Ann White

Infusing PDA Technology Into Nursing Education

Use of the personal digital assistant (PDA) has been infused into the accelerated baccalaureate program at Duke University to help prepare nursing students for professional practice. The authors provide an overview of the use of PDAs in the classroom, laboratory, and clinical setting. Technical aspects of PDA infusion and steps to ensure regulatory compliance are explored. Benefits of PDA use by both faculty and students in the program and challenges met with the infusion of this technology are also described.

Acute aortic emergencies--part 2: aortic dissections.

Patients with aortic disease are some of the highest acuity patients that emergency clinicians encounter. Dissection is the most common aortic catastrophe and involves separation of the aortic layers in a longitudinal fashion leading to diminished perfusion and systemic ischemia. Characteristics of pain, branch vessel involvement, and incidence lead to an understanding of patient presentation, morbidity, and mortality. Diagnosis, selection of diagnostic studies, the degree of preoperative ischemia, and risk of operative mortality can be accomplished using validated clinical decision tools. Emergency interventions are guided by the type of dissection according to the Stanford classification system. Medical management includes pain control and anti-impulse, antihypertensive therapy through vasodilatation and blockage of the sympathetic β-response. The patient may then be evaluated for open surgical intervention, aortic fenestration, endovascularly placed stent grafts, or a combination possibly in a staged approach. Morbidity includes rupture, stroke, paraplegia, acute renal failure, bowel ischemia, and peripheral ischemia.

Change strategies make for smooth transitions.

Nurse managers can usher in change successfully by focusing on evidence-based change concepts, such as selecting the right leadership skill, anticipating how people will respond to change, and choosing the correct implementation strategies.

Acute aortic emergencies--part 1: aortic aneurysms.

This article is a 2-part series about patients with aortic emergencies. Patients with acute aortic disease who present to the emergency department represent some of the highest acuity patients that emergency clinicians will ever encounter in acute care settings. Part 1 focuses on aortic aneurysms in the thorax or abdomen. An aortic aneurysm involves transverse dilatation, leading to rupture and hemorrhage. Diagnosis is largely based on clinical presentation and carefully selected imaging studies. Emergency interventions are guided by whether or not the patient is hypertensive or in shock. For patients in shock, attention should focus on restoring intravascular volume while not generating excessive blood pressure. Open surgical intervention or endovascularly placed stent grafting should then be expedited. Both options are not without complications, most commonly being stroke, paraplegia, and death. Part 2 will explore aortic dissection.

Heimlich valve orientation error leading to radiographic tension pneumothorax: analysis of an error and a call for education, device redesign and regulatory action

Medical errors are commonly multifactorial, with adverse clinical consequences often requiring the simultaneous failure of a series of protective layers, termed the Swiss Cheese model. Remedying and preventing future medical errors requires a series of steps, including detection, mitigation of patient harm, disclosure, reporting, root cause analysis, system modification, regulatory action, and engineering and manufacturing reforms. We describe this process applied to two cases of improper orientation of a Heimlich valve in a thoracostomy tube system, resulting in enlargement of an existing pneumothorax and the development of radiographic features of tension pneumothorax. We analyse elements contributing to the occurrence of the error and depict the implementation of reforms within our healthcare system and with regulatory authorities and the manufacturer. We identify features of the Heimlich valve promoting this error and suggest educational, design, and regulatory reforms for enhanced patient safety.

Emergency Care of Postpartum Patients with Preeclampsia and Eclampsia

Patients with preeclampsia and eclampsia as complications of pregnancy can present to the emergency department sometimes days to weeks after delivery, with a varied spectrum of signs and symptoms and many emergent needs. Preeclampsia is an immune-mediated, systemic, vasospastic condition of the endothelium, the innermost cell layer of the vasculature. Because of the severe vasospastic situation, severe ischemia develops, with resultant endothelial damage and eventual necrosis in key organs, resulting in status epilepticus, stroke, shock, end organ failure, and cardiac arrest. Eclampsia involves seizures with preeclampsia that cannot be attributed to any other cause. Emergency interventions focus on preventing maternal injury, ensuring oxygenation, decreasing blood pressure, and preventing seizures.

Emergency Care for Patients With HELLP Syndrome

HELLP stands for hemolysis, elevated liver enzymes, and low platelets, and is associated with preeclampsia. The intense vasospasm in the microvessels essentially crushes the red blood cells and platelet cells and causes hepatocellular necrosis and edema. Complications are progressive and sudden and must be anticipated. The clinical course includes disseminated intravascular coagulation, liver infarction, rupture or hemorrhage, renal compromise or failure, abruptio placentae, eclampsia, pulmonary edema, acute respiratory distress syndrome, fetal compromise, shock, and cardiac arrest. Early interventions include identification and stabilization, fetal assessment, transport to a tertiary center, rapid platelet and red blood cell transfusion, emergent childbirth, steroid therapy, liver transplantation, and tremendous psychological support.