Aguirre Legal Nurse Consulting, PLLC

The Impact Of E-Cigarettes

9/21/2015

Someone recently shared with me that "vaping" helped him quit smoking after enabling the habit for over 20 years. It occurred to me, trading one habit for another, what is the impact of e-cigarettes?

An electronic cigarette, otherwise known as an e-cig, personal vaporizer (VP), or an electronic nicotine delivery system (ENDS), is essentially a battery powered device that vaporizes a liquid solution called an e-liquid.
E-liquids usually contain a mixture of propylene glycol, glycerin, nicotine and/or flavorings. It's the assumption because "vaping" does not burn tobacco, that it should be safer than conventional cigarette smoking. However, e-liquids decompose into known carcinogens such as formaldehyde and acetone, when aerosolized. Additionally, both conventional cigarettes and e-cigarettes deliver nicotine.

One component of the marketing efforts promote e-cigarettes as a smoking cessation product. However, a recent article in the Journal of the American Medical Association states that "data supporting the effectiveness of e-cigarettes at helping smokers quit are lacking."

Data shows that manufacturers are also marketing these products toward minors and individuals who have never smoked. Nicotine cartridges can be found in different appealing flavors such as fruit, candy and cola. The device itself can resemble a decorated accessary or even a cartoon character. Some of these products also have refillable cartridges to allow e-liquids to be changed or mixed, which has resulted in an increase in unintentional overdoses.

The simple truth is that e-cigarettes have not been fully studied. We don't fully understand the potential risks of e-cigarettes when used as intended. We don't know how much nicotine or other potentially harmful chemicals are being inhaled during use. This includes secondhand vapors that can be inhaled by bystanders. The World Health Organization (WHO) has recommended that e-cigarettes should be banned indoors, because they emit chemicals potentially as dangerous as cigarettes and have a potential passive smoking risk.

We also don't know whether there are any benefits associated with using these products. The California Department of Public Health has issued a health advisory warning related to the toxicity of e-cigarettes, stating the nicotine in them is as addictive as the nicotine in conventional cigarettes. There is also concern that e-cigarettes can increase nicotine addiction among young people and lead kids to try other tobacco products, including conventional cigarettes, which are proven to cause disease and lead to premature death.

Currently, the FDA only regulates cigarettes, cigarette tobacco, roll-your-own tobacco, and smokeless tobacco. However, efforts have been made by the FDA to extend its tobacco authority to additional tobacco products, including e-cigarettes.

Contact Aguirre Legal Nurse Consulting to keep you up to date on the latest medical trends, practices and techniques. Call (443) 598-2562 or email us at AguirreLegalNurseConsulting@gmail.com

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Back To School Concussion Screenings

8/11/2015

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It will soon be back to school time, and many public schools are posting the message "No Shots, No School" on their reader boards. This is no surprise, since public schools require all children to be up to date on vaccinations, with the exception of religious declination, before the school year begins. What may be surprising, however, is a new trend that partners schools with healthcare facilities in order to promote baseline concussion screenings for student athletes. This is in part a result of growing concern over the increasing number of head injuries occurring in our young athletes and the potentially dangerous and detrimental effects of undiagnosed head injuries.

The CDC estimates that approximately 1.6 million to 3.8 million sports-related concussions occur annually in the United States. A concussion is caused by a bump, blow, or jolt to either the head or the body that causes the brain to move rapidly inside the skull. This sudden movement can cause the brain to bounce around or twist in the skull, stretching and damaging the brain cells and creating chemical changes.

A concussion may occur with or without a loss of consciousness. Signs and symptoms can show up right after the injury or may not be noticed until days or weeks later. Standard neuroimaging studies are typically normal; therefore, concussion is a clinical diagnosis.

The most common symptom is headache. However, children and teens with concussion may exhibit any of the following:

Can’t recall events prior to or after a hit or fall
Appears dazed or stunned
Forgets an instruction, is confused about an assignment or position, or is unsure of the game, score, or opponent
Moves clumsily
Answers questions slowly
Mood, behavior, or personality changes
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision, bothered by light or noise
Feeling sluggish, hazy, foggy, or groggy
Confusion, or difficulty with concentration and memory
Just not “feeling right,” or “feeling down”

Concussions that are unrecognized or are mismanaged increase the risk of developing a potentially catastrophic sequelae known as Second Impact Syndrome. This results when an athlete has not fully recovered from an initial concussion before sustaining a subsequent concussive injury. This in turn causes diffuse brain swelling and severe, permanent neurological dysfunction or death. This type of repetitive head trauma can occur from participation in contact sports such as boxing, football and/or ice hockey.

Pre-season concussion screenings are relatively new to youth sports, but obtaining pre-injury baseline data on athletes who engage in contact sports can make sideline assessment more accurate. Concussion screenings are typically a short computerized test that measures selected brain processes, such as word description and memory. It also measures processing speed and reaction time. The scores obtained at completion establishes each athlete's baseline score. Without establishing an individual's baseline, the athlete's post-injury performance on assessment must be interpreted by comparison with a generalized "normal" based on a large population sample. In the event, an athlete sustains a concussion during the season, he or she can take a re-test and the scores will be compared to the baseline. These computerized tests do not diagnose concussion, however they can be helpful during the management or treatment of a concussion. The changes or improvements in scores over time can assist in evaluating progress toward recovery.

The following is a list of some of the computerized concussion screening programs available:

What should you do if you think your child has a concussion? SEEK MEDICAL ATTENTION RIGHT AWAY. A health care professional will be able to decide how serious the concussion is and when it is safe for your child to return to regular activities, including sports.

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Let's Take The Pressure Off!

6/29/2015

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The National Quality Forum (NQF), a voluntary organization that sets consensus standards for health care quality, has adopted a list of 28 "Never Events" and the first condition listed is pressure ulcers stages III and IV. As a result, the Centers for Medicare & Medicaid Services will not reimburse or pay for costs incurred to the patient if a stage III or stage IV pressure ulcer develops while the patient is hospitalized.

The cornerstone of pressure ulcer management is prevention. Recognizing and assessing patients who have not yet developed a pressure ulcer provides a framework for implementation of a prevention strategy that reduces the risk of pressure ulcer occurrence. This in turn can decrease a patient's morbidity and mortality as well as increase comfort and general quality of life.

Most healthcare facilities utilize standardized tools, such as the Braden Scale, to assess risk for developing a pressure ulcer. Dependent upon the calculated level of risk, electronic medical records (EMR) have been beneficial in “planning” what necessary interventions should be implemented. Essentially, the computer either automatically assigns the necessary intervention(s), or it provides a drop down list with suggestions for measures to be implemented. However, checking a box in a computer system does not guarantee an action is always performed.

How are sensory perception deficits being managed?

Is a pressure-reducing surface utilized for a patient with completely limited ability to feel pain or an ordinary hospital bed?
What other pressure-relieving devices are available for use in the facility?

What measures are being implemented to manage moisture?

How does the staff ensure a patient’s skin stays clean and dry?
Is there an established bowel and bladder program for urinary or fecal incontinence?

How does the facility manage activity and mobility?

What measures are applied to ensure increased frequency in turning? How often are patients repositioned? Is a turning schedule utilized?
Did you know hospital bed manufacturers have mattress surfaces that detect weight-based movement? Can you imagine if this science was adapted to provide the capabilities to record what time the patient was moved and to what degree his/her weight was shifted?

How does the facility manage friction-shear?

What products are utilized to lift, turn or transfer a patient?
What is the elevation of the patient’s head of bed?

How does the facility manage nutrition?

What are the laboratory parameters to determine nutritional status?
Is dietary intake and body weight being documented accurately and consistently?

Pressure ulcers present a variety of physical, functional and psychosocial issues. Consistent and correct performances of the basic measures can help prevent pressure ulcers as well as heal existing ones. If you have a legal case involving one of these “Never Events,” contact Aguirre Legal Nurse Consulting to assist you in identifying adherences to and deviations from the standards of care.

Source: Centers for Medicare and Medicaid Services, SMDL #08-004, National Quality Forum's (NQF) List of Serious Reportable Events (commonly referred to as "Never Events"), July 31, 2008.

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Not All Ulcers Are Created Equal

6/8/2015

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To the general public an ulcer is just an ulcer. It’s merely a wound or sore needing treatment from our billion dollar wound care industry. However, did you know there are different types of ulcers? Ulcers, dependent on their distinctive pathologies, also require different treatments and thereby involve different standards of care. To avoid comparing apples to oranges, it is important to identify what type of ulcer is involved in your legal case.

Diabetic ulcers are usually located on lower extremities and caused by peripheral neuropathy associated to small or large vessel disease in chronic, uncontrolled diabetes.

Ischemic ulcers are typically found on the distal lower extremities, such as the tips of the toes. These types of ulcers result from a decrease in blood flow to the tissues, which may be caused by coronary artery disease, diabetes, hypertension, hyperlipidemia, peripheral arterial disease or even smoking.

Venous ulcers also develop in the lower extremities, but have yet another different and unique pathology. They are caused by venous hypertension from incompetent venous valves, post-phlebitic syndrome or venous insufficiency. These specific ulcers tend to be irregular in shape.

A pressure ulcer is a localized injury to the skin or underlying tissue due to unrelieved pressure combined with shear or friction. These ulcers are typically found over bony prominences such as the shoulders, buttocks, hips, heels or elbows. Pressure ulcers are even further broken down and described by “stages.”

A Stage I pressure ulcer describes intact skin that is red and non-blanchable. It may be painful, firm, soft, and warmer or cooler compared to surrounding skin. It is also an indicative sign of risk for further skin breakdown.
A Stage II pressure ulcer is described as “partial thickness” loss of the dermis layer of skin. It resembles a shallow, open ulcer with a red, pink ulcer bed. It also may present as an intact or ruptured serum-filled blister. This stage does NOT describe skin tears, tape burns, maceration or excoriation. It also does NOT involve bruising or “slough” (necrotic tissue).
Stage III pressure ulcers are deeper ulcers involving subcutaneous tissue (the fatty layer of skin). It is a “full thickness” tissue loss. Bone, tender or muscle are NOT exposed in this stage.
A Stage IV pressure ulcer is also “full thickness” tissue loss, however bone, tendon and/or muscle will be visible or directly palpable. It often involves undermining and tunneling (similar to a pocket hidden under the skin).

It is important to note when attempting to stage a pressure ulcer that if “slough” or “eschar” is present in the ulcer bed, that the ulcer is “unstageable.” Until this dead tissue is removed to expose the base of the ulcer and a the true depth, a stage cannot be determined.

The National Pressure Ulcer Advisory Panel (NPUAP) serves as an authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment. Keep an eye out, they will be announcing a new and updated pressure ulcer staging system in 2016.

This is a brief summary of ulcers; there are still many other types of ulcers caused by trauma and dermatologic disease. The nurses at Aguirre Legal Nurse Consulting can assist you in properly identifying which type of ulcer is involved in your legal case. We also know some of the best wound care experts available to provide testimony. Call us at (443) 598-2562 or email AguirreLegalNurseConsulting@gmail.com

Stay tuned for my next post on pressure ulcer prevention….

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Tips to Measure Pain & Suffering

5/14/2015

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How do you measure pain and suffering? Pain is subjective; it is what an individual says it is. To add more ambiguity, no two persons will experience the same level of pain from a similar injury as a result of unique, individual pain thresholds. There is great difficulty in estimating the true value of subjective symptoms in the comparative absence of physical signs.

To help quantify pain in the healthcare system, we use a numeric pain scale. Even in the pediatric population, the Wong-Baker FACES Pain Rating Scale is a widely accepted tool to quantify pain in younger patients. Based on the number level reported by the patient, certain pain management therapies are implemented.

To help measure pain and suffering in the legal system, you will assess how pain impacts the individual’s daily activities and ability to work. Something you should also consider is evaluating the individual’s pain management therapies. This can offer great insight into the type and level of pain a person may be experiencing. Is the individual receiving pharmaceutical interventions or non-pharmaceutical interventions? They may even be receiving a combination of both.

If the injured client involved in your legal case is receiving pharmaceutical interventions for pain, then assess what medication is being prescribed, along with the dosage, the route, and the frequency. There is a wide range of pharmaceutical interventions utilized for pain management. Different drug classifications are used for different types of pain as well as the intensity of pain experienced. Some classes are “stronger” than others. There are also therapies that involve combinations of drugs useful to manage acute breakthrough pain with extended-release drugs used to deliver therapeutic effects over a period of time.

Higher pain medication dosages typically indicate an increased level of pain. However, dosages may be adjusted if an individual’s pain tolerance changes over time. An increased frequency in taking pain medications also may indicate an increased level of pain.

Lastly, the route in which a pain medication is administered impacts the time by which therapeutic effects are achieved. Is the pain medication administered intravenously or through epidural injection? Is it ordered to be given by mouth or via patch? Injectable administration of pain medications is typically administered for more acute and/or severe pain.

Aguirre Legal Nurse Consulting understands the management of pain. We can assess injuries and identify contributing factors that could affect your settlement value. We can also help identify and locate medical experts who can support your case. Call (443) 598-2562 or feel free to email AguirreLegalNurseConsulting@gmail.com

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Preventing Hospital-Acquired Pneumonia

5/6/2015

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Since Medicare and the National Healthcare Safety Network started mandating prevention policies and monitoring device-associated infections (i.e. catheter-associated UTIs, central-line associated blood stream infections and ventilator-associated pneumonia), the incidences of these infections have declined tremendously. In fact, studies show that these device-associated infections only account for approximately 25% of hospital-associated infections. Today, one of the most common hospital-associated infections is hospital-acquired "nonventilator" pneumonia and can be prevented by basic nursing and oral care!

Poor oral health and hygiene are increasingly recognized as major risk factors for pneumonia particularly among the elderly. Studies provided by the American Association for Dental Research also show that wearing dentures during sleep is associated not only with oral inflammatory and microbial burden but to the incidence of pneumonia as well. Sleeping in dentures actually doubles the risk of pneumonia in the elderly.

The hospital presents another myriad of problems regardless of age. A patient’s natural immune defense is weakened. The ability to maintain basic hygiene often declines. Additionally, changes in oral bacterial colonization occur within 48 hours of admission. Microaspiration combined with decreased mobility and changes in the oral flora create a perfect environment for microbes to flourish in the respiratory tract.

Hospital-acquired "nonventilator" pneumonia has the same mortality as ventilator-associated pneumonia. The costs are higher; it leads to prolonged hospital stays and creates a greater risk for readmission within 30 days. Evidenced-based nursing and oral care can make a difference!

Let one of our nurses at Aguirre Legal Nurse Consulting help you define the applicable standard of care and provide authoritative research on clinical practice guidelines for your next medical malpractice case! Call (443) 598-2562 or email AguirreLegalNurseConsulting@gmail.com

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Defibrillators Failing To Function Correctly

4/23/2015

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Sudden cardiac arrest is one of the leading causes of death in the U.S. About 360,000 cases occur yearly, and a person currently has about a 5% chance of surviving an incident of cardiac arrest. It can happen to anyone, anytime, anywhere and at any age. An automated external defibrillator (AED) is the only effective treatment for restoring a regular heart rhythm during sudden cardiac arrest and is an easy to operate tool for someone with no medical background.

Time is of the essence! The average response time for first responders once 911 is called is approximately 8-12 minutes. For each minute defibrillation is delayed, the chance of survival is reduced by 10%.

Consequently, it is important that AEDs are readily available and located in public areas such as malls, airports, schools, churches, fitness centers and even medical facilities. Optimal AED placement allows a person to grab the AED and return to the victim within 90 seconds.

Unfortunately, these life-saving devices have been associated with malfunctioning problems and 2 million devices have been recalled. The FDA has received approximately 72,000 reports associated with the failure of such devices between January 2005 and September 2014. During this same period, defibrillator manufacturers have issued 111 recalls.

The FDA will begin requiring more rigorous reviews of defibrillators through a premarket approval process focusing on safety and reliability of machines and their necessary accessories, including batteries, pad electrodes, adapters and hardware keys for pediatric use. Enforcement will begin mid-2016.

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Failure To Call A Rapid Response

4/9/2015

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When does failure to call a rapid response create liability? A rapid response team (RRT) is a team of health care providers that responds to hospitalized patients with early signs of clinical deterioration on non-intensive care units to prevent respiratory or cardiac arrest.

The concept was first introduced in 2005 by the Institute for Healthcare Improvement's "100,000 Lives Campaign." Today, 10 years later, the implementation has been widespread and RRTs have been found to be responsible for improving patient outcomes throughout the hospital by:

Reducing non-critical care cardiopulmonary arrests,
Reducing patient deaths from cardiopulmonary arrests, and
Reducing non-essential transfers to critical care.

Patients whose condition deteriorates acutely while hospitalized often exhibit warning signs. In fact, research shows that cardiac arrests in hospitals are usually preceded by observable signs of deterioration, often six to eight hours before the arrest occurs. When a patient meets one of the criteria, or the nurse or family member feels concerned about the patient’s worsening condition, a team consisting of ICU physician(s), nurse(s), and/or respiratory therapist(s) responds to the patient at the bedside. The team is responsible for stabilizing the patient’s condition and integrating his/her care with the primary team. Appropriate criteria for notifying the RRT may be one or more of the following:

Acute change in level of consciousness
Acute change in HR < 40 or > 140
Acute change in systolic BP < 90 or > 180 mmHg, change in diastolic BP > 100
Acute change in RR < 8 or > 28
Acute change in oxygen saturation less than 90% despite additional oxygen therapy
Urine output < 50 ml over 4 hours
Chest pain unrelieved by nitroglycerine or new onset of chest pain
Symptoms of a stroke (such as loss of change in speech)
Threatened airway
Seizure
Unrelieved pain

Failure to recognize when a patient's condition is deteriorating can lead to failure to rescue and become a key contributor to in-hospital mortality.

Aguirre Legal Nurse Consulting can assist you in identifying adherences to and deviations from the applicable standards of care. We help assess injuries and identify causation issues and contributing factors. Let one of our legal nurse consultants help you develop your next medical-related case. Call (443) 598-2562 or email us at AguirreLegalNurseConsulting@gmail.com.

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Irish Remedies!

3/17/2015

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To celebrate this fine holiday,
we wanted to share a few traditional IRISH herbal medicine remedies:

WHISKEY assists the body in releasing GABA neurotransmitters, which helps “calm the nerves.” It has been used historically to help treat angina and other heart problems as well as anxiety.
BILLBERRY has antioxidant and anti-inflammatory capabilities which can help heal minor cuts and abrasions. It has also been used to help treat GI problems such as diarrhea, dysentery and even hemorrhoids. The leaves of the plant can also aid in lowering blood sugar levels for diabetics.
NETTLE leaves have antihistamine properties which helps treat allergy symptoms like hay fever. The plant also has anti-inflammatory properties to help soothe arthritic joint pain.
COBWEBS were used in ancient times to bandage cuts similar to modern day gauze. Cobwebs actually have Vitamin K properties, which triggers blood clotting….who knew???

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Brain Injury Awareness

3/9/2015

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March is "National Traumatic Brain Injury Awareness Month." TBI is a general term for all injuries to the brain caused by trauma and is often used synonymously with the term concussion. It results in an immediate impairment of neural function (ionic, metabolic, neurotransmitter, or vascular) secondary to a mechanical impact to the head. Such an injury has the potential to cause a variety of neurological deficits, including physical, behavioral, cognitive and lingual symptoms.

Physical symptoms can affect motor, sensory and speech skills and include headaches, dizziness, nausea and vomiting, balance problems, loss of smell or taste, blurred or double vision and sensitivity to light. Post-traumatic seizure disorder is also common which refers to early or late seizure activity following a traumatic brain injury. (These seizures are considered acute symptomatic events and not epilepsy.)

Behavior symptoms include irritability, withdrawal, loss of libido, fatigue, emotional lability (a state of being unstable or changeable), anxiety and sleep problems, as well as neurobehavioral alterations, such as impulsivity and uninhibited aggression.
Cognitive and lingual symptoms include memory deficits, poor concentration, slow mentation, inefficiency, distractibility, word-finding problems and comprehension deficits. Another common problem is loss of awareness or memory. After severe head injury, amnesia for periods immediately before and after loss of consciousness may occur.

Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases, symptoms may be prolonged. Symptoms can gradually disappear but can also be exacerbated by strenuous physical exercise, emotional stress, or the use of alcohol. A major problem arises when the symptoms do not resolve in a reasonable length of time. Such patients often become depressed and angry, which are factors that can cause the symptoms to increase. Many patients with symptoms lasting more than 6 to 12 months typically have other psychologic, legal, financial, or social factors also responsible for the perpetuation of their symptoms.

Neurological injuries, to include neuropsychological disturbances, can be completely disabling and adjusting to these changes can be a challenge. The individual may have to learn to deal with and accept the life-long physical and mental changes and the impact on their family and vocational function. Thus, the residual disability from a TBI must be objectively assessed to support the damages impacting the ability to work and change in quality of life.

Need help on your TBI case??? Contact Aguirre Legal Nurse Consulting. We can assist you in analyzing the medical records, providing a summary or research and even locating medical experts to support your case. Call us at (443) 598-2562.

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<<Previous

The Impact Of E-Cigarettes

Back To School Concussion Screenings

Let's Take The Pressure Off!

Not All Ulcers Are Created Equal

Tips to Measure Pain & Suffering

Preventing Hospital-Acquired Pneumonia

Defibrillators Failing To Function Correctly

Failure To Call A Rapid Response

Irish Remedies!

Brain Injury Awareness

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