employee assistance called in
Defusing & debriefing conducted
Individual staff members offered time off
Food & follow-up provided for next several
days by leadership / organization
Its Profoundly Sad

Its about when its hopeless


Its about when it affects the young
Its about when it impacts the staff
Its Profoundly Sad

Its about when its hopeless


31 y/o M racing his street bike against a
motor vehicle, lost control & struck a
stop sign
CPR on scene
Transported to trauma center
Atlanto-occipital dislocation with locked
in syndrome
Its Profoundly Sad

Its about when it affects the young


Ability to communicate information that
required a response
Language barrier
Family dynamics
Decision to withdraw care
Lifesharing & organ donation
Its Profoundly Sad

Its about when it impacts the staff


Compassion fatigue
Its Personal

Its about when its one of your own


Its about taking care of your own
Its about compassion fatigue
Its about self care
Its Personal

Its about when its one of your own


Long time emergency room nurse
Vivacious, fun loving, compassionate
Divorced mother of two children
Christmas time
Domestic dispute with ex husband
resulting in SWAT incident & her death
Its Personal

Its about taking care of one of your


own
Debriefed & diffused with EAP
Leadership made available to staff 24/7
Dedicated an area to honor her
Memorial service & funds collected
Its You

Its about compassion fatigue


Is the combination of physical,
emotional & spiritual depletion
associated with caring for patients in
significant & emotional pain & physical
distress

Schroeter, K. (2014). Compassion fatigue: An unwanted reflection of your


reality. Journal of Trauma Nursing, March/April 21(2); 37-38.
Its You

Its about self care


Health care providers have the same
feelings as everyone else but are
trained to put their feelings aside
Its You

Its about self-care


Stress hardy personality
Awareness of ones limits, needs,
emotions & resources
Maintaining balance in life activities
Private time
Friends and family