Tag Archives: critical care

Community Health Centers

Community health centers increase availability of (i.e. access to) health care and is shown by some to improve health outcomes (Taylor, 2009). Improving access to health care is achieved by placing these community health centers geographically proximate to underserved and at-risk populations. Taylor (2009) boasts improvements in health outcomes due to the number and placement of community health centers, but she provides no compelling evidence to say that any improved outcome is not directly caused by the improved access. Forrest and Whelan (2000) discuss a need to improve access to physician offices more than community health centers to improve follow-up care which continues to lack in the community health center model, though the point may be moot if the community health centers can improve the delivery of service to allow for proper follow-up. Forrest and Whelan do, however, acknowledge the value of community health centers in providing increased access to health care to underserved and vulnerable populations.

Dieleman et al. (2004) offers collaboration of health care providers in the primary care setting as a means of improving efficiency and thereby improving health outcomes. The testing instrument used during this study indicates an overall improvement of the attitudes towards role recognition, provider satisfaction, patient satisfaction, and patient health status, as well as the quality of patient care provided. In my experience with many community-based health clinics, they tend to be less than spectacular as far as quality of care, cleanliness, and patient-provider attitudes. By adding other providers into the patient-provider relationship, it would allow others to comment within the team where improvements can be made in relation to each patient-provider relationship and in a more general sense.

A collaborative holistic approach to patient care, whether in primary care, emergency care, or in critical care, will foster a sense of partnership within the team, including the patient and family, that will allow the team to truly care for the patient, will allow the patient to be invested in his or her care, and will promote a complete view of the whole patient both when sick and when well. Collaboration will, hopefully, allow improved efficiency in the provision of care while maintaining a trustworthy and committed relationship with the patient. Forging these relationships will, hopefully, help to overcome any challenges faced within our continually changing health care landscape.


Dieleman, S. L., Farris, K. B., Feeny, D., Johnson, J. A., Tsuyuki, R. T., & Brilliant, S. (2004). Primary health care teams: team members’
perceptions of the collaborative process. Journal of Interprofessional Care, 18(1), 75-78. doi:10.1080/13561820410001639370

Forrest, C. B. & Whelan, E. (2000). Primary care safety-net delivery sites in the United States: A comparison of community health centers, hospital outpatient departments, and physicians’ offices. Journal of the American Medical Association, 284(16), 2077-2083. doi:10.1001/jama.284.16.2077

Taylor, T. (2009, October). The role of community-based public health programs in ensuring access to care under universal coverage [Issue brief]. American Public Health Association. Retrieved from http://sylvan.live.ecollege.com/ec/courses/53027/CRS-WUPSYC6205-4570539/CommunityBasedReformupdtd.pdf

Quality in Interdisciplinary Critical Care Medicine

To improve the overall quality of care provided in critical care medicine, Curtis et al. (2006) promote a framework, as well as some key concepts, for measuring performance improvement outcomes within the critical care or intensive care setting. Curtis et al. introduce the reader to Donabedian’s (as cited in Curtis et al., 2006) model of improving the quality of healthcare, which focuses on “structure, process, and outcome” (p. 212). With quality improvement the focus of this article, Curtis et al. approaches the dynamics of interdisciplinary teams in the context of the multitudes of ICU variations available throughout the United States. Additionally, Curtis et al. recognize that high-quality care is dependant on both clinical and non-clinical processes, citing organizational management as a key requirement that has significant impact on overall patient care.

“Successful quality improvement programs require interdisciplinary teamwork that is incremental and continuous” (Curtis et al, 2006, p. 216).

In reading Curtis et al. (2006), I find that approaching patient care with a team approach addresses all of the available topics and more. Improving patient satisfaction requires improving performance which, in turn, creates efficiency and can improve reimbursement (especially under pay-for-performance models). On the other hand, addressing a requirement to increase reimbursement under a pay-for-performance model can ultimately lead to increases in patient satisfaction by improving inefficient processes. Overall, one of the largest benefits of operating within a team environment is the access to a larger knowledge-base, increasing the application of knowledge for all team members.


Curtis, J. R., Cook, D. J., Wall, R. J., Angus, D. C., Bion, J., Kacmarek, R., … & Puntillo, K.(2006). Intensive care unit quality improvement: A “how-to” guide for the interdisciplinary team. Critical Care Medicine, 34(1), 211-218. doi:10.1097/01.CCM.0000190617.76104.AC

A Personal Ethnographic Narrative

I have always viewed my being from philosophy. I do not believe that I have ever appreciated myself from an anthropological viewpoint. Though I have always been more interested in where did we come from, anthropology and ethnography certainly does help to answer how did we get here.

On December 7, 1975, at 4:48 a.m., I was born in Providence, Rhode Island. A healthy boy of healthy weight, I never suffered much in childhood. I do remember the chicken pox, however. My mother was sure to make me play with every child suffering from the chicken pox until it finally gripped me. This was my first experience in active inoculation. I was always well cared for, received all of my shots in timely fashion, and the doctor’s office remains a fond childhood memory. Medicine was just practiced differently in those days.

My early childhood was based primarily around my grandparents. My mother was a single parent, and though it irked her to do so, she relied heavily on State-sponsored welfare. My mother was a strong and determined woman, however. She continued her schooling, found a job with a sustainable wage, and made a great home for us. Until this time, though, I spent the majority of time with my grandfather. From a very young age, I was learning his trade as well as his life lessons. Today, I do not think many five-year-olds would be able to cut and wet sand glass in a licensed shop. Working with my grandfather, once a week when I attended school, framed my work ethic and provided an early education in engineering. This opportunity allowed me comfort in engineering at an early age. In fact, my interest in engineering was so pronounced that I was already considering California Institute of Technology at age ten. Massachusetts Institute of Technology was my second choice.

My family had it hard. My grandparents raised five children and helped to raise 13 grandchildren. We were not an affluent family by any means, but we lived comfortably if not rustic. Though my ancestry is primarily Italian, my mother’s parents are primarily Irish, English, and German, and this is how we ate. Meat and potatoes were the staples of dinner while fresh vegetables were cultivated in my grandfather’s garden. Simplicity did not end at the kitchen door. My grandfather’s first meaningful gift to me was a knife. Very simple with a fork and spoon on the sides, the knife was very utilitarian in nature. His belief was that you could not be a good steward of the environment without a knife: “How can you take a walk in the woods if you can’t even whittle a walking stick?” (personal communication with Malcolm Webb, n.d.). It was very important to him that I had honed my outdoor skills.

For leisure and sport, my grandfather would hunt rabbit with beagles. He belonged to a club in Rhode Island that held competition trials, and I was always made welcome. After a few years, I started to enter dogs that I helped to raise and train. Immediately, I began accumulating trophies that were taller than me. To be honest, the trophies might have had my name on them, but the dogs earned them more than I had. It was this foray into competition that introduced me to the team concept. Thinking back on this today, however, I find that this concept is alien to most people. Many people today, I find, want to do no work and take most of the credit. It is only when you stand up to these people that you hear comments about being a part of the team. It is a shame. It seems that yesterday’s definitions need to be defended today.

I have always been aloof and wondrous as a child. With translation assistance from the Native Languages of the Americas website (2009), my name might have been mautáubon tamóccon nemík kéesuck túppaco (morning fog sees the heavens by night or one with many questions) if I was Narragansett. Rhode Island has a rich Narragansett and Algonquin heritage and history, and this is transmitted to every inhabitant of Rhode Island. Many of our streets, villages, cities, and towns are named with Indian words and names, such as Apponaug, Chepatchet, Metacom, Misquamacut, Woonasquatucket, and Pawtucket. We are very proud of the relationship that Roger Williams, our State founder, had with the local tribes. This lasting relationship may be the reason why Rhode Islanders are typically naturalistic and prefer a rustic life proximate to water over city life.

During my formative years, my mother married and we moved to North Providence from Warwick. My step-father was Italian, and it was from his family that I learned of my Italian heritage and culture. Beyond the Mediterranean-style food, the most important lesson that I learned was loyalty. Many people have a misconception about Italian loyalty. Hollywood often depicts Italians as mafioso who shakedown store owners on a daily basis. In fact, we are very supportive of each other. So long as you are considered loyal, as an Italian, people will do you favors. It is expected that you return the favor. I have applied this lesson many times throughout my life. Again, this is a trait that many hold as one-sided, like teamwork.

After moving to North Providence, it seems that I did not much care for school. I always felt that I was being cheated out of an education. I am a reader, a learner, a student, and a teacher. I do not appreciate being taught incomplete and erroneous facts merely because it is written in the textbook. I began my own education from this point onward focusing on the arts and music, taking up drawing, poetry, and studying music theory and some of the classical languages. These, though, were hobbies and I made sure to keep them that way.

Aside from school, I remained focused on the outdoors. I would walk everywhere within the State. Distance was not a barrier. Rhode Islanders are known for staying local. If a Rhode Islander had to travel 10 miles or more, the joke was that they had to get a motel room for the night. As true as this held for most, it was not descriptive of me. I always took the road less traveled.

Throughout my high school years, I gave up on the engineering dream. I started to focus more on giving back to my community. A friend of mine introduced me to one of the local volunteer fire departments and I was hooked. After graduating from high school, I enlisted in the Marine Corps, but when I returned to civilian life, I focused on the fire service. This was the impetus for my attaining my emergency medical technician license and, ultimately, my paramedic and critical care credentials.

Though I have traveled extensively, I always seem to return to New England. I am currently living just beyond the Western border of Rhode Island in Connecticut (another Indian name).

Considering the anthropological roles outlined in Omohundro (2008), I would have to align myself with all five roles. The reformer looks to make the world a better place, regardless of his or her motivations. The critic is necessary to use introspection to identify personal weaknesses ingrained in cultural learning so that he or she may contemplate self-improvement. This, I feel, is the best role to take on first. Only after seeking to improve one’s intrinsic nature should someone seek to change the extrinsic. The scientist role is important to really think about the factors relating to certain problems. Without this role, one could have lofty goals only to find failure in execution for a lack of understanding. The role of the humanist should be used as an umbrella. When considering anthropology, we need to have a certain understanding and tolerance. This role allows us be compassionate when considering cultural issues. Finally, the means to the end is the cosmopolite role. This role gives us more tools to further our understanding. Hand-in-hand with the humanist role, the cosmopolite has a truer understanding of origination and context when dealing with the various cultures of the world.

Personally, I take on more aspects of the critic and the scientist. I am not an anthropologist, and I do not consider myself as having a platform to affect cultural change, but I do like to identify and understand problems so that I do not contribute to them negatively. More so, being mindful of the critical and scientific anthropology roles leads me to understand that there is still much to learn about my own culture and heritage and how this identity relates to the world around me. Foremost, I want to know the effect that my ancestors have had on world. I want to understand the problems they faced and the means employed to overcome them. I want to know decisions that have been made and the fallout associated with these decisions. I have always found it important to learn from the past, and though the sins of the father shall not encumber the son, we should still strive to avoid repeating historical mistakes. Second, I want to find a means to assess my own life and better understand how my existence impacts my community. I have always believed that I should make positive contributions to my community, but there is no benchmark. As a critical care paramedic, I assume that alleviating suffering and saving lives positively contributes to my community, but how can I know the harm that I might be causing in other aspects of my life? We cannot only understand the good we impart, but we must know the bad in order to prevent it.


Native languages of the Americas website. (2009). Retrieved from http://www.native-languages.org

Omohundro, J. T. (2008). Thinking like an anthropologist: A practical introduction to cultural anthropology. New York, NY: McGraw-Hill.

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)


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