Emotional Support for Health Care Professionals: A Therapeutic Role for the Hospital Ethics Committee.

Hospital ethics committees (HECs) are typically charged with addressing ethical disputes, conflicts, and dilemmas that arise in the course of patient care. HECs are not widely viewed as having a therapeutic role for health care professionals who experience psychological distress or anticipatory grief in the course of discharging professional duties. A case is presented in which an ethics consultation was requested, chiefly, to secure emotional support for health care professionals who had been asked by a patient to discontinue life-sustaining treatments. As the case demonstrates, HECs may be called upon to provide emotional support and reassurance to health care professionals who willingly carry out psychologically difficult actions, even though these actions may be ethically uncontroversial. In providing this service, the HEC may not necessarily engage in its customary activity of deliberating an ethics issue and resolving a conflict but may still provide valuable assistance, as in the case presented.

Perioperative use of bispectral (BIS) monitor for a pressure ulcer patient with locked-in syndrome (LIS).

The bispectral (BIS) monitor uses brain electroencephalographic data to measure the depth of sedation and pharmacological response during anaesthetic procedures. In this case, the BIS monitor was used for another purpose, to demonstrate postoperatively to the nursing staff that a patient with history of locked-in syndrome (LIS), who underwent pressure ulcer debridement, had periods of wakefulness and apparent sensation, even with his eyes closed. Furthermore, as patients with LIS can feel pain, despite being unable to move, local block or general anaesthesia should be provided for sharp surgical debridement and other painful procedures. This use of the BIS has shown that as a general rule, the staff should treat the patient as though he might be awake and sensate even if he does not open his eyes or move his limbs. The goal of this study was to continuously monitor pain level and communicate these findings to the entire wound team, i.e. anaesthesiologists, surgeons and nurses.

Better to light a single candle.

The following is a clinical narrative that describes one nurse's attempt to motivate a patient who had recently sustained an injury that caused quadriplegia and the practice implications that arose from "silo" thinking between disciplines.

Percutaneous enterogastric tube dislodgement in tetraplegics.

STUDY DESIGN: Case reports describing abdominal complications following percutaneous enteral gastric (PEG) tube placement in three tetraplegics. OBJECTIVES: The aim was to increase provider awareness of PEG tube dislodgement as a complication in tetraplegics. SETTING: Spinal cord injury center, Veteran's Administration hospital. METHODS: The charts of three spinal cord injured veterans with tetraplegia were reviewed for clinical presentation and radiographic findings supporting the diagnosis of acute abdominal complications following PEG tube dislodgement. RESULTS: PEG tube dislodgement in tetraplegics can present with occult findings and lead to disastrous outcomes if the diagnosis is delayed. CONCLUSION: PEG tube dislodgement should be considered in tetraplegics who develop even subtle abdominal complaints, especially if the injury is complete. Further assessment with computed tomography (CT) scans or fistulograms should be considered to help with decision making.

Buried bumper syndrome causing rectus abdominis necrosis in a man with tetraplegia.

STUDY DESIGN: Case report. OBJECTIVES: To enhance the early recognition of buried bumper syndrome in patients with tetraplegia requiring percutaneous endoscopic gastrostomy (PEG). SETTING: Inpatient unit, Massachusetts, USA. METHODS: A 44 year-old man with C2 American Spinal Injury Association grade A tetraplegia with a relatively recent PEG insertion secondary to poor nutritional intake. RESULTS: Several months after PEG placement, patient became febrile, hypotensive and complained of abdominal pain. Plain films showed a dilated bowel suggestive of ileus. Abdominal and pelvic computed tomography with and without contrast revealed PEG tube dislodgement, and a 21 cm x 2.8 cm left anterior abdominal wall collection consisting of air and contrast. Upon surgical intervention, the left rectus abdominis sheath and muscle were found to be necrotic. CONCLUSION: Buried bumper syndrome is a serious complication related to PEG tubes. For many people with tetraplegia, PEG is a life-saving procedure with minimal risks. However, emergencies do occur, making prompt recognition imperative to prevent a fatal sequela.

Having a permanent resident in intensive care: the rewards and challenges.

BACKGROUND: Intensive care units are generally structured and staffed to care for short-term critically ill patients. This is in contrast to the increasing incidence of patients who require long-term (i.e. greater than 6 months) intensive care in the contemporary health care context. AIM: The aim of this paper is to share our experience of caring for a long-term ventilated patient in intensive care, including providing a summary of strategies and considerations that proved effective in our setting. PROCESS: Dealing with the initial reactions of the staff, patient and family was the first focus of care, with strategies developed to manage the psychological as well as practical challenges. Core to subsequent strategies was the early formation of a multi-disciplinary case management team. Ongoing challenges included integrating rehabilitation care into the intensive care, developing effective multi-dimensional communication strategies, facilitating appropriate involvement of the patient and her family, operationalising trips outside the intensive care environment and adapting the model of nursing care to suit the context. CONCLUSION: Elements essential for the effective care of a long-term patient within the intensive care setting included the development and maintenance of an open and honest relationship with the patient and family, regular multi-disciplinary case management meetings and effective communication strategies throughout the health care team. Importantly, clinical leaders should remain open to considering new ideas and strategies that facilitate effective care for a patient whose primary focus is different to the majority of intensive care patients.

The meaning of assisted feeding for people living with spinal cord injury: a phenomenological study.

AIM: This paper is a report of a study to explore the meaning of assisted feeding through the experiences of people with high cervical spinal cord injury. Background. Eating difficulties are known to affect a person's self-image and transform social lives. Little is known about the experience of assisted feeding as a permanent situation. METHOD: Sixteen people with high cervical spinal cord injury were interviewed twice within a period of 18 months in 2005-2006. The second interview was combined with observation. Transcriptions of interviews and notes from the observations were analysed using the phenomenological guidelines by Dahlberg and colleagues. FINDINGS: The essence of the phenomenon assisted feeding was described as a constructed pattern based on coordinated attention between the person with high cervical spinal cord injury and the helper. The constituents of the essence were: paralysis as a condition of life, facing the altered meal, reconciling with diminished bodily anchoring, sensitive cooperation between self and helper, realization of own values around meals, balanced use of meal-related devices and negotiating relationship with helpers. CONCLUSION: Assisted feeding should be adjusted to each individual person. Fixed procedures or routines should be avoided and assistive devices used with care. We recommend that continuity in the cooperation between the parties involved in assisted feeding is given priority, and that personal standard and social norms around meals are acknowledged.

Preventive skin care beliefs of people with spinal cord injury.

Although health beliefs have been correlated with self-care adherence in other chronic conditions, little is known about skin care beliefs after spinal cord injury (SCI). The purpose of this qualitative study was to identify the skin care beliefs of individuals with SCI. The conceptual framework was the Health Belief Model (HBM), which proposes that adherence to a health regimen is motivated by beliefs about susceptibility, severity, barriers, benefits, and self-efficacy. Purposive sampling was used to recruit 22 people with SCI. Content analysis of data collected using semistructured questions was used to identify domains of skin care beliefs, including HBM components. Themes that emerged about skin care beliefs included taking vigilant care, taking charge, maintaining health, and passing up care. Although most participants believed they were susceptible to pressure ulcers and preventive care was important, paradoxical statements about beliefs and preventive behaviors were common. These incongruent responses may reflect ambivalence about competing priorities or the efficacy of preventive practices. Further research is needed to understand this phenomenon. Increased understanding of skin care beliefs will assist in developing tailored teaching programs for people with SCI.

Design and evaluation of a stand-up motorized prone cart.

BACKGROUND/OBJECTIVE: Prone carts are used for mobility by individuals with spinal cord injury in whom seated mobility (wheelchair) is contraindicated due to ischial or sacral pressure ulcers. Currently available prone carts are uncomfortable, subjecting the user to neck and shoulder strain, and make social interaction and performing activities of daily living difficult. A better design of prone carts is needed. In addition, standing devices have shown some medical benefits. The objective was to design and evaluate an improved prone cart that facilitates standing. DESIGN: Engineering development project with user feedback through questionnaire. Users selected by convenience sampling. METHODS: A marketing survey was performed of nurse managers of spinal cord injury units. Then 2 prototype carts were designed and built. These carts are able to tilt up to 45 degrees and have a joystick-controlled motor for propulsion and other design features, including a workspace storage shelf and rearview mirrors. The carts were evaluated by both patients and caregivers at 2 Veteran's Administration hospitals. OUTCOME MEASURES: Questionnaire of subjects, both patients and caregivers, who used the cart. FINDINGS: Both patients and caregivers liked the carts and the ability to assume a nonhorizontal body angle. The major complaint about the cart was that it seemed too long when it came to making turns. CONCLUSION: This prone cart design is an improvement over the standard, flat variety. However, further design changes will be necessary. This study provided valuable information that will be useful in the next-generation prone cart design project.

The challenge of assessing and diagnosing acute abdomen in tetraplegics: a case study.

The assessment and diagnosis of an acute abdomen in a spinal cord-injured patient presents a significant challenge to even the most experienced practitioners because of the muted or altered presentations secondary to paralysis. Because the patient with spinal cord injury is at increased risk for peptic or duodenal ulcers and a number of other gastrointestinal emergencies, clinicians need to maintain a high index of suspicion for acute abdomen when working with this population.

Speaking Up to Save a Life.

A nurse's advocacy alters the path of a patient with locked-in syndrome.