Category Archives: Emergency Medical Services

Emergency Medical Services, Public Health

A Tertiary Care Transfer

On December 18, 2009, “Simon Jones” called 9-1-1 and summoned emergency medical services (EMS) to his residence after developing a significant difficulty in breathing over the last few days. Mr. Jones is an elderly male who lives alone after his wife passed away three years ago. His two adult children live out of state. As EMS arrived, they found Mr. Jones to be in moderate distress with difficulty breathing, a low-grade fever, pale and cool skin, and general complaints of weakness. Mr. Jones stated a significant past medical history, including coronary artery disease, diabetes, hypertension, angina pectoris, myocardial infarction, congestive heart failure, and chronic obstructive pulmonary disease. Mr. Jones was treated by EMS with intravenous fluids, provided a breathing treatment, and transported to the local community hospital’s emergency department (ED).

Upon arrival at the local hospital, Mr. Jones was registered as a patient during turn-over from EMS to the nurse and attending physician who initially prescribed antibiotics and continual oxygen by nasal cannula. Within an hour, Mr. Jones spiked a high fever, became severely short of breath, and his blood pressure dropped precipitously indicating systemic inflammatory response syndrome (SIRS), or sepsis. The attending physician quickly ordered IV fluids run wide open with vasoactive medications added to support the patient’s blood pressure. Mr. Jones was unable to breathe effectively, however, and required intubation and was subsequently placed on a ventilator. The attending physician consulted with the University Hospital “One Call” physician who recommended transferring Mr. Jones to the intensive care unit (ICU) at University Hospital. A critical care transport (CCT) unit, staffed by two critical care paramedics and an emergency medical technician driver, was called for the transfer.

Mr. Jones was transferred to University Hospital without issue. Upon arrival, the intensivist accepted patient care from the CCT crew and began formulating a team to care for Mr. Jones, specifically mindful of his complicating medical history. Mr. Jones still had a low blood pressure and required ventilatory support, but his core temperature began dropping below normal. After a few days of using medication to attempt to correct the infection and hemodynamics (blood pressure, et al.), the patient developed acute renal failure (ARF). Mr. Jones, however, did not develop acute respiratory distress syndrome (ARDS), which was a concern from being on the ventilator with SIRS. Mr. Jones received continuous bedside hemodialysis for added kidney support.

After eight more days in the ICU, Mr. Jones’s hemodynamics began to self-regulate, and he seemed to be improving quite well. After three more days, Mr. Jones’ kidney function began to improve and hemodialysis was discontinued. Four days later, Mr. Jones was extubated, removed from the ventilator, and transferred to a medical/surgical bed. After a short stay, Mr. Jones was discharged to a skilled nursing rehabilitation center for improvement of his activities of daily living (ADLs). Mr. Jones soon returned home with no lasting effects from the medical confinement. He continues to follow up with his primary care physician.

Academia, Culture, Emergency Medical Services, Health Care, Society

Codes of Ethics

Of the three ethical codes presented by Lewis and Tamparo (2007), I align myself most with the Principles of Medical Ethics: American Medical Association (AMA). The AMA promotes honesty, integrity, compassion, respect, and most importantly, responsibility. In all manners of occupation, it is virtuous to remain honest; this is paramount in medicine. Physicians, nurses, paramedics, and other health professionals may make mistakes during their career, and it is important that these mistakes be corrected as soon as possible and understood to promote practices that may minimize the same mistake from happening. Honesty leads to integrity. Integrity is a hallmark of professionalism and, in conjunction with honesty, promotes trust. Having compassion and respect for patients regardless of political, societal, economic, or other divisions allows a provider to actually care for his or her patients rather than just deal with them. As a paramedic, I try to be as trustworthy and caring as possible to each and every patient I see. Ultimately, I understand my responsibility to my community, to fellow clinicians and technicians, to patients, and to myself. I hold ultimate responsibility for my actions and inactions, and I take care to not let these adversely effect the perception others hold of me as a professional. The AMA expects this of all physicians, and as an extension of the physicians I work for, I must strive to meet the same demands.

The Hippocratic Oath is dated in its language and demands. Though the oath can be approached as symbolism, the metaphor can be lost on some. I appreciate the Hippocratic Oath for what it is (a foundation for the ethical practice of medicine), but contemporary words, meanings, and application serve me better.

I find the Code of Ethics of the American Association of Medical Assistants lacking in context, applicability, and substance when adopted for paramedicine, my chosen occupation; therefore, I do not align as well with this code as I do with the previously mentioned codes of ethics.

Codes of ethics provide baseline philosophies that serve to direct the actions of groups. By ascribing to such, the professional belonging to such a group allows the code to guide moral judgments when the answer is unclear. In medicine, this is especially true. Medical professionals deal with life and death decisions which stretch the boundaries of personal moral beliefs. By ascribing to a notion of a slightly higher directive than one’s self, the professional can remove his- or herself from the situation with more clarity and less bias.

My personal ethics are bound by a sense of personal liberty and the responsibility of that liberty. Without responsibility, there are no consequences. Without consequence, there is no learning. I like to learn so that I may be the best paramedic that I can to the next patient in my care. For me, it is always about the next patient; they deserve the best that I can offer.

References

Lewis, M. A. & Tamparo, C. D. (2007). Codes of ethics. In Medical law, ethics, and bioethics for the health professional (6th ed.; pp. 241-243). Philadelphia, P.A.: F. A. Davis.

Emergency Medical Services, Politics

Conversations in the Back of the Ambulance

MS: So, we have about a half-hour ride to the other hospital. Would you be willing to help me out with a project for my anthropology class?

AP: Sure, we’ve been having quite a conversation so far.

MS: Okay, for the record and because of medical privacy concerns I will acknowledge your participation with the initials AP for Anonymous Participant. Also, I have to make sure that I note the generational differences between us.

AP: Well, that shouldn’t be too hard to do.

MS: No, certainly not. For documentation sake, let us say that you are in your 70’s, and we can leave it at that.

AP: I’m closer to eighty, though?!

MS: Wow, can’t even do a guy a favor!

AP: HA! So, what are these questions? I imagine it’s how to pick up the ladies, right?

MS: Yeah, sure, let’s start there! Actually, I wanted to ask more about your views growing up. Politics, religion, et cetera.

AP: Well, let’s start with religion. I think that will be the easiest.

MS: Okay, religion.

AP: Well, let’s see… I grew up in a fairly Protestant family. I mean, we went to church every Sunday and all, but we were never overly religious.

MS: Would you say that you were tolerant of other religions, or did you view your religion as the true religion of your god?

AP: Oh, no! We were very tolerant. We would never look down on anyone else because of their beliefs, especially their religious ties. The only problems that I have ever had with people were, well, the neighborly scuff – whose fence is on whose property – and, of course, mechanics. $1000 to install a $25 part… highway robbery for sure! And, I am sure I won’t like you too much after I get your bill!

MS: Obama will take of that, though, right? Actually, I do want to talk about your political views here in a minute, but let’s keep on religion for now. Do you think your views of religion have changed much over the years?

AP: Well, that’s tough to say. I’m pretty old, and I know that I’m gonna die pretty soon. It makes you think, you know? I mean, I know I want to make sure that I get a chance to tell the kids and the grandkids how proud I am of them, and I pray to God every day that I will get that chance. They all live in different States, so it’s tough to get them all together, lately. But, I find myself talking to God a lot more these days, but I am not sure if I believe in Him any more than I used to, as an adult, I mean. As a kid, he’s like Santa Claus or the Tooth-fairy; you believe in Him for no other reason than you were told to.

MS: Yeah, that’s kinda where I’ve been. I can understand that there might be a consciousness that is ultimately responsible for our creation, but I am not sure if I believe he knows what exactly he has created. Accidental or otherwise, we do exist, and it would only make sense that something put this in motion. Maybe I’m a theist, but mostly I don’t think about it. I’m usually agnostic or atheistic. Perhaps, I’m an agnostic theist?!

AP: Well, when you get as old as me, you want to make sure you are on the good-boy list.

MS: That’s Santa?!

AP: Close enough.

MS: Alright, let’s talk politics. I’ll keep it simple at first. George Washington, good or bad?

AP: Good, no great! He was a great man, Washington.

MS: Tyler?

AP: Who?

MS: Abraham Lincoln?

AP: Great!

MS: Wilson?

AP: What? Woodrow Wilson? Ungh… That was an evil man. Let me tell you about Wilson. Wilson is why this country is the way it is. I imagine that others before him wanted to do some of the things that he did, but sheesh, Wilson was the one that got it done. And, done, indeed, it is.

MS: What was so bad about Wilson?

AP: Have you ever heard of the Great Depression? That was Wilson’s work, there. Yeah, it happened a few years after he died, but the framework was his alone. Who were those other two guys? They came after Wilson…. I can’t think.

MS: Harding and Coolidge?

AP: That’s them. I remember my father telling me that if it weren’t for those two, Hoover wouldn’t have had a chance. Hoover was actually in office during the start of it, the depression. Lucky for me, I don’t remember it. In fact, don’t remember him. I think the first President that I can remember was F.D.R. He was the war President. As far as I recall, though, I think Hoover just ran with the Wilson plan, killing everything Harding and Coolidge did to fix the problems.

MS: So, I’m guessing you are a Conservative? A Republican, perhaps?

AP: I remember waving the flag for Roosevelt, so I guess I was a Democrat, then, you know, at twelve years old, or however old I was then… probably more like nine or ten. But, as I got older, especially from the time the war ended, I started paying attention to politics. I’ll tell you, it makes not one lick of difference if the guy is black, brown, yellow or white; if he’s a politician, he’s both a liar and a thief! We have had very few politicians that were honorable men, very few. And, these Progressives, well, they are the worst of them. This Obama is one of them.

MS: Yes, I believe Obama is a self-proclaimed Progressive.

AP: And, it shows. Wilson was a Progressive. Too many of them are. And, they don’t tell you! That’s the worst of them. They tell you what you want to hear, you elect them, then they do this about-face and spend, spend, spend us into oblivion. Looking back, this is certainly not my father’s country anymore. Ford was good, though. He never gets any recognition.

MS: So, Ford, good; Wilson, bad. Is that right?

AP: Yup!

MS: Interesting. I’m going to have to read up on Ford a bit more. You mentioned something about race a minute ago: “Brown, black, yellow, white”, something. What are your views on race relations in the United States?

AP: Oh, no… You aren’t gonna like me much after this conversation, but I’ll be honest. I always try to be honest.

MS: Okay, Ben Franklin, let me have it.

AP: Ha! Well, I can honestly… heh, honest… say that I have no problem doing business or maintaining friendships with anyone of any race, nationality, or creed. The problem that I have is the laziness and the sense of entitlement that many people have today. Fifty years ago, you didn’t see that, not like today, anyway. It’s just unfortunate that the minorities tend to have this attitude, this air of you’re not better than me, so give me money so I don’t have to work.

MS: Ahh, so the Progressives rear their ugly heads once again!

AP: Exactly! And, that’s what I was talking about. It’s this idea that if we give them money, they will use it to rise up and overcome poverty or something. Almost magical thoughts of levitation, if you will. One day, they will learn that if you keep giving people stuff, there will come a time when they forget how to earn it. Same with me. I’m sure that if the government sent me a check every week for not working, at some point, I would become complacent and not work. I doubt it, but it is possible I guess.

MS: Is it the government’s place to give out all of these entitlements?

AP: Again, I’m old, but I’ve made a pretty decent living for myself over the years. Medicare is a horrible system, but between that and my other insurance, at least you’ll get paid!

MS: Well, I’m not too worried about that. You sign my form, and that’s all I care about for payment. We have people!

AP: Yeah, tough guys always have people. But, community… community and family is what we need to get back to. That used to be enough. Granted, there were times that were really tough, especially for my family when I was born and right before. We had tough times, but we got through them. We were smart about it. We trusted that it couldn’t last too long, and it never did.

MS: Well, one thing that I’ve noticed is the propensity of my generation to move away from family. I think we rely on the internet for communication and planes, trains, and automobiles to visit from time to time.

AP: Well, we had a farm. When the family has a farm, you help run it. Actually, I think it was the farm that kept our heads above water all those years.

MS: I always wanted a farm. Is it still in the family?

AP: Nah. None of the kids wanted to keep it up. It is hard work running that farm, but we sold it off, paid our debts, and invested the rest. Pretty much been living on that after we retired.

MS: So, what was life like on the farm? I mean, family life specifically.

AP: Well, our farm was a part-time venture, so to speak. I would wake up, do some chores, have breakfast, go to work, come home, do some chores, eat dinner, do some chores, go to bed, and repeat. Don’t get me wrong, I enjoyed the hell out of it. The kids helped out when they were old enough, but the wife kept the whole ship running smooth. If it weren’t for her… well, let’s just say I wouldn’t still be here.

MS: Television and movies about years ago seemed to marginalize women. The wives cooked, cleaned, did the laundry, had babies… you’re laughing?

AP: My wife cooked, cleaned, did the laundry, had babies, sure, but I cooked, I cleaned, I did laundry, and I was very involved in the raising of our children. Don’t let those programs fool you. Family was family. We did it all. In fact, we both left for work at about the same time, though she would get home sooner than me. She only worked around the corner.

MS: You are describing a very concerted effort at keeping house and home.

AP: If you find a young woman to love, you take good care of her, and she will take good care of you. I remember a few guys that would mistreat their ladies, but back then, well, back then, we took care of things like that. Times get tough, but don’t mistreat your lady.

MS: Speaking of your wife, she said that she would meet us up here. So, I should give her all the respect in the world?

AP: Anything less, and I’ll smack you one!

MS: It seems chivalry ain’t dead!

AP: Not as long as I’m around, and I ain’t going anywhere, yet!

MS: No, it seems that you will be around to cause her grief for a little while longer, at least, but not with me. It seems like we’ve arrived. It was absolutely great hearing your story. I am honored. Is there anything that you would like to add?

AP: Yeah, tell the driver not to hit so many bumps next time!

MS: He’ll be opening the doors here in a minute. You can tell him yourself. Thank you again.

AP: Anytime, but next time, come by the house. I don’t need another ambulance bill!

MS: Understood.

As a paramedic, I enjoy many benefits. The single best benefit is certainly the ability to meet new people and talk to them. For this assignment, I felt it best to rely on the random nature of my job to gain the perspective of someone I have never met before. There are limitations, though, to this method of choosing a potential informant for this interview. Paramedics are bound by confidentiality, and though the informant granted express permission to use his words and his story, I could not ask him to waive his rights under the Health Insurance Portability and Accountability Act (1996). I felt that the limitation was not an undue hardship, and the benefits of gaining such a random perspective far outweighed the benefits of identification of the informant.

The informant that I interviewed was a 70-something year-old gentleman who was more than eager to share his story with someone so interested in listening. The most important discovery of the entire interview was that we all have interesting life lessons to share. If only more people would stop to listen, important lessons could be taught.

It is very important to note that this interview was conducted during a time when the informants mortality was in question. I feel that this opportunity is unique in the honesty and conviction of the responses to my questions. We started the interview by talking about religion.

The informant and I feel that we have quite the same religious background and beliefs (personal communication, June 2010). When I approached the topic of religious tolerance, he seemed to be more cognizant of character and overall morals separate from specific religious practices. This thought reinforced some of my core beliefs about the human condition, about how we are moral creatures.

Discussing politics gave me some real insight into how earlier Americans might have viewed the progressive versus conservative debate originally (Anonymous, personal communication, June 2010). I am sure that the informant is not an exemplar of all twentieth century American political thought, but he was able to draw some parallels with the current political environment. Tough times arise and people tend to get nervous about economic survival. It is easy to conceive that an incomplete understanding of politics and economics fuels the debate on both sides of the issues.

From politics, we moved on to discuss his view of race relations in the United States. Interestingly, it seems as though my informant might have been resigned to accept that he might have some racist tendencies until I asked him his thoughts and understanding of race (personal communication, June 2010). It turns out that he was slightly mistaken. My informant realized, during our conversation, that it was not racial differences that he was upset about but a general lack of motivation seen in many people over the years. It is just an unfortunate twist that he associated this laziness with racial stereotypes. Though we changed the subject quite abruptly, I could sense a rebuilding of his understanding of racial differences. It was good to see such a thing take place.

Family was strong throughout my informants life (personal communication, June 2010). Whether we were speaking of being raised by post-depression era parents or farm life with his own family, there was always cooperation to make the family structure work. I took exceptional notice during this portion of the interview. In the contemporary United States, I have noticed a disintegration of family and community. In childhood, I recognized the meaningfulness of family bonds and community spirit. I wonder how this changed. My informant describes a time that was not particularly easy on him or his wife, but they remained loyal to each other and to the family, specifically. Today, it outwardly appears to makes more sense for some to seek a better alternative at the first hint of difficulty or trouble. This is not what family means to either of us, and I am glad to see an example of how things work out pleasantly in the end.

Our interview ended with a particularly entertaining joke about him protecting his wife from any irresponsible comments that I might make (Anonymous, personal communication, June 2010). I am sure that he did not feel that he had to actually protect her from me, but I think he felt that he needed to make me understand how much he cared for his wife. Man to man, an idle threat seems to convey a universal understanding between men, whether serious or joking. I am glad to have witnessed this show of strength. I am sure that he is contemplating the fact that he will not be around much longer. I hope that he understands that he would leave his wife with good people in the world. I believe that this discussion was the impetus for my patient to realize that the world outside of [his neighborhood] is not a hostile or unfriendly world. I also think he realized that he will not be here forever, and his wife will be taken care of by the community that he supported for so long. I am glad to be a part of that community.

References

Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, §1177, 110 Stat. 2029 (1996).

Academia, Clinical, Emergency Medical Services, Health Care

Flawed Conclusions in Literature Review

For this week’s discussion, I have chosen to analyze an article (Sakr et al., 2006) that attempts to outline the efficacy and potential dangers of certain drugs used to treat shock. As a critical care paramedic, the discussion surrounding this article can provide insight to choosing alternative therapies when caring for my patients, but it is important for me to understand the potential biases and limitations of such a study that could lead to flawed conclusions (Gluud, 2006).

Sakr et al. (2006) collected data on ICU admissions over a two week period to further understand how dopamine effects mortality and morbidity when administered in response to hemodynamic compromise. Also, other administered vasoactive drugs were included in the analysis whether administered concomitantly with dopamine or instead of dopamine. The researchers did not distinguish between etiologies except to delineate between septic shock and non-septic shock. Patients who presented with shock or suffered a shock state within the first 24 hours of admission were included in the analysis. Patients admitted to the ICU mainly for 24 hour surgical observation where not included.

Shock is defined as “a state of inadequate cellular sustenance associated with inadequate or inappropriate tissue perfusion resulting in abnormal cellular metabolism” (Hillman & Bishop, 2004, p. 121). There are many etiologies of shock, including sepsis, anaphylactic, neurogenic, hypovolemic, cardiogenic, and others, which respond differently to various therapies. This confounder creates an information bias, as this variable is not identified in the data collection and cannot be scrutinized. Simply identifying the etiology of each shock state would limit this bias. The researchers, however, acknowledge this limitation and others.

Another confounding variables is the time constraint of the data. In regards to septic shock, this variable becomes evident. Many pathogens spread predictively during certain times of the year. The concomitant treatment of these infections could predispose patients to suffer a prolonged state of shock (in cases where the pathogen might not be immediately recognized) or provide for an ideal treatment pathway when the pathogen and the antibiotic regimen are fully understood and effective. This selection bias could be controlled by choosing patients who present throughout the year.

As Gluud (2006) points out:

When intervention effects are moderate or small, the human processing of data, unsystematic data collection, and the human capacity to overcome illnesses spontaneously limit the value of uncontrolled observations. Experimental models are essential for estimation of toxicity and pathophysiology.
(p. 494)

References

Gluud, L. L. (2006). Bias in Clinical Intervention Research. American Journal of Epidemiology, 163(6), 493–501. doi:10.1093/aje/kwj069

Hillman, K. & Bishop, G. (2004). Clinical Intensive Care and Acute Medicine. West Nyack, N.Y.: Cambridge University Press.

Sakr, Y., Reinhart, K., Vincent, J., Sprung, C. L., Moreno, R., Ranieri, V. M., De Backer, D., & Payen, D. (2006). Does Dopamine Administration in Shock Influence Outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study. Critical Care Medicine, 34(3), 589-597. doi:10.1097/01.CCM.0000201896.45809.E3

Academia, Clinical, Culture, Emergency Management, Emergency Medical Services, Health Care, Public Health, Technology

Patient Safety Considerations for EMS

 In the out-of-hospital emergency care setting, patient safety is paramount. Initially, victims of trauma or illness are already suffering in an uncontrolled environment. It is this same environment where first responders, emergency medical technicians, and paramedics must operate to stabilize and transport the victim to the hospital, a more controlled environment. Unfortunately, there is little research in the area of patient safety in this setting (Meisel, Hargarten, & Vernick, 2008; Paris & O’Conner, 2008).

Importance

Focusing on patient safety and developing processes to ensure optimal safety would allow the study of inherently dangerous, yet potentially beneficial therapies, such as rapid sequence intubation where the clinician uses a series of medications to rapidly sedate and paralyze a critical patient for ease of inserting a breathing tube. Focusing on safety, an EMS department in Maryland successfully instituted such a program (Sullivan, King, Rosenbaum, & Smith, 2010).

With more research in this area, the Emergency Medical Services (EMS) can improve the care they seek to deliver to their patients.

Challenges

There are many challenges facing EMS as they seek to deliver safe and effective care to their patients. Motor vehicle accidents (including air transportation accidents), dropped patients, medication and dosage errors, other inappropriate care, and assessment errors all contribute to the number of adverse events in the EMS out-of-hospital care setting (Meisel et al., 2008). Unfortunately, it has proved difficult to identify both the existence and the cause of each event (Meisel et al., 2008; Paris et al., 2008). Additionally, there are adverse events that are impossible to track, such as the iatrogenic exposure to a pathogen. It would be very difficult to distinguish how and when a patient was first exposed to the infecting pathogen without considering community-acquired infections and hospital-acquired infections, which are both equally difficult to ascertain (Taigman, 2007).

Strategies for improvement

As EMS seeks to increase the professionalism among its ranks, the stakeholders must acknowledge responsibility for providing evidence-based processes to ensure patient safety.

References

Meisel, Z. F., Hargarten, S., & Vernick, J. (2008, October). Addressing prehospital patient safety using the science of injury prevention and control.Prehospital Emergency Care, 12(4), 4-14.

Paris, P. M. & O’Connor, R. E. (2008, January). A national center for EMS provider and patient safety: helping EMS providers help us. Prehospital Emergency Care, 12(1), 92-94.

Sullivan, R. J., King, B. D., Rosenbaum, R. A., & Shiuh, T. (2010, January). RSI: the first two years. One agency’s experience implementing an RSI protocol. EMS Magazine, 39(1), 34-51.

Taigman, M. (2007, July). We don’t mean to hurt patients. EMS Magazine, 52(4), 36-42.

Academia, Clinical, Emergency Medical Services, Health Care, Politics, Public Health, Society

Pay-for-performance in EMS?

There has been much discussion regarding reimbursement models for health services, and two main themes have emerged, the historical fee-for-service model and a quality-driven pay-for-performance model (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007). While many providers argue that the reimbursement level is currently too low to sustain operations (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007), patient advocates cite an overwhelming number of medical mistakes allowing providers to benefit from poorer outcomes leading to increased needs of critical care services which lengthen hospital stays dramatically (Committee on Quality of Health Care in America & Institute of Medicine Staff, 2001; Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007). While considering more effective designs within our health care system, treatment efficacy, reimbursement paradigms, and patient safety could possibly be used as a foundation upon which to rebuild our health care infrastructure. The Committee on Quality of Health Care in American and the Institute of Medicine Staff (2001) offer “six aims [safe, effective, patient-centered, timely, efficient, and equitable] for improvement that can raise the quality of care to unprecedented levels” (p. 5).

Fee-for-service models, the traditional norm in health care reimbursement, seek to itemize care expenditures based on particular procedures or services rendered to the patient. Though fee-for-service models reward providers for timely, and possibly effective and efficient, delivery of care, it does little to address safe, patient-centered, and equitable considerations.

Financial barriers embodied in current payment methods can create significant obstacles to higher-quality health care. Even among health professionals motivated to provide the best care possible, the structure of payment incentives may not facilitate the actions needed to systematically improve the quality of care, and may even prevent such actions.
(Committee on Quality of Health Care in America et al., 2001, p. 181)

As a paramedic, I am bound to a Medicare reimbursement model that focuses solely on the transportation of the patient and not on the care rendered. For a patient experiencing cardiac chest pain, merely placing them on a continuous ECG monitor and providing transportation to the hospital allows my employer to be paid the same as if I initiated an intravenous line, administered oxygen, aspirin, nitroglycerin, and morphine, and performed serial diagnostic 15-lead ECG readings during the transport. In any case, though, payment is withheld if the patient is not transported. I have to assume that this inequitable reimbursement scheme is replicated across the health care spectrum.

Pay-for-performance models, however, seek to reward the provider for improving the quality of care delivered and “represents an attempt to align incentives in the payment system so that rewards are given to providers who foster the six quality aims set forth in the Quality Chasm report” (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007, p. 36; Committee on Quality of Health Care in America et al., 2001). Some detractors of pay-for-performance worry that providers serving poor and ethnic communities that have typically poor health and preventative compliance will not benefit from such performance measures. The worry is that the numbers of providers will be lacking in these communities, worsening the communities health outcomes (Nafziger, 2010). Though, “pay for performance is not simply a mechanism to reward those who perform well; rather, its purpose is to encourage redesign and transformation of the health care system to ensure high-quality care for all” (Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff, 2007, p. 44). Pay-for-performance focuses on safety, and a search of the literature does not reveal any complicating risk to patients under a pay-for-performance system so long as the system is patient-centric, taking into account the patient population serviced by each provider.

For instance, regarding a certain type of heart attack called a “STEMI”, or ST-segment elevation myocardial infarction, it is beneficial for the paramedic ambulance to bypass the local community hospital and transport the patient to a primary coronary intervention (PCI) facility for a cardiac catheterization. In this instance, the local community hospital is losing potential revenue. Perhaps if the reimbursement model reflected this evidence-based and patient-centered decision and provided a small monetary reward to the local community hospital for allowing the directed care at the PCI center, then mortality and morbidity from STEMI in the community would be reduced and the local hospital would be rewarded for their involvement in the process even if they did not provide any direct care. This is just one instance in the realm of emergency care where pay-for-performance can help to ensure safe, effective, patient-centered, timely, efficient, and equitable delivery of care to the patient.

As both a health care provider and consumer, I would prefer the pay-for-performance model of reimbursement. As a provider, I am a patient advocate, and as a patient, I will, of course, advocate for myself. Pay-for-performance enables provider growth, evidence-based practice, better patient safety mechanisms, and an overall efficient and a more complete and holistic delivery of care.

References

Committee on Quality of Health Care in America (Author), & Institute of Medicine Staff (Author). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.

Institute of Medicine, Committee on Redesigning Health Insurance Performance Measures, Payments and Performance Improvements Staff (Author). (2007). Rewarding provider performance: Aligning incentives in Medicare. Washington, DC: National Academies Press.

Nafziger, B. (2010, May 6). Pay for performance could hurt docs who serve poor, blacks and hispanics. DOTMed News. Retrieved from http://www.dotmed.com/fr/news/story/12570/

Academia, Clinical, Emergency Management, Emergency Medical Services, Health Care, Public Health

Botulism: A Measurement of Occurrence

 Botulism, caused by the Clostridium botulinum bacterium, is typically caused by poorly prepared, home-canned foods and can cause symptoms as simple as blurred or double vision to full body paralysis, sometimes causing death (Centers for Disease Control and Prevention [CDC], 1996). The incidence of botulism is said to be extremely low with only 126 reported cases in the United States in 2003; with only eight attributable to foodborne vectors, the predominant cause is accidental contamination (CDC, 2004).

One of the concerns regarding botulism is its toxicity. Botulinum toxin is the most potent toxin known to man (CDC, 2006). This potency lends to botulinum’s ability to be used as an agent of bioterrorism, though most of the known cases have been shown to be accidental in nature (CDC, 1996; CDC, 2006). Another concern is the accidental or negligent contamination of any food prepared for wide distribution, such as canned vegetables from a large manufacturer.

Surveillance is important to identify each and every case in order to have the most accuracy possible when considering increasing or decreasing trends of incidence and prevalence of the disease. The cause of any increase or decrease in incidence of botulism should always be investigated.

Any increase of incidence could identify a possible problem while a decreased incidence could foretell efficacy in the efforts of mitigation. More appropriately, though, as Friis and Sellers (2009) show, further identification should be made in order to focus on specific descriptive factors, such as affected populations, the geography of these populations, known vectors, and factors of time. This process will ensure that more accurate trends are observed.

For instance, the CDC (2004) has stated that in a typical year, such as 2004, the incidence of botulism is less than 200. With incidence reporting covering the entire United States, increases or decreases in this crude number serve only to identify general changes in frequency; whereas, further identification of certain characteristics of the disease pattern will help to further isolate affected individuals and etiologies (Friis et al., 2009). Within the CDC’s (2004) data, infant occurrence of botulism is identified as the major contributor to incidence, thereby isolating the remaining occurrences to adults. The CDC has gone further to separate the incidences of botulism into three groups, infant occurrence, foodborne infection, and wound infection. A separate group is reserved for other occurrences relating to the use of pharmacological botulin.

Using descriptive factoring of the 2003 CDC data (2004), further geographic isolation of occurrences show that infant occurring botulism is fairly wide-spread with a small number of incidences in each of twenty-two States, though California and Pennsylvania account for about half of the reported infant occurrences. Foodborne and wound occurrences of botulism were isolated to Alaska, California, Colorado, Oregon, Utah, and Washington. Texas had the only two reportable cases classified as “Other”. Theoretical assumptions can now be used to show that the problem in Texas is resolved but should continue to be monitored, and food safety education projects should focus on home-canning in the western regions of the United States.

In conclusion, epidemiology is an important means of understanding and identifying causation and etiology, as well as preparing for mitigation and outbreak response. In this example of botulism, I have identified localization of the disease, common pathways of infection, or vectors, and means of helping to mitigate future occurrences of the disease. Botulism numbers are quite low, but dealing with other diseases of larger scale, grouping the data into useful subsets will assist in following the progression of the disease from outbreak to outbreak and in consideration of mitigation techniques employed.

References

Centers for Disease Control and Prevention, U. S. Department of Health and Human Services. (1996). Botulism (Clostridium botulinum): 1996 case definition [CSTE Position Statement No. 09-ID-29]. Retrieved from http://www.cdc.gov/ncphi/disss/nndss/casedef/botulism_current.htm

Centers for Disease Control and Prevention, U. S. Department of Health and Human Services. (2004). Surveillance for Outbreaks of Botulism [Summary of 2003 Data]. Retrieved from the Centers for Disease Control and Prevention website: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/files/Botulism_CSTE_2003.pdf

Centers for Disease Control and Prevention, U. S. Department of Health and Human Services. (2006). History of Bioterrorism: Botulism. CDC Emergency Preparedness and You [Podcast]. Washington, DC: CDC Bioterrorism Preparedness and Response Program.

Friis, R. H., & Sellers, T. A. (2009). Epidemiology for public health practice (4th ed.). Sudbury, MA: Jones & Bartlett.

Academia, Clinical, Emergency Medical Services, Health Care

Relationships Among Health Services Organizations

 As a critical care paramedic, I am fortunate enough to experience our health care system as an active participant, caring for the sick and injured, and as a passive observer, following the pathways of the patients whom I have treated. The health care system in the United States is, admittedly, fractured (Kovner & Knickman, 2008), but there are components that serve to create harmony and efficiency within this system, and I will describe just a few of them.

The primary care physician is meant to be the coordinator of all care for his or her patients. The importance of this role cannot be overstated, as it is the keystone to “health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses” (American Academy of Family Physicians, 2010, para. 7). When appropriately utilized, the primary care physician can coordinate a patient’s care to ensure efficiency and efficacy of treatment while ensuring safe and comprehensive care (Kovner et al., 2008).

There is a growing number of specialties and sub-specialties within the practice of medicine today (Bureau of Labor Statistics, 2010b). Specialists focus on their chosen area of practice and are an asset to the general practitioner, or primary care physician, who can concentrate on the coordination of the patient’s care. The inclusion of specialists in medicine is an efficient and effective means of offering the patient a level of expertise not otherwise available. One of these specialties is emergency medicine.

Emergency departments are necessary entry points into the health care system for victims of acute trauma and illness, but often times, the emergency department is used as the primary portal for those who lack insurance or other means of accessing health care appropriately (Committee on the Future of Emergency Care, 2006; Kovner et al., 2008). These patients tend to utilize the emergency room for even minor ailments, distressing this important component of the system, causing a “nationwide epidemic of [emergency department] overcrowding, boarding, and ambulance diversion” (Committee on the Future of Emergency Care, 2006, p. 19).

Laboratories and radiology departments are great assets to providers, allowing technicians to perform tests at the behest of the physicians and only requiring the physician to interpret the results of the tests. This seems to be a cost-effective and efficient component of the system, so long as the tests are performed timely and accurately.

Pharmacists have been regarded as patient-focused consultants who can provide both patient-specific and general information regarding over-the-counter medications as well as prescription medications. In our health care system, pharmacists have a valuable role of safeguarding patients from over-medication, as well as under-medication, medication compatibility, and also educating patients to the possible side-effects of their prescribed medicines (Bureau of Labor Statistics, 2010a).

In conclusion, the safest and most efficient use of our health care system begins at primary care. Though, in emergency situations, there is certainly a need to seek immediate care by other means, patients can suffer financial challenges as well as safety issues by trying to remove the primary care physician from the health care paradigm. Not only is this unsafe for the patient seeking primary care elsewhere, but misuse of emergency departments cause unnecessary delays for truly emergent patients. The health care system in the United States is vast and can be confusing. The primary care physician can provide a safe and efficient pathway of care that will save a patient time, money, and, possibly, his or her life.

References

American Academy of Family Physicians. (2010). AAFP policy on primary care. Retrieved May 1, 2010, from http://www.aafp.org/online/en/home/policy/policies/p/primarycare.html

Bureau of Labor Statistics, U. S. Department of Labor. (2010a). Pharmacists. Occupational outlook handbook (2010-11 ed.). Retrieved from http://www.bls.gov/oco/ocos079.htm

Bureau of Labor Statistics, U. S. Department of Labor. (2010b). Physicians and surgeons. Occupational outlook handbook (2010-11 ed.). Retrieved from http://www.bls.gov/oco/ ocos074.htm

Committee on the Future of Emergency Care in the United States Health System. (2006). Hospital-based emergency care : At the breaking point. Washington, DC: National Academies Press.

Kovner, A. R., & Knickman, J. R. (Eds.). (2008). Jonas & Kovner’s health care delivery in the United States (9th ed.). New York, NY: Springer.

Academia, Culture, Emergency Medical Services, Health Care, Politics, Public Health, Society

Health Care Costs, Quality, and Access

It is the general consensus that the structure and organization of the U.S. health care system is fractured and disorderly. For many health care consumers, especially those who rely on governmental health assistance, there is no motivation to seek appropriate care responsibly. Many of these consumers rely on the local hospital’s emergency department and municipal emergency services for their primary medical needs. The Committee on the Future of Emergency Care in the United States Health System (2006) states “[Emergency Departments] are an impressive public health success story in terms of access to care” (p. xiv), and continues to describe how the emergency departments have “become the ‘safety net of the safety net’, providing primary care services to millions of Americans who are uninsured or otherwise lack access to other community services” (p. xv). With health care comprising one sixth of the nation’s economy, doubling in the last 30 years, the focus should be to create a model of efficient and effective delivery of care so that we, as a nation, may be able to care for our sick and injured without becoming bankrupt (Kovner, Knickman, & Jonas, 2008; Mushkin et al., 1978).

As emergency medical services are considered as the health care gateway for many, allowing the emergency medical services to refer patients into appropriate pathways (e.g. primary care providers, urgent care clinics, psychiatric services) for their conditions would allow for more directed care for the patient with shorter wait times and shorter care times overall. Unfortunately, insurance providers, including Medicare and Medicaid, do not allow remuneration for such services, requiring the transportation component to trigger payment; therefore, the only option left is to transport these patients to the emergency departments. This promotes the inefficient use of such services and continues the current paradigm of inefficiency throughout the system. Though this change would increase insurance payments to emergency medical providers, increasing the initial cost of seeking health care, this would allow the provision of selecting more efficient pathways leading to more cost-effective care. Hopefully, this paradigm would result in an overall net savings.

This is only one example of modifying a current system to be more effective and help to promote efficiency throughout the health care experience. We need to consider where we can shift roles and responsibilities within the health care system in order to promote a more usable system, one that promotes integrity, efficiency, responsibility, and efficacy by both providers and consumers. Once we realize the opportunities that efficient use of current services will offer, we can realign the services to better fulfill the needs of the population where it comes to health and wellness.

References

Committee on the Future of Emergency Care in the United States Health System. (2006). Emergency medical services: At the crossroads. Washington, DC: National Academies Press. Retrieved from http://www.nationalacademies.org/nas/

Kovner, A. R., Knickman, J. R., & Jonas, S. (Eds.). (2008). Jonas & Kovner’s health care delivery in the United States (9th ed.). New York, NY: Springer.

Mushkin, S., Smelker, M., Wyss, D., Vehorn, C. L., Wagner, D. P., Berk, A., … Louria, M. (1978, October). Cost of disease and illness in the United States in the year 2000. Public Health Reports, 93(5), 493–588. Retrieved from http://www.ncbi.nlm.nih.gov/

Academia, Emergency Medical Services, Health Care, Politics, Public Health, Society

Reducing our Health Care Expenditures

With the recent signing into law of the Patient Protection and Affordable Care Act (2010), more affectionately known as ‘Obama Care’, much of the health care discussion has turned from deciding what we should do to how we should do it. Many us acknowledge that the current state of our health care needs reformation; the only problem seems to be choosing the best approach. As a licensed out-of-hospital provider, I am in a unique position to observe patients entering our health care system, being treated by our health care system, and exiting (for good or bad) our health care system. I can see that our health care needs are not being met, and I can see both how patients approach their care and how practitioners approach their patients — inefficiently and ineffectively. We need to resolve these issues.

Canada is a fairly close approximation to the United States in locale, geography, economy, and political ideology (Doran, ca. 2000; “GNI per capita”, 2010). It might make sense for us to look towards Canada to see if they have adopted a plan that we could either emulate, or, in the very least, research for a sense of best practices. Kovner, Knickman, and Jonas (2008) describe Canada as having a national health insurance (NHI) system of health care, in that the system is provisioned by a mix of both public and private contributions. Two benefits of Canada’s health care system include a high life expectancy (77.4 for males at birth) and a low cost ($3,165 per capita, or 9.9% of GDP; Kovner et al., 2008, Table 6.2, p. 165). In comparison, Kovner et al. shows that the life expectancy for males in the United States is 74.8 under a system that costs $6,102 per capita (or, 15.3% of GDP). These numbers are significant because we need to understand what we can expect from our investments, and I feel that the average life expectancy is a great benchmark of a health care system as a whole. One worry that I would have, though, is if we were to adopt the same pharmaceutical cost controls, research and development in the industry may suffer, as well as any other technology burdened by cost-cutting measures. I have to assume that the free market would effectively drive these areas, however.

In order to adopt such sweeping changes of our health care system, both liberals and conservatives would have to negotiate their ideals. I am a fairly conservative citizen who believes in smaller government and spending constraints. If reducing our health care expenditures by realigning the modes and methods of health care delivery was realistic, I could be in favor of such a reform. Political agendas aside, Canada’s health care system is certainly one that we should further consider.

References

Doran, H. (ca. 2000). Politics and political parties in Canada. Internet sources for journalists and broadcasters. Retrieved on April 22, 2010, from http://www.synapse.net/radio/can-pol.htm

“GNI per capita, Atlas method (current US$)”. (2010). Data catalog. The World Bank Group. Retrieved on April 22, 2010, from http://data.worldbank.org/indicator/NY.GNP.PCAP.CD

Kovner, A. R., Knickman, J. R., & Jonas, S. (Eds.). (2008). Jonas & Kovner’s health care delivery in the United States (9th ed.). New York, NY: Springer.

Patient Protection and Affordable Care Act of 2010, H.R. 3590, 111th Cong. (2010).