Who to contact after a patient expires

I wanted to touch on a subject that is important but often not laid out in a concise manner - the protocol after a patient expires. 

I want to break this down into responsibilities of each of the staff. For residents (like myself) this often seems like a seamless process that happens in the background, but the reality is, multiple members of the ED are all coordinating together to progress this process.

Physicians- 

1. Attending physician must pronounce dead.

2. Admitting must be called with time of death, cause of death, whether or not the medical examiner will accept the case (more on that in a bit). Admitting will then process this info, and upload info to NYC Certify. The attending will then have to go into NYC Certify and certify the death.

3. The patient's family must be notified. Hopefully they are in the hospital, as it is more appropriate to have this conversation with the patient's family face to face, in private and to give them time to grieve with the patient.

4. Medical examiner must be notified in certain instances. The ME will take the following types of cases - trauma arrests, homicides, suicides, younger patients that are not terminally ill. Typically the ME will not take older patients with comorbidities. When in doubt, call the ME and they can decide.

5. Finally, the death note needs to be completed. 

Nursing- 

1. Charge nurse will call the expeditor / patient rep (more on that in a bit).

2. NYC LiveOn. This is the organ donor group. In our ED, nursing typically calls them. This requires answering questions about time of death, cause of death, medical comorbidities. 

3. Nursing and PCTs are typically responsible for post mortem care in patients that are not Jewish (more on the Guardians of the Sick in a bit). This involves removing lines, ET tubes, cleaning the patient, etc. This is NOT to be done in ME cases.

4. There is a written nursing protocol, on the MMC intranet site, I have shared the link below.

Expeditor/Patient Rep-

1. If the patient is Jewish, the expeditor will contact the operator, who contacts the Guardians of the Sick, who come and do post mortem care.

2. The patient rep may go to the family and offer support and comfort. Cannot provide suggestions regarding funeral homes (this is a conflict of interest).

3. Contact transport if the patient is going to our morgue (sometimes the family will arrange for the patient to be transported to a funeral home instead). 

Hope this helps outline the process and responsibilities during these stressful situations!

http://intranet.mmc/Main/DocumentLibrary/Post_Mortem_Care_2762.aspx

Wayne Pneumothorax Tray

I wanted to do a little blurb about the pigtail kit at Community. I often find that we as providers become pretty comfortable with what we know and uncomfortable with any tools we haven't used before. Back in July, I had to do a chest tube at Community, and the kit was totally different (and rest of the procedure was completely different because of this). This kit is not saldinger technique, and doesn't require use of needles (though you still should use lido obvs). I was initially confused when I was looking at the kit, and so wanted to write this out in case you face the same!

The kit comes with a 14Fr pigtail, trocar, long blade that goes in trocar (looks like a hollow bore needle, but isn't!), 11 blade, tubing, three way stopcock, and one way air valve. The main difference from the pigtail kits that we're used to, is there is no guidewire and no needle! Meaning, you're not going in with the needle first. 

Essentially, you will end up inserting the pigtail with trocar and long blade in one piece, into the incision site. The trocar is placed in a larger fenestrated hole towards the end of the pigtail.

The steps for the procedure include;

1. Confirm the location, fool (pick the side with the pneumo, and do it in the triangle of safety)

2. Prep the site with chlorhexadine

3. Anesthetize the site with lido

4. Get sterile

5. Drape and re-prep (you could probably prep once, but I'm a little OCD)

6. Combine the pigtail, trocar, and long blade as shown in image

7. Make your incision above the rib with the 11 blade

8. Taking the combined long blade, in trocar, in pigtail - insert at your incision, aimed towards the lung apex

9. Remove the long blade once you pass the resistance of the pleura

10. Advance the trocar and pigtail, before removing the trocar and continuing to advance the pigtail to the desired depth (usually around 15-20 cm)

11. Suture the pigtail in place and place a dressing over it

12. Attach the tubing with the one way valve or to a pleurovac

Now for those of you that may read this and say "omg, I'm not trying to just stab someone," well, you are not alone. Others have commented the same. And if you are so inclined to place this pigtail using saldinger technique, that is still possible. You will need to crack open a central line kit and pillage the needle, syringe, and guidewire. The trocar in the Wayne Pneumothroax tray is hollow bore, and the guidewire can still be fed through that. Hope this was helpful! 

Use (or lack thereof) of speculum exams in the ED

Today I want to talk about the use of speculum exams in the emergency department. A recent post on Life in the Fastlane discussed this topic and questioned whether there is much valuable information to be gained, and whether that warrants doing an invasive procedure. The post laid out a stringent set of presentations that definitively require a speculum exam in the ED. Those presentations are;

1. Cervical shock – vaginal bleeding with associated hypotension and bradycardia. This is due to products on conception stuck in the cervix, and causing a vagal response. Removing these products will reverse the shock.

2. Heavy PV Bleeding – similar idea as above, remove clots or products of conception, in this instance to encourage the uterus to contract and slow bleeding.

3. Suspected vaginal foreign body – this is obvious. These need to be removed to prevent infection and potential toxic shock syndrome.

The article goes on to argue against doing speculum exams in certain presentations. Here are the instances it argues against speculum exams;

1. Light bleeding in early pregnancy – speculum exam does not rule out ectopic and ultimately that is the priority over whether something is a threatened vs inevitable miscarriage. Imaging and likely follow up will be necessary in these patients regardless of speculum exam.

2. Suspected PID or torsion – suspicion of either of these diagnoses will require further testing, rendering the examination superfluous. Some combination of imaging, swabs, or empiric treatment will all be necessary regardless of pelvic examination.

A prospective cohort study in 2011 surveyed providers in the emergency department to ask whether pelvic examination changed management plans or not. 171 of the 187 patients (91%) in this study did not have a change in clinical plan before and after pelvic examination.

While neither of these articles are arguing against speculum examinations as an important tool for emergency providers, they are arguing against speculum examinations for all female patients with lower abdominal pain. The procedure is invasive, time intensive given space limitations, and some of the actual exam findings (adnexal tenderness) are nonspecific and will require imaging or other testing anyways. Should we as a practice reexamine the clinical use of this procedure? Should our threshold for doing speculum examinations be higher?

Brown J, Fleming R, Aristzabel J, Gishta R. Does pelvic exam in the emergency department add useful information? West J Emerg Med. 2011 May;12(2):208-12. PMID: 21691528; PMCID: PMC3099609.

Mackenzie, J., & Beech, A. (2024, January 11). Procedure: Speculum examination. Life in the Fast Lane • LITFL. https://litfl.com/procedure-speculum-examination/