How to apply these alternative approaches
As alternative therapies move to the forefront, possibilities for application in the ED may increase.
"There is a new trend in openness, brought on by a grassroots movement," says Patty Campbell, RN, MSN, CCRN, ANP, CS, a Phoenix-based emergency nurse practitioner and assistant editor of the Journal of Emergency Nursing. "As patients have increased their use of alternative therapies, this has made nursing and medicine take a closer look at it."
Alternatives should be used together with traditional methods, says Campbell. "People normally come to the ED to get medical care for acute illness or injury. Most of the therapies that are considered alternative should be done in conjunction with allopathic medicine," she explains." Allopathic medicine is the response to a disease or injury with active treatments, such as medicine and surgery. "We can’t deviate from our purpose, which is to provide the best allopathic care," says Campbell.
Both approaches are effective in different ways, stresses Jay Kaplan, MD, FACEP, chairman of the department of emergency medicine at Saint Barnabas Medical Center in Livingston, NJ.
"There are certain things Western medicine does very well, such as [treating] acute trauma or infectious illness; although with overuse of antibiotics, there are some superbugs’ out there calling that into question. But alternative medicine does a better job with chronic disease or autoimmune disease," he says.
Hospitals are becoming more open to alternative approaches, notes Kaplan.
"There are still issues of medical staff acceptance of new approaches," he notes. "However, some places are actually putting herbal medicines in the hospital formulary, and acupuncture is used in some hospitals."
Here are examples of alternative approaches that can be implemented in the ED:
• Acupuncture. "With chronic illnesses, where traditional medicine has failed to control a patient’s pain, integrated therapy would be an excellent next step," says Campbell. "Instead of narcotics, maybe the next step for a patient with chronic back pain would be acupuncture or massage therapy."
Some hospitals have an acupuncturist certified and credentialed by the facility, notes Campbell.
"Several hospitals are proceeding in that direction. Many MDs are getting certified to incorporate acupuncture into their practice. Eventually, we will be seeing it in the ED," she notes.
Acupuncture could be an alternative for drug-seeking patients, notes Kaplan. "One of the most difficult patients we see in ED is the person with severe headaches who is allergic to every known drug other than a narcotic," he explains. "I would love to be able to offer that patient acupuncture as a therapeutic modality."
• Visualization or guided imagery. "Nurses can take classes to learn techniques such as visualization," recommends Campbell. "Sometimes patients are waiting long periods of time to be seen, which only increases their stress. Incorporating visualization techniques while patients are waiting for test results or to see a physician would be very beneficial."
Visualization can help patients in crisis, says Kaplan. "In addition to taking care of the strictly medical physiologic things going on, I will ask patients to visualize themselves in a favorite place, where they can feel totally comfortable and relaxed," he says.
Asthmatics with breathing difficulties can also be helped with visualization.
"Ask them to recognize that their lungs are in spasm, and try to think about how their lungs could relax. Ask them to grip your hand and feel the tight muscle, then relax their hand," Kaplan suggests. "Explain that right now their lungs are like a fist, and their lungs need to relax like an open hand."
Guided imagery involves visualization, but it’s a longer process, Kaplan explains.
"You are taking a person on a journey by having them use their imagination," he says. "For example, you may have a patient close his or her eyes, and imagine they’re in a very beautiful place, then help them to visualize that location."
• Placebo effect. "Most of the time, people think the placebo effect means you’re trying to put something over on the patient. But you are actually helping to mobilize the patient’s emotional and mental resources to help them heal," says Kaplan. "The mind can help the body heal. If you have a person who comes in with an injury and [he or she] says, How long will it take to get better,’ and you tell the person three weeks, it may well take three weeks. But if you say, People heal at different rates, and you may feel better in three or four days,’ that sets up an expectation that their body is beginning to work on getting better already."
• Herbal medicine. "By learning about herbal medicine, ED nurses can begin to raise the issue of what other kinds of medications they might potentially recommend to patients," says Kaplan. "Because by and large, you are dealing with substances less potent than prescription medications, they are less effective acutely but may be effective over time. But there certainly are some herbal remedies out there that can be very helpful to patients who really don’t want to take traditional medications."
Many herbal remedies have been shown to be effective with specific conditions, notes Kaplan. "For example, studies in Europe have shown ginger to be as effective as medications such as Dramamine, in treatment of post-op nausea and motion sickness," he says. "Gingko biloba has shown improvement in memory of Alzheimer’s patients in randomized, double-blind studies." (See section on ginko biloba in cover story on p. 90.)
Saw palmetto can be helpful to men experiencing benign prostratic hypertrophy, Kaplan notes. "There are some good, controlled studies that show St. John’s Wort is as effective as some of the antidepressant medications people are taking, at far less cost."
However, exercise caution and act as an educator, not an advocate. "If you tell a patient, I think that you should take feverfew to prevent your migraines,’" you are putting yourself at some risk," says Kaplan. "Instead, say, I’ve heard that this particular herb might be helpful, why don’t you read about it a little more and see what you think.’"
• Music therapy. "We build up our tolerance to all the noise in the ED so we don’t hear it, but our patients do, which increases their stress level," Kaplan notes. "If you decrease a person’s stress level, you increase the body’s capability to fight infection."
Portable CD players can be used with headsets at the patient’s bedside, Kaplan recommends. "This isolates them from all the extraneous noise in a busy ED and has a calming influence," he explains. "Studies have shown that this lowered children’s anxiety levels in a pre-op setting, so certainly it could be used on any patient in crisis or in pain. I’ve had anxious 50-year-old men with chest pain on a stretcher a curtain away from an active CPR, with their eyes closed and a smile on their face."
Music therapy is very effective in children undergoing an examination or invasive procedure, Campbell reports. "If they get to listen to a favorite tape and sing along, it really alleviates their anxiety," she says. "We put headsets on them and have them listen to therapeutic music. Studies have suggested that this may reduce their response to pain and enhance their healing. We are looking into expanding this into the adult population."
• Massage therapy. "There are case reports of guided imagery and massage therapy reducing the impact of an acute asthmatic attack," reports Campbell. "Once you start traditional therapies, you can add massage therapy or therapeutic touch."
• Diet. "A dietary regimen potentially can have a profound effect on the course of an illness," says Kaplan. "If patients have coronary artery disease, you can recommend they look into the Ornish diet. Patients with autoimmune diseases should be instructed to look into changes in their diet that can possibly help, such as becoming a vegetarian."
• Therapeutic touch. The ED at Navapache Regional Medical Center in Show Low, AZ, has a nursing protocol to incorporate therapeutic touch. Therapeutic touch involves using the hands to identify and correct energy imbalances, with the palms of the hands several inches away from the patient’s body. (See protocol on p. 93.)
"After the patient’s permission is obtained, we help the patient focus, and assess where their energies are low," says Kathleen Kelly, RN, an ED nurse at the facility. "The patient’s response is documented on the chart."
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