13Apr/17

Pray for Paris

Image from http://www.cnn.com/2015/11/13/europe/paris-attacks-at-a-glance/

On November 13th between 9:20pm to 12:20am November 14th suicide bombers and men armed with assault rifles attacked 6 different locations in Paris: a soccer stadium, a concert auditorium and various cafes crowded with locals and tourists during a Friday evening. Paris was well prepared for this disaster. The Assistance Publique-Hôpitaux de Paris (APHP) mobilized the “White Plan” which resulted in the rapid response of emergency medical services and the APHP crisis unit. The APHP crisis unit is the largest of its kind in Europe with a collaboration between 40 hospitals, 100,000 health professionals, a capacity of 22,000 beds, and 200 operating rooms (Hirsch, 2015). To address the possibility of a large influx of wounded, 2 additional hospitals in the crisis unit would serve as extensions. However, there was no need to utilize the 2 extension hospitals. The APHP also recognized the need for psychological care and had a team of psychiatrists, psychologists, nurses, and volunteers to provide support at Hôtel Dieu in central Paris (Hirsch, 2015).

The types of trauma care that would have been provided were gunshot wounds, lacerations and penetration from debris, hemodynamic shock, skeletal fractures and blunt trauma. An “injury” I did not realize would be a problem was heart attack (Hirsch, 2015). Care would also have needed to address psychological trauma, anxiety and stress. As a healthcare provider during that event, triage skills would be crucial in recognizing which people were the most injured and who had the highest chance of survival. In addition, a healthcare provider would need to initiate the ABCDE assessment and intervention strategy, recognizing that prehospital care and the “Golden Hour” are important in achieving good patient outcomes. Socioeconomics and environment made a positive impact on outcome. Paris is a city in a well-developed country which had the benefit of access to multiple resources, well-trained professionals and updated technology. Paris is also a large city, generally a location that would contain a greater concentration of healthcare resources, first responders and law enforcement. The APHP was able to maximize the capabilities of these agencies.

Image from http://www.cnn.com/2015/11/13/europe/paris-attacks-at-a-glance/

Although the “White Plan” was largely successful, it was not perfect. Some of the disaster sites experienced problems such as a shortage of stretchers and not enough tactical [on-site] physicians for the number of casualties. The “exclusion zone” was also a barrier to care; the danger zone in which explosives are a threat to those within (Service, 2015). Access to the “exclusion zone” was given to the French police counter-terrorism team and tactical physicians but not conventional prehospital health workers. Although this policy made the safety of healthcare workers a priority, it would delay the treatment of victims to some extent.

Image from http://www.cnn.com/2015/12/08/europe/2015-paris-terror-attacks-fast-facts/

Although it was the pilot execution, Paris seemed to be well prepared for this disaster with the successful execution of the “White Plan.” The “Plan” was developed 20 years prior and during the time of the terrorist attacks, the healthcare workers who responded had completed recent education and updating on emergency response and planning. These healthcare workers were experienced with crisis situations and were long-time colleagues. This highlights the importance of teamwork and collaboration. As a result of the current political climate of the globe and the prevalence of terror attacks worldwide, Paris, an iconic and densely populated city, anticipated the possibility of experiencing terror attacks. It can be assured that future disasters will be handled with efficiency, organization and speed. In the U.S., terrorism is addressed by agencies such as Metropolitan Medical Response System (MMRS), the Public Health Emergency Preparedness (PHEP) program, managed by CDC, and Hospital Preparedness Program (HPP), managed by the United States Department of Health and Human Services (HHS) (U., 2017).

References
2015 Paris Terror Attacks Fast Facts. (2016, November 30). Retrieved April 12, 2017, from http://www.cnn.com/2015/12/08/europe/2015-paris-terror-attacks-fast-facts/
Hirsch, M., Carli, P., Nizard, R., Riou, B., Baroudjian, B., Baubet, T., . . . Lafont, A. (2015). The medical response to multisite terrorist attacks in Paris. The Lancet,386(10012), 2535-2538. doi:10.1016/s0140-6736(15)01063-6
Service Médical du RAID. (2015). Tactical emergency medicine: lessons from Paris marauding terrorist attack. Critical Care20, 37. http://doi.org/10.1186/s13054-016-1202-z
U.(2017). Metropolitan Medical Response System. Retrieved April 13, 2017, from http://www.homelandsecuritygrants.info/GrantDetails.aspx?gid=17164

 

06Apr/17

Neuroprosthetics

Brain prosthetics are a newer concept in neurotechnology. Currently we have cochlear and retinal imlplants which aid in restoring sensory function. On the horizon, brain prosthetics may one day be advanced enough to help in epilepsy, depression, chronic pain, Alzheimer’s, PTSD, traumatic brain injury, spinal cord injury, and amputations (Varrasi 2014). Recent discoveries have been made in the use of thin, flexible polymer that would hold itself in the human brain without posing too many adverse risks. This article shows the possibilities of future advancement in neural regulation and treatment. Brain prosthetics still have years of development to improve and enhance safety, but the prospects are promising in improving quality of life of those with neurologic deficits.

https://www.asme.org/engineering-topics/articles/bioengineering/next-generation-in-neural-prosthetics

05Apr/17

Phantom Pain Management

Phantom limb pain (PLP) is when painful stimuli is perceived in the area of the lost limb. This is not to be confused with Residual limb pain (RSL), which is located at the stump. For example, the area of amputation such as the arm can result in pain sensory in the “phantom” thumb. Management for phantom limb pain is usually done by an injection of local anesthesia at the peripheral nerve (Moesker, 2014). New studies demonstrate effective use of cyroanalgesia to resolve PLP. In a study conducted by Moesker et al (2014), 5 patients with an amputation participated in being administered cyroanalgesia for their PLP. Cyroanaglesia is a specialized technique able to provide long-term relief of chronic pain my applying cold which acts as a conduction block that works similar to local anesthesia (Moesker, 2014). Three of these patients experienced a 90-100% decrease in their pain levels, 1 with a 60% decrease, and the last one with a 40% decrease (Moesker, 2014). For long-term pain treatment this demonstrated positive effects as the average follow-up time was 1.2 years (Moesker, 2014). Patients who lose their limb to trauma or PVD may now have an option of cyroanalgesia for long-term pain management.

Moesker, A. A., Karl, H. W., & Trescot, A. M. (2014). Treatment of Phantom Limb Pain by Cryoneurolysis of the Amputated Nerve. Pain Practice, 14(1), 52-56. doi:10.1111/papr.12020

05Apr/17

The Aging Population

It’s no secret that America is getting older. We are currently in the period where all the baby boomers are finally hitting the ripe age of 65+. The trends in healthcare certainly do not favor the older adult population unfortunately. Many older adults have insurance through Medicare but according to Moeller (2015), Medicare is not enough to cover all of the needs of older adults, particularly long-term custodial care. So where does that leave this vulnerable population? One hospitalization can bankrupt them. Some of them rely on family members to care for them long term if something happens, because Medicare can’t cover it. But the sad reality is that not everyone has the luxury of younger family members who are close enough or willing to care for their older relatives. Some may have opted out of starting a family since it is the 21st century (it’s not a requirement to have kids). Moeller (2015) goes on to explain that Medicaid is the “default provider of long-term care in this country”. The problem with that is Medicaid is not an option for every older adult. In order to quality for Medicaid the older adult would essentially have to spend away almost all of their assets which is a very sad and embarrassing thing to do. Over the next 5-10 years we will need to find other options for how to manage care for these older adults who cannot afford long-term care when something happens. It is a huge concern already in Japan and in countries in Europe and will become a similar problem here if we do not change how we will support our older population.

Reference:

Moeller, P. (2015). Medicare coverage for aging parents’ care is not nearly enough. Retrieved from http://www.pbs.org/newshour/making-sense/medicare-coverage-aging-parents-care-nearly-enough/

04Apr/17

Aging Population

By the year 2050, the number of citizens 60 years and older is expected to nearly double from 11% to 22% (Kanasi, Ayilavarapu, & Jones, 2016). For healthcare, this means an increase in the amount of patient’s requiring medical services. Preparing for this large increase in demand for the need of healthcare may require additional education and training to health care workers. With a large increase in diabetes, hypertension, and other risk factors for the development of threatening conditions, education has been a main priority in caring for the elderly. Additionally, diseases such as dementia, Alzheimer’s, and Parkinson’s require a more specialized approach. In the article titled, ” Population Aging, the Needs of the Elderly and Challenges for Nursing” discusses the need for specialized courses in gerontology for nurses that need to be implemented in order to increase knowledge and skills in caring for the elderly (Savic, Zurc, & Touzery, 2010).  Additionally, a common concern is that the average lifespan is increasing, meaning individuals needs to be prepared financially for the future. We all know of the hardships many U.S. citizens undergo in receiving low cost healthcare. With the aging population, there will be many more individuals requiring higher level care and they need the financial support to allow them to receive the medications and care they require. The healthcare system needs to be prepared for the large increase in geriatric patients seen in the upcoming years.

Kanasi, E., Ayilavarapu, S., & Jones, J. (2016). The aging population: demographics and the biology of aging. Periodontology 2000, 72(1), 13-18. doi:10.1111/prd.12126

Savic, B., Zurc, J., & Touzery, S. (2010). Population ageing, the needs of the elderly and challenges for nursing. Obzornik Zdravstvene Nege, 44(2), 89-100.

03Apr/17

Advanced Neurological Monitoring

An article titled “Advanced Neurological Monitoring” was published in 2016 in the Oxford Journal discusses the advantages of using intensive neurological monitoring in conjunction with conventional monitoring to promote better outcomes in patients who have suffered traumatic brain injuries (TBI) and/or subarachnoid hemorrhage (SAH). The monitoring modalities included in the discussion involve the following: pressure monitoring, cerebral perfusion pressure monitoring, jugular bulb oximetry, transcranial doppler ultrasongraphy, brain tissue oximetry, near infrared cerebral spectroscopy, cerebral microdialysis, cerebral imaging, and continous EGG. This article suggests that using a combination of the above listed monitoring strategies will improve outcomes through early detection and intervention secondary to advanced monitoring. Furthermore, it is suggested that “An integrated approach to measuring intracranial pressure alongside cerebral oxygenation and metabolites may therefore be useful in predicting patients at risk of deterioration.” Through use of a variety of measurements nurses and physicians are able to gain a more clear understanding of the cellular and pressure changes occurring in the brain of a patient who has sustained a TBI or SAH. Below is a summary of the purpose of the above mentioned monitoring strategies:

Pressure Monitoring: the intraventricular catheter is considered the most accurate way of monitoring and draining CSF

Cerebral Perfusion Pressure: is equal to the MAP- ICP. CPP below 50mmHg is directly related to blood flow and means ischemia may occur in the brain injured patient and leads to poorer outcomes. Target CPP should be between 50-70 mmHg

Jugular Bulb Oximetry: catheter that is inserted into internal jugular vein. normal oximetry for such a catheter is between 55%-85%, if less than 55% the patient has a deficit of cerebral oxygen delivery. The most common reason for jugular bulb desaturation is reduced CPP secondary to increased ICP. “Acute hyperventilation is a life saving ICP-reducing maneuver that can be titrated to SjO2 lmiting hypocapnia-induced vasoconstriction and ischemia”. ( Ralph & Singh, 2016, p. 95)

Transcranial Doppler Ultrasonography: non-invasive tool used to help approximate cerebral blood flow. This monitoring tool is most commonly used to assess for vasospasm, cerebrovascular autoregulation, emboli detection and, cerebral perfusion (Ralph & Singh, 2016).

Brain Tissue Oximetry: this is used to assess oxygen tension within brain tissues extracellular fluids. It is thought that balancing oxygen delivery through this type of monitoring improves patient outcomes.

Near Infrared Cerebral Spectroscopy: non-invasive method to assess cerebral oxygen concentrations. Mostly used in pediatrics but has proven helpful in TBI and SAH patients as well

Cerebral Microdialysis: used to assess and quantify the extracellular fluid makeup inside the brain itself. It filters small molecules through diffusion and allows for sample testing of the fluid drained to assess for chemicals, drugs and byproducts of metabolism

Cerebral Imaging: produces very detailed photographs of the metabolic and hemodynamic status of the brain (Ralph & Singh, 2016)

Continuous EEG: allows for the early recognition and rapid intervention of a patient experiencing seizure activity which often occurs after TBI and SAH.

 

03Apr/17

Virtual Stroke Rehab

Early intervention with physical therapy has been a mainstay of stroke rehab for many years. Recent research has shown, however, that PT alone might not be enough to help these patients regain their fullest physical potential. A rehabilitation professor at Rutgers University has said that PT alone is boring and exists only at the level of the muscle. Therefore, that have been developing video games that are designed to mimic every day physical activities while at the same time engaging a patient’s cognition in addition to movement, which makes the exercise have more impact and meaningfulness on long term rehab. By increasing motivation, these video game PT sessions last longer, provide more repetition, and lead to more successful rehab sessions.

While similar rehab products were available 20 years ago, they were much too expensive to be practical to home use. Now, the hardware required to utilize this PT modality is approximately $100, substantially increasing affordability of this technology. Imagine how patient compliance would increase in this day and age if we could prescribe an hour of video games for every medical condition?

If you’d like to learn more about the Rutgers University V-Step game, click the link below:

http://www.newsworks.org/index.php/local/the-pulse/92651-fun-side-of-qserious-gamesq-could-aid-in-rehab-

03Apr/17

The Aging Adult Population

Often times due to declining health, older adults will live with their family members and thus providing long-term care for their elders. Greater than 70 percent of elderly men and 40 percent of elderly women live with family (Hooyman et al., 2015). Older adults may also choose to live with their children due to financial constraints, a desire for companionship, and due to the loss of their partner or previous caregiver.  With a growing aging adult population as the baby boomers enter into ages 65+, there will be increased reliance on family to act as caregivers. Space in long-term care facilities is limited, can be costly, and difficult to find placement for older adults in need. This places increased emotional and financial burden on family members. Although there is an increased burden on families to act as caregivers, it is estimated that family caregivers of adults 65 and older save society around $450 billion per year (Hooyman et al, 2015). This in turn greatly affects the American economy, heath care systems, and long-term services.

Hooyman, N. R., Kawamoto, K., & Kiyak, H. A. (2015). Aging matters: An introduction to social gerontology.