Emergency Department Handoff Checklist!!!

What do you think???

Emergency doctors promote patient handoff checklist

■ The initiative aims to counter the hectic pace in emergency departments that can lead to fumbled transitions of care.

By KEVIN B. O'REILLY amednews staff — Posted April 17, 2013

A group of emergency physicians recently launched a website offering free tools designed to standardize the patient handoff process to reduce the risk of harmful communication miscues.

About half of so-called sentinel events — mistakes that result in death or serious patient injuries — involve errors that occur during handoffs in care, according to the Joint Commission. The problem is pronounced in the fast-moving arena of emergency care, where noisy environments, frequent interruptions and high-acuity patient loads combine to make handoffs a hazardous endeavor, said Drew C. Fuller, MD, MPH, an emergency physician who gave a presentation April 5 about the new handoff procedure at the Maryland Patient Safety Foundation’s 9th Annual Patient Safety Conference in Baltimore.

“Handoffs are considered one of the riskiest procedures in the emergency department or any high-risk area in the hospital,” Dr. Fuller said. “We wanted a system that invoked high reliability.”

Dr. Fuller works for Emergency Medicine Associates, a Germantown, Md.-based provider of emergency medical services in the mid-Atlantic region. He and his colleagues at EMA developed the new handoff protocol, dubbed Safer Sign Out, which was finalized after surveying more than 100 of the company’s doctors. It already has been implemented at 12 hospitals serviced by EMA in Maryland, Virginia, Washington, D.C., and West Virginia.

Checklist encourages vital communication

The key to the handoff protocol is the Safer Sign Out Form, a quality assurance tool separate from the medical record that serves as a checklist for the physician whose shift is ending to complete along with the physician taking over. The doctors note patient diagnoses, key issues, potential safety concerns and pending items. The physician signing out asks the doctor coming on shift the open-ended query, “What questions do you have?” to promote discussion.

The next step, ideally, is for the physicians to go together to the bedside to meet with patients about the plan of care. The final piece of the sign-out process is to relay that plan to nurses and other members of the care team.

“There’s this comprehensiveness to it, because we’re reaching out to the nurse and letting the nurse know who is signing out and what the big issues are,” Dr. Fuller said. “Believe it or not, that’s not common practice. This process gives everyone the opportunity to build teamwork and for the nurse to provide critical updates that the physicians might not be aware of.”

The Maryland Patient Safety Foundation is partnering with EMA, the Emergency Medicine Patient Safety Foundation, and the American College of Emergency Physicians’ Quality Improvement and Patient Safety Section to make the handoff tool, along with educational and promotional materials, available on the Internet  http://safersignout.com

Implementation has gone well so far, thanks to physician champions at the 12 hospital EDs where the Safer Sign Out process is being used, Dr. Fuller said.

“The first impression of some doctors when they hear about it is: ‘You don’t need to tell me how to sign out. I know how to do that, and I don’t have the time for this,’ ” he said. “Well, the average shift in emergency medicine is 500 to 600 minutes, and it takes me about five minutes to do this safer sign-out. I think my patients and my team are worth 1% of my time. When doctors realize how it can be done efficiently, it overcomes the initial resistance.”

Dr. Fuller plans to secure funding to study the sign-out tool’s effectiveness in improving the quality of handoffs and preventing errors.

How To Think Like an Emergency Physician

THIS IS A GREAT LECTURE!!!

Rueben Strayer from Mount Sinai Medical Center gives a superb 30 minute talk an how the cognitive process in the Emergency Depart is 'Oh so special'.

This lecture is a great warm up for our May 1st Education session.  Check it out if you have the time.

https://vimeo.com/14983747

Medical Education in the Small Group Setting

http://tjdogma.com/2012/11/medical-education-challenge/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+tjdogma+%28tjdogma%29

Decision Making in The Emergency Department: The Cognitive Pause

Read more at: http://www.epmonthly.com/features/current-features/to-reduce-medical-errors-take-a-cognitive-pause/

Pediatric Case of the Week 19: Burn

Winter has lingered far too long in your cozy little mill-town.  Children and their shortened attention spans are wreaking havoc in homes all across the land.  Parents are begging for the momentary relief that comes with a bit of green grass and a few extended beams of sunshine.

Unfortunately, the glut of indoor time has probably contributed to your next case...




A 2 year old boy presents with his parents in severe distress after a steaming pot of water (intended for yet another meal of macaroni and cheese) was pulled off the stove by his 4 year old sister and onto his torso, arms, and legs.  He is distraught, crying, and inconsolable with areas of blistering and denuding skin.  Specifically, his burn involves the left side chest, abdomen, and left lateral arm/leg.






You estimate about 20% burn involvement.  Arm and leg burns are non-circumfirential.

Vitals: HR 121 BP 75/60 RR 43 Sat 97%RA

What is your initial management?

If you elect to intubate, what agent(s) would you use?

How do you estimate burn surface area?

How do you calculate fluid replacement?

Do you want any labs?  What lab abnormalities might you find in a burn patient?

What is the most common type of pediatric burn?

If the patient presented with an isolated gluteal burn or plantar foot surface burn, what would you suspect?

What would you do about that blister?

What is this patient's disposition?


--------------WEEKEND UPDATE--------------


Burn injuries are the 3rd leading cause of unintentional injury in children age 0-18 years old.  (Behind  motor vehicle accident and drowning.

Scald injury is the most common pediatric burn accounting for 70-80% of cases.  These burns occur most commonly in age less than 4




Burns Classification:

-Superficial: only the epidermis, non-blistering

-Superficial Partial-Thickness: entire epidermis and superficial layers of the dermis, +/- blister

-Deep Partial-Thickness: entire epidermis and dermis, waxy appearance, significant scarring

-Full Thickness: entire epidermis and dermis, insensate, charred or leathery, skin graft







You may use the modified pediatric "rule of 9's" or the "Lund and Browder chart" to estimate burn surface area.  (Remember Pediatric Patients have BIG HEADS)

Burns greater than 20% total body surface area (TBSA) can have systemic effects that require aggressive fluid resuscitation.

There are several resuscitation formulas that can be used to initiate infusion:  ***  Most important that you AGGRESSIVELY HYDRATE because burns result in significant fluid loss.


Interestingly, lab studies are considered important in patients with burn injury.  Burns can lead to anemia so a CBC is recommended.  Electrolytes are important because of the potential for large fluid shifts.  Hypoglycemia can occur due to decreased glycogen stores.  Also, muscle injury associated with electrical, thermal, crush, or blast burns can easily lead to Rhabdomyolysis.  Also, if fire related, consider checking carbon monoxide levels.

Don't forget about other injuries.  Blast victims may also have associated traumatic injuries.

Burns should be cleansed with mild soap and water, derided, and treated with topical antimicrobial dressings or occlusive dressings.  Blisters should remain intact (this remains controversial...but let someone else do it.)  During the initial resuscitation you can simply cover large burn areas with cool wet gauze. There is little evidence that silver sulfadiazine reduces infection and it may actually increase the risk of allergic reaction.   If you're really concerned about infection, I'd recommend bacitracin over silver.

Always, Always, Always consider child abuse.  Sadly, approximately 6% of burned children under the age of 12 years old are victims of abuse.

GIVE ANALGESIA.  Oligoanalgesia is far too common among pediatric burn patients.  GIVE them meds. Morphine, Fentanyl, or dilauded...treat the pain.

"Ay is fah' Ayaway!!!"  if there are any signs of inhalation injuries or burns near the mouth/nose, carbonaceous sputum, singed nasal hair, CONSIDER EARLY INTUBATION.  Airway edema can evolve, so remember that just because the airway is patent NOW might not mean that it will be patent over time.  Err on the side of caution and have LOW THRESHOLD TO  intubate.


Don't forget to check the patient's tetanus status.

Disposition:

Indications to transfer child to a burn center (Developed by the American Burn Association)

-Partial thickness burns greater than 10% total body surface area
-Burns involving face, hands, perineum, genitalia, or major joints
-Full thickness burn in any age group
-Electrical burns, including lightning
-Chemical burns
-Inhalation injury
-Pre-existing conditions that complicate management, recovery, or mortality
-Burn injury with Trauma
-Injury that will require special social, emotional, or rehab intervention

May 1st, 2013: Education Session Invite; Do's and Don'ts of Documentation

For a clearer image try linking to the Vimeo broadcast below!!!

https://vimeo.com/64592353

ACEP: Disaster Preparedness Resources

http://www.acep.org/disaster/

Colbert on Boston

http://www.hulu.com/watch/479708

Why Boston Hospitals Were Ready

Posted in the New Yorker
By Atul Gawande

http://www.newyorker.com/online/blogs/newsdesk/2013/04/why-bostons-hospitals-were-ready.html

Pediatric Case of the Week 18: Disaster Preparedness

This week's case is not really a practice case.  It is, unfortunately,  a reality.  There are countless disasters which take place throughout the world on a daily basis.  Monday's bombing in Boston is a harsh reminder of those tragedies.  Having trained in Boston and knowing many of the providers who were directly involved with first response and emergent care, I have asked myself, how would I have responded?

I will not attempt to recreate those events, I have no first hand experience with such horror or chaos, and any attempt would likely seem contrived and diminishing.  But, I would like each of us to think about this disaster, and others that could come through our door at any time.

Think about what you would do if you you were first on the scene, (if you were volunteering in the medical tent?) What would you focus on, what resources would you request, and how would you triage patients?

What if these patients came to your Emergency department?  What would you prioritize? Are you familiar with the disaster plan for your department? Do you know how to access it?

My update will be a brief summary of Disaster Preparedness, Blast Injuries, and Pediatric Trauma specifically related to such events. Complete coverage of these topics is outside the scope of this blog, Hopefully, I can offer a few pearls and reminders.

I do not know if reviewing this topic will ever decrease suffering or reduce tragedy.

I DO KNOW THAT IF WE IGNORE OUR MEDICAL RESPONSE TO THESE TRAGEDIES, FAILURE IS GARUNTEED.

Thank you for your interest and continued participation.

THANK YOU FOR YOUR COMMITMENT TO EMERGENCY MEDICINE.

------------WEEKEND UPDATE----------------



Disaster defined (medical):   Whether a multiple car crash involving 4 or 5 seriously injured patients which overwhelms a small rural hospital or a mass casualty resulting in 25 injured patients rapidly overwhelming a large Level I Trauma Center; the definition of disaster is partly defined by the concept of "massive disruptive impact" to the medical system.

In the field: 

Rescue personnel often use a Simple Triage And Rapid Treatment (START) technique that utilizes quick assessment of Respirations, Perfusion, and Mental Status (RPM).

I would fall back on my primary survey, ABC's and possibly prioritize Circulation if indicated, I would also prioritize Environment if the surrounding conditions were unsafe:

Airway: Make sure that the airway is patent and that there is no obstruction.
Breathing: Identify the presence of respirations, and whether or not they are labored.
Circulation: Feel for pulses, note skin color, identify areas of bleeding an apply pressure/tourniquet.
Disability: Is the patient Alert/Oriented, eyes open, talking, moving all extremities.
Exposure: Visualize all parts of the patient (remove clothing), examine the back.
Environment: If environment is a factor, address it or adapt to it. (This includes your safety.)

I would guess that EM residents trained at a Level I Trauma Center run through this mnemonic 2000 times before graduating.  It quickly becomes hardwired. I find the mantra "Airway, Breathing, Circulation, IV, O2, Monitor" incredibly helpful whenever I feel "stuck."  I go back to my ABC's.  I make sure I am seeing the vital signs.  If something is abnormal, I address it.  In the field I would reflexively turn to the ABC's and let them guide me. I'll never forget my first trauma shift in Boston.  A crashing bloody patient: Gowns, Masks,  IV's,  CHAOS,...and I froze....stared at the scene like a deer in headlights.  One of the ER nurses, who was young but seasoned (her father was a Boston cop), loud, and very assertive; saw the look on my face.  She stared intently into my eyes and in a deep Boston accent said; "AY IS FAH' AYAWAY."   It worked.  I reassessed the patient and got busy.  The message is clear: keep it simple.  Focus on the basics and you are less likely to be affected by the noise and chaos.

Back to the field...

When transportation resources are available, on-site medical care can proceed in fairly normal manner (meaning rapid stabilization and transport on injured to nearby hospitals).  Transport is a major priority.  In cases of prolonged extrication, life saving interventions should be initiated in the field,  e.g. IV fluids for hypovolemic shock.  Additionally, rapid transport with minimal treatment should be practiced when there is danger to the rescuers such as: fire, explosion, falling buildings, hazardous materials, extreme weather conditions.

When transportation resources are overwhelmed, advanced field medical and surgical treatment may be beneficial.  This may necessitate the formation of field hospitals where patients can be brought for further assessment and initial treatment. After stabilization/observation, they may be sent home, or if indicated, transported to an available hospital.

In mass casualty events, EMS protocol suggests transporting patients in equal distribution to appropriate centers, however this can easily be undermined by challenges in communication.  Additionally, the problem is exacerbated by "walking wounded" and "worried well" who may arrive on foot to a nearby facility and quickly overwhelm it's capacity to care for patients with greater urgent need.

When local hospitals are overwhelmed (or likely to be overwhelmed) it may be better to treat victims in the field.  Field triage my be applicable and separating patients into 3 categories is suggested:

1. those who will die regardless of how much care they receive
2. those who will survive whether or not they receive care
3. those who will benefit significantly from field interventions

In the Emergency Department:

It is important to have a disaster plan which describes: Activation of the plan, Assessment of the hospital's capacity, Establishment of disaster command, Communications, Supplies, Hospital disaster and treatment areas, Training and drills, Security and crowd control.

The traditional concept of TRIAGE becomes essential to disaster management.

The most common triage classification still involves assigning color codes to 4 categories of injury:

Red: First priority, MOST URGENT, Life threatening shock or hypoxia is present or imminent, but the patient can likely be stabilized and, if given immediate care, will probably survive. 

Yellow: Second priority, URGENT, The injuries have systemic implications of effects, but patients are not yet in life-threatening shock or hypoxia; although systemic decline may ensue, given appropriate care, can likely withstand a 45 to 60 minute wait without immediate risk. 

Green: Third Priority, NON-URGENT,  Injuries are localized without immediate systemic implications; with a minimum of care, these patients generally are unlikely to deteriorate for several hours, if at all.

Black: Fourth Priority, Dead, No distinction can be made between clinical and biological death in a mass casualty incident, and any unresponsive patient who has no spontaneous ventilation or circulation is classified as dead.  Some place catastrophically injured patients who have a poor chance for survival regardless of care in this triage category.

---------

Blast Injuries:

Large amounts of energy in the form of expanding gases compress and superheat surrounding air, creating a "Blast Wave", which then delivers high over pressures to surrounding surfaces.  Surfaces that are pliable will "spring back" (internal organs) and surfaces that are rigid (bones) will shatter.  The blast wave also induces shear forces which can tear tissues beyond their tensile strength.

4 types of injuries:

Primary: Injury related to the immediate effect of a high pressure wave on the body.  Air contracting, then expanding, can cause severe damage to gas filled organs: ears, sinuses, lungs, and bowel.  Additionally, "spalling" is a phenomenon that occurs when the blast wave moves from an initial higher density medium to another of lesser density.  This leads to micro and macroscopic tears at the surface of the two medium.

Secondary: Injury caused by flying debris, projectiles can cause both penetrating and blunt force injury.  Eyes are often effected.  All parts of the body are subject to penetrating missiles.

Tertiary: Injuries sustained when victims are thrown by the blast wave.

Quaternary: Any injury that is "other" than the above.  Examples include burns and inhalation injury. Exacerbation of chronic disease are also included here.

Specific Injuries to consider:

Airway Compromise: (massive hemoptysis, decreased loc, face/neck trauma, and inhalation injury)
Treatment: Intubate/secure airway

Ventilatory Insufficiency:
Treatment: Oxygen, CPAP, positive pressure ventilation

External Hemorrhage: bleeding wounds, amputation.
Treatment: direct pressure, tourniquet.

Tension Pneumothorax:
Treatment: needle thoracostomy followed by tube thoracostomy when available

Shock: external/internal hemorrhage, tension pneumothorax, hypoxia, pulmonary embolus
Treatment: Correct cause and administer IV fluids and blood products.

Arterial Air Embolism: (consider in sudden deterioration: mental status, seizure, chest pain)
Treatment: Hyperbaric oxygen

Pulmonary Primary Blast Injury: hemo/pneumothorax, lung contusion, infiltrate. (Can be occult)
Treatment: Specific to injury

Gastrointestinal Primary Blast Injury: similar to blunt abdominal trauma
Treatment: Specific to injury

**EXTERNAL HEMORRHAGE IS MUCH MORE LIKELY THAN AIRWAY COMPROMISE**

---------

Pediatric Trauma Considerations:

From Lecture by:  Daniel Fagbuyi, George Washington University

http://www.childrensnational.org/files/PDF/ForDoctors/cme/GrandRounds/GRounds09-26-12.pdf



Summary:

Most terrorist attacks involve explosive devices.

It is false to believe that terrorists will not target children.  

Children have unique characteristics which place them at risk for blast associated injuries. 


Some Slide Highlights:

Additional Sources for this Blog:

Emergency Medicine A Comprehensive Study Guide, 6th edition; Tintinalli, Kelen, Stapcynski

Blast Injuries, A Review; Medscape Emergency Medicine Education; S Sutphen 11/9/05

US Dept of Health and Human Services, American College of Emergency Physicians; Blast Injury Radiologic Diagnosis, 2009

Dedication:

Dedicated to the victims of the April 15th Boston Marathon Bombing and to all Boston Medical Providers who cared for them.  You are a model to our Nation. Thank you.

ER Doctor Describes Bombing Aftermath

I have been thinking about Boston over most of the past day.  Dr Medzon was one of my attending physicians at Boston Medical Center.  I thought this was a powerful description of what the Emergency Department was like following the bombing.  A harsh reminder of what we do, and hopefully, a small lesson as to why it matters.

http://hereandnow.wbur.org/2013/04/16/er-doctor-bombing

The audio file is worth a listen.

Do's and Don'ts of Documentation Test lecture on Vimeo

DDD-Test Lecture posted to vimeo

https://vimeo.com/63945627

Clinical Calculators: Test Lecture

Clinical Calculators: Test Lecture

Discharging Low Risk PE from the ED? What do you think?

Guideline from the ACCP(American College of Chest Physicians):  Kearon C et al. Antithrombotic Therapy for VTE Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012;141 (suppl 2): e419-e494S

Here is a summary:  http://pulmccm.org/2012/review-articles/antithrombotic-therapy-for-dvt-pe-vte-pulmonary-embolism-anticoagulant-accp-recommendations/

LMWH has become quite accepted.  (From the ACCP guidelines): 

"ACCP suggests low-molecular weight heparin (enoxaparin or Lovenox) or fondaparinux instead of unfractionated heparin (Grade 2B-C suggestions). Caveats to this are patients in whom subcutaneous absorption may not be adequate, or patients who are being considered for thrombolytic therapy: they should receive IV unfractionated heparin."

I'm not sure DC to home is ready for prime time.  Not yet "standard of care" but certainly worth considering in the "right patient."  The issue (as you know), like DVT, they need to be relied upon follow up for INR testing and adjustment of Coumadin.  (From the ACCP Guidelines): 

"Patients with low-risk pulmonary embolism (see below) who have good support at home, are likely to follow up, and can inject parenteral anticoagulants (or their family, or home nursing, can inject them) should be discharged home “early,” which means as early as the day of diagnosis, rather than staying in the hospital for 5 days (Grade 2B, suggestion based on moderate strength evidence). These patients can be safely discharged home from the emergency department without hospital admission, suggests the ACCP."

If you do send someone home, you may want to consider calculating a Pulmonary Embolism Severity Index (PESI), (From the ACCP Guidelines): 

The Pulmonary Embolism Severity Index (PESI) is a validated tool the ACCP mentions as a reasonable method of identifying people with low-risk PE. (Click the link for an online calculator.) Scores on the PESI < 85 without hypoxia, systolic BP < 100, severe chest pain, bleeding, thrombocytopenia < 70,000, severe liver or kidney disease, or PE while on anticoagulation suggest low risk PE. There’s also a simplified PESI calculator; a score of 0 suggests low-risk PE

Remember, these are only recommendations.  I do not know of any studies which have actually compared outcomes between low risk PE patients who were hospitalized vs discharged to home from the ED.

Anyone?

Pediatric Case of the Week 17: Spring Cleaning

13-year-old boy is brought in by EMS after he was found in bed with confusion, headache, and nausea.  According to his parents' he had slept in his “new man-cave bedroom” which they had just created in the basement of their old house. The room also happens to be adjacent to the “mechanicals” which include a hot water heater and a hot water boiler.

EMS noted initial hypoxemia with sats in the low 90’s and placed him on non-rebreather.

No significant past medical history, he is otherwise healthy and doing well in school.  Parents do not suspect drug use and he has no history of depression.

VS:  Temp 97.4, HR 112, BP 95/60, RR 30, Sat 99% on 10L

Primary survey: Airway: is patent.  Breathing: rate is slightly increased.  Circulation: skin is pale and pulse is slightly increased.  Deficits: he appears confused, oriented to person only, GCS 12, without additional focal neurologic deficits.

Secondary Survey: No signs of head trauma.  He is moderately confused (as noted on primary), PERRLA. CV RRR, no murmurs. Lungs are notable for faint crackles at the bases. Abdomen NT/ND and normal bowel sounds.  Skin warm, axilla normal sweating.

IStat: pH 7.3, PaCO₂ 31.8, HCO₃ 16, SaO₂ 99%, Na 141 mEq/L, K 3.8 mEq/L, BUN 12, Cr 0.9, glucose 198 mg/dL, Hb 16.3 g/dL.

EKG shows sinus tachycardia with no additional abnormalities. 

Portable CXR shows subtle pulmonary edema.

If his respiratory status were to diminish, which chemical agents would you use to paralyze/sedate?

If he were to become hypotensive, which pressor(s) would you initiate?

What additional labs would you like to order?

Assuming his status remains unchanged in the ED, where would you likely admit this patient: ICU, Telemetry, Floor?



----------------------------WEEKEND UPDATE------------------------------------

Carbon Monoxide toxicity is most frequently associated with smoke inhalation. But it should be considered in less obvious scenarios in which patients present with symptoms ranging from severe altered mental status to mild headache and “flu-like” symptoms. 

Toxicity ranges from asphyxia, myocardial dysfunction, and a full spectrum of neurological dysfunction.  It can be very difficult to diagnose and is commonly misdiagnosed as Headache or Viral Syndrome. Unfortunately, CO has the quality of being both odorless and tasteless (Similar to a certain colleague of mine just after a he’s taken a rare but much needed shower.)

The CDC reports that in 2001-2002 about 15000 people were treated for unintentional non-fire-related CO exposure.  Most of these exposures occurred during the winter months and were related to faulty enclosed heating systems. The same report noted that children younger than 4 had the highest incident of unintentional CO exposure, but fortunately the lowest rate of death.

The differential for altered mental status is VERY LONG.  In this case you would definitely want to consider other toxidromes, seizure, neurologic, and cardiac etiologies.

Some key points regarding CO toxicity:

-Patients may not appear cyanotic, because Hgb takes on a red hue when bound to both O2 and CO.

-GET AN EKG, (you would want get an EKG in all Altered Mental Status patients regardless) however, CO can specifically cause cardiac toxicity.

-Standard pulse oximetry will not differentiate oxyhemoglobin from carboxyhemoglobin.  O2 Sats will often be falsely elevated.

-Carboxyhemoglobin levels can be directly measured by arterial or venous blood samples.

-For anyone taking the Boards soon: CO shifts the oxyhemoglobin dissociation curve to the left; which inhibits the release of oxygen to the tissues.  (It decreases both O2 loading in the lungs AND unloading of in the tissues.)

 (This image was intentionally left small and insignificant because, personally, I loathe it and think it should be obliterated from all medical texts. I have learned it 15 times and can never remember it.) 

-If the patient is maintaining his/her airway, the treatment is 100% O2.  If not, have a low threshold for intubation. 

-I think, as long as the potassium comes back normal, you could intubate using etomidate and Succinylcholine or Rocuronium.  If the K comes back elevated, or you don’t have it but are worried about seizure or prolonged down time, you may want to consider Rocuronium (a non-depolarizing paralytic and less likely to drive up K precipitously.)

-Hyperbaric O2: The magic number for CO level is >25 (>20 if pregnant).  Other high risk situations include: pregnancy with signs of fetal distress, LOC, pH <7 .="">

-Additional interesting facts/thoughts:

-Smokers walk around with a baseline CO as high as %10.  They are MORE susceptible to the toxic effects of CO (as if they needed another reason to quit.)

-After hurricane Katrina there were 78 cases of non-fatal CO exposure and 10 deaths.  Nearly all the cases were related to gasoline powered back up generators being run outside but near the home’s air-conditioner blower unit.

-In winter (Minnesota): Ice houses

 

-In summer (Minnesota): Napping in the back of a motorized boat

-All Season: riding in the back of an old truck (I might have been a neurosurgeon had I not made a trip "up north" in one of these bad boys at age 12...)