In trauma care, protocol is paramount. Guidelines are published and regularly updated from the World Health Organization, The American Association for the Surgery of Trauma, The Eastern Association for the Surgery of Trauma, and more. When a trauma patient arrives, it is common for the code team to begin utilizing pneumonics, acronyms, and checklists to spring into action.
First, the ABCs: airway, breathing, and circulation. Next, specific processes depending on the injury. Head injury, do this. Burns, do that. It is imperative that trauma centers and clinicians are up to date on the latest recommendations and are constantly evaluating the environment and their procedures to perform at an elite level to facilitate the best possible outcome for the patient.
But...What if Guidelines Don’t Exist?
However, what do healthcare workers do when no guideline exists? How do they protect themselves against possible injuries or exposures considering an increasing epidemic of opioid use and abuse?
According to the National Institute of Drug Abuse, opioid overdose is responsible for 115 deaths in the United States each day. Further, Dr. Ali Raja, the vice chair of emergency medicine at Massachusetts General Hospital, states that around 75% of patients coming into the emergency room due to opioid overdose also have an injury.
Depending on the severity of injury, patients with a currently toxic level of opioids in their system, may present in the trauma bay. However, there currently aren’t guidelines for inpatient emergency workers as to what to do to protect themselves from exposure.
Understanding the cases and protocols for emergency response teams in the field is necessary to protect the nurses and physicians in an emergency room.
Two Cases of Opioid Exposure in Healthcare Emergencies
Emergency department personnel can unknowingly encounter a fatal dose of opiates.
In August 2017, three nurses were exposed to a highly potent opioid while tending to a patient. Moments later they had to be revived with 14 milligrams of Narcan (a typical dose of Narcan is about 0.5 milligrams). The three nurses recovered. While few details were released, experts suspect carfentanil was the culprit.
Carfentanil is a drug approved for tranquilizing elephants and is 10,000 times stronger than morphine, 100 times more potent than fentanyl. It rapidly brings on narcotic-induced hypoventilation, nausea, and coma. Authorities says it is being used to cut or mix with heroin. Even a small grain is very potent.
Even with the Opioid Crisis ravaging lives for almost two decades at the time of the incident, national guidelines for limiting exposure to opioids in healthcare settings has yet to be established. This leaves healthcare workers in clinics and hospitals as vulnerable as first responders to secondary opioid exposure, opioid use, and variation in safety protocol.
“We are looking at this [event] as a canary in a coal mine,” said Michelle Mahon, RN, a union representative for National Nurses United. The Joint Nursing Practice Commission is developing a practice alert for treating opioid patients and asking for information about what are the protocols and equipment healthcare employers are using to limit exposure and protect workers.
In another case, a patient was admitted for a fever and was using opioids while being treated. Nine days into the treatment, the patient’s health did not improve. After doing a toxicology screening, the patient admitted to intravenous heroin drug abuse. He was placed on a 24-hour one-to-one observation and visitor screening. After this, his blood cultures no longer had bacillus cereus which was causing the fever. He was counselled about the effects of IV drug abuse and that the heroin he was using was contaminated. He was discharged with instructions to return to take antibiotics daily at the hospital for four weeks.
The existing occupational exposure guidelines by the National Institute for Occupational Safety and Health (NIOSH) are primarily for first responders and public safety exposures. While the guidelines are instructive for the prehospital setting, it still leaves first responders and hospital staff exposed to unexpected circumstances. While the actual dispensed opioid prescriptions decreased 10.2 percent in 2017, it may not lead to lower rates of overdose deaths because of the growing illicit trade and smuggling of synthetic opioids.
Two Ways Trauma Centers Can Be More Prepared
1. Educate on Behavioral Health, especially in the Emergency Department (ED)
The CDC reports that approximately 1 out of every 8 patients who visit the ED has underlying behavioral health conditions, or in absolute numbers 17 million patients. Due to the shortage of psychiatric and behavioral health services, the burden of providing behavioral health care has been placed on EDs, where patients are legally entitled to a screening exam and stabilizing treatment. Provide your team with education on the crucial role that behavioral health conditions can play in presenting patients.
First responders and hospital staff also need to be trained and better equipped to handle exposure to high dosage opiates and conditions co-occurring with addiction.
2. Stay Informed on Current Clinical Practice and Research
While keeping up to date on new guidelines published from various associations and bodies will keep you practicing at standard of care, it may not be enough to secure safety and positive outcomes for staff and patients. Having a designee stay well-informed on new cases and potential hazards as soon as they are published and sharing this crucial information to the team is the first step to an environment of continual improvement and excellence.
As our trauma cases become more complex or when the healthcare industry is experiencing an unprecedented epidemic, like the Opioid Crisis, the unexpected should be expected. Knowledge and information is key to getting ahead of future risks before they cause unnecessary harm.
Learn more about how you can provide the latest trauma research and techniques to your team, while fulfilling CE/CME requirements.
As an Associate Product Manager for Payers and Community Health, Ling Guo is researching about the opioid crisis, and continuing medical education. Ling brings four years of experience in research about civil society and international development. Ling received her Bachelor’s degree from the University of North Carolina at Charlotte.