A few years ago my wife suffered a few consecutive serious medical emergencies, which involved air ambulance and ground ambulance treatments and transports, ER treatments, emergency surgery, and hospitalizations. Had we been uninsured we would now be in-debt more than we could expect to recover from. She would not have been able to finish college. I would not be in college. We would not be able to own a home. We would simply work our asses off as we always have, in true fear of getting sick again. I am so incredibly thankful that we didn't have to go through that. Our lives would be so different. I know there are people in this country in that exact situation, and it breaks my heart. If my wife and I had lived in a third-world nation, with no access to advanced medical care, she would simply be dead. I am so incredibly thankful.
I work in healthcare, and in a nation with so much medical capability I feel responsible for meeting people's basic healthcare needs, and yes, I'm willing to pay a few extra pennies for it because the alternatives are the status quo, or turning people away from the hospital to go die in the parking lot. In the country where I live, healthcare workers have higher incomes than any other industrialized nation, while also paying almost the lowest personal tax rates (beat only by Mexico, Korea, and a couple others). And somehow, we manage this without everyone in the country able to pay their medical bills, regardless of whether they work or not. The current laws don't even require the ER to treat everyone; only to assess everyone and then treat them if they are having a true emergency (which is by far not every patient). They aren't required, and yet they don't turn anybody away in a non-emergency for inability to pay even though it would save any ER thousands and millions of dollars. And why not? Well, one reason is obviously liability, but just as much because it wouldn't pass the newspaper test. It would be found absolutely socially appalling not to provide healthcare to people who ask for it, and no amount of explanation would snuff the outrage. This is because at our most basic level we find it unacceptable not to take care of people. We just don't want to pay for it.
Americans are for some reason afraid of the world socialism. All it means is taking care of the basic wellness of your society. And we do it already.
Friday, November 9, 2012
Sunday, November 4, 2012
Disrespect for the deceased on the TV news
I just sent this email after watching the evening news:
Dear Fox 40 News, I just watched the story this evening of the quadruple-fatality accident on I-5 in Elk Grove, and was appalled to see multiple shots of the dead bodies on the live TV news. All the yellow paper blankets shown have dead bodies beneath them; the bodies of people's family members, shown on the live TV news. I'm sure the reporter and your organization know that this is what those yellow blankets are for. This is disgusting, appalling, disrespectful, and grossly irresponsible newscasting. I understand that pictures of the accident have an emotional effect that you use to better your ratings, as do all major newscasts, but you can have the same effect while not showing dead bodies. Please have some integrity and avoid showing people's dead family members on television. Please embrace the shame that is appropriate for such disregard for the dignity of the deceased, and use it to influence your policies and practices.
Sincerely,
Paramedic Jake Schulke
I am simply disgusted, appalled, and amazed that this is permitted. Frankly I think that the media have no right to be that close to a fatality accident still under investigation. Only minutes later the fire department had placed their ladder truck in the way so the Fox News crew could not so easily broadcast images of the newly deceased. Firefighters and CHP officers were seen in later shots staring at the cameras in disgust. Do these reporters not care? How can they be so cavalier in their reporting and behave so casually about traumatic death of members of the community - the family members and friends of people potentially watching the news? Mark my words, any newscast that subjects my family to such traumatic emotional experiences will explain it to a judge. The reporters have no idea what it is actually like. I would love to have that reporter participate hands-on in the cleanup - I'll spare the details of what this entails as all my colleagues understand and others can imagine. If they had to stare the deceased in their lifeless eyes and imagine their own family it would have an effect. Perhaps the experience would enhance their understanding and personal shame, and maybe change their practices. Perhaps other influences can change their practices. I hope so, because this is just disgusting. I am forced to see the truly gruesome version of this type of thing at work, and it's not pleasant by any means. I really wish I could escape it at home.
Dear Fox 40 News, I just watched the story this evening of the quadruple-fatality accident on I-5 in Elk Grove, and was appalled to see multiple shots of the dead bodies on the live TV news. All the yellow paper blankets shown have dead bodies beneath them; the bodies of people's family members, shown on the live TV news. I'm sure the reporter and your organization know that this is what those yellow blankets are for. This is disgusting, appalling, disrespectful, and grossly irresponsible newscasting. I understand that pictures of the accident have an emotional effect that you use to better your ratings, as do all major newscasts, but you can have the same effect while not showing dead bodies. Please have some integrity and avoid showing people's dead family members on television. Please embrace the shame that is appropriate for such disregard for the dignity of the deceased, and use it to influence your policies and practices.
Sincerely,
Paramedic Jake Schulke
I am simply disgusted, appalled, and amazed that this is permitted. Frankly I think that the media have no right to be that close to a fatality accident still under investigation. Only minutes later the fire department had placed their ladder truck in the way so the Fox News crew could not so easily broadcast images of the newly deceased. Firefighters and CHP officers were seen in later shots staring at the cameras in disgust. Do these reporters not care? How can they be so cavalier in their reporting and behave so casually about traumatic death of members of the community - the family members and friends of people potentially watching the news? Mark my words, any newscast that subjects my family to such traumatic emotional experiences will explain it to a judge. The reporters have no idea what it is actually like. I would love to have that reporter participate hands-on in the cleanup - I'll spare the details of what this entails as all my colleagues understand and others can imagine. If they had to stare the deceased in their lifeless eyes and imagine their own family it would have an effect. Perhaps the experience would enhance their understanding and personal shame, and maybe change their practices. Perhaps other influences can change their practices. I hope so, because this is just disgusting. I am forced to see the truly gruesome version of this type of thing at work, and it's not pleasant by any means. I really wish I could escape it at home.
Tuesday, February 28, 2012
Vacuum Spine Board Paper
The follower is a research paper/letter I recently wrote regarding the use of vacuum spine boards. We have been using them at my agency for a few years, and we occasionally get them back from the ED with apparent malicious damage to them. Many ED staffers have voiced a dislike for the devices, and I think there just needs to be a little more education as to why rigid spine boards are going the way of stacked shocks, leeches, and bloodletting. Some of the formatting was lost here from copying and pasting. Feel free to email me with any questions you may have; I'll also respond to any questions in the comments section.
Use of Vacuum Spine Boards for Prehospital Spinal Immobilization
Jake Schulke, MICP
Vacuum spine boards (VSBs) were invented in France in the 1960s, and have been utilized for prehospital spinal immobilization throughout Europe and elsewhere since at least the early 1990s. However, VSBs have only gained popularity in the US over the past ten years or so. At (agency) we have been using them since 2007, primarily because they are better for the patient. Extensive research has proven that rigid spine boards, though a useful tool for extrication, cause several complications when used for spinal immobilization and are greatly inferior in their quality of immobilization. The VSB is proven to decrease complications associated with rigid boards, greatly improve the quality of immobilization, and thusly increase the quality of care.
Common relevant complications associated with spinal immobilization are:
• skin breakdown
• inadequate spinal immobilization and support
• pain and discomfort
• ventilatory compromise
• quality of radiological imaging
(Kwan & Bunn, 2005)
Research has shown that due to such complications, rigid boards placed in the prehospital environment should be removed in the ED immediately after the primary assessment and resuscitation phases (Vickery, 2001). The VSB negates this need by alleviating the complications associated with rigid boards and so allows patients to be left on the VSB much longer than on a rigid surface.
Skin complications
The human spine has natural curvature, and placing a human being on a rigid surface creates three main pressure areas: the occiput of the head, the scapular region of the thorax, and the sacral region. These areas are all associated with pressure sores, and studies show that prolonged time spent immobile on a rigid surface exacerbates longer-term skin breakdown (Mawson, Biundo, Neville, Linares, & Lopez, 1988). This is because the interface pressures created by the rigid surface impede circulation to the tissue area, and result in local hypoxia and necrosis. Other factors related to illness, trauma, and hospitalization do further complicate skin breakdown, but it is clear that time spent on a rigid board plays an integral role in the development of pressure ulcers. The VSB however conforms to the patient’s entire posterior surface area, eliminating these extreme pressure areas and decreasing the interface pressures on the skin which cause pressure sores (Main & Lovell, 1996; Sheerin & Frein, 1997).
Quality of immobilization
An experimental study proved that VSBs provide better immobilization than a rigid board and straps universally in all planes of motion, and showed a reduction of motion by about 75% on average (Luscombe & Williams, 2003). The VSB conforms to a patient’s unique anatomy and spinal curvature, reducing motion and allowing effective immobilization of patients with kyphosis and other spinal irregularities which cannot be effectively immobilized on a rigid board.
Pain
Luscombe and Williams (2003) demonstrated a 64% average reduction in pain while immobilized with a VSB versus a rigid board using a standard 0-10 numerical rating scale. Kwan and Bunn (2005) also indicated that the increased pain associated with spinal immobilization results in “multiple radiographs and unnecessary radiation exposure, longer hospital stays, and increased costs.” Further studies have concurrently supported the increased comfort of the VSB over the rigid board and the subsequent improvement in overall care (Johnson, Hauswald, & Stockhoff, 1996).
Ventilatory restriction
The VSB conforms laterally to the individual shape of a patient’s body from head to toe and restricts lateral motion as a solid unit. Equal motion restriction cannot be achieved with a rigid board and straps, and attempting such restriction requires uncomfortable tension on the straps and is proven to cause ventilatory restriction (Bauer & Kowalski,1988 ). This restriction is associated with impaired ventilation, significantly reducing forced vital capacity (FVC) and forced expiratory volume (FEV). Loosening straps to facilitate improved ventilation renders the already inferior rigid board system even less effective in immobilizing the spine than the VSB.
Radiography
The VSB contains no metal, and according to Med Tech Sweden, the manufacturer of the VSB, it is “both MRI compatible and X-Ray translucent”. There should hence be no need to remove the patient from the device during the initial assessment and resuscitation. The patient can be left on the VSB for initial radiographs taken as part of a trauma assessment and resuscitation. As aforementioned, VSBs eliminate the complications that warrant early removal from a rigid board, thus the patient can be left on the VSB much longer than on a rigid board.
When using the VSB the patient can still be log rolled with manual spinal immobilization to assess the back when necessary, just as one would with a rigid board. The VSB can be inflated (loosened) and released for the log roll, and then can be replaced and deflated (made rigid) to reinstate immobilization using standard wall suction.
Though rigid boards are useful for certain circumstances and applications, the overall conclusion, supported by medical research and field use, is that the VSB is a far superior device. It decreases complications, improves immobilization, offers unique splinting and extrication opportunities in the field, and so overall is an excellent treatment tool. Promoting its use is a benefit to quality of patient care, and so it is our hope that it will be embraced by our local emergency medicine community.
It has come to our attention that many hospital personnel have an aversion to VSBs and are perhaps uncomfortable with use of the devices. We feel that this is a result of a deficit of education and training with the devices, and we are enthusiastic to do all we can to help facilitate an understanding and appreciation of the benefits and use of VSBs. Please feel free to contact us to arrange training for your staff.
(signed)
References:
Kwan, I., & Bunn, F. (2005). Effects of prehospital spinal immobilization: A systematic review of randomized trials on healthy subjects. Prehospital and Disaster Medicine, 20(1), 47-53.
Vickery, D. (2001). The use of the spinal board after the pre-hospital phase of trauma management. Emergency Medicine, 18(1), 51-54.
Mawson, A., Biundo, J., Neville, P., Linares, , Wichester, Y., & Lopez, A. (1988). Risk factors for early occurring pressure ulcers following spinal cord injury. American Journal of Physical Medicine and Rehabilitation, 67(3), 123-127.
Main, P., & Lovell, M. (1996). A review of seven support surfaces with emphasis on their protection of the spinally injured. Journey of Accident and Emergency Medicine, 13(1), 34-37.
Sheerin, F., & Frein, R. (2007). The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: A trial of three surfaces. Journal of Emergency Nursing, 33(5), 447-450.
Luscombe, M., & Williams, J. (2003). Comparison of a long spinal board and vacuum mattress for spinal immobilization. Emergency Medicine, 20(1), 476-478.
Johnson, D., Hauswald, M., & Stockhoff, C. (1996). Comparison of a vacuum splint device to a rigid backboard for spinal immobilization. American Journal of Emergency Medicine, 14(4), 369-372.
Bauer, D., & Kowalski, R. (1988). Effects of spinal immobilization devices on pulmonary function in the healthy, non-smoking man. Annals of Emergency Medicine, 17(9), 915-918.
Use of Vacuum Spine Boards for Prehospital Spinal Immobilization
Jake Schulke, MICP
Vacuum spine boards (VSBs) were invented in France in the 1960s, and have been utilized for prehospital spinal immobilization throughout Europe and elsewhere since at least the early 1990s. However, VSBs have only gained popularity in the US over the past ten years or so. At (agency) we have been using them since 2007, primarily because they are better for the patient. Extensive research has proven that rigid spine boards, though a useful tool for extrication, cause several complications when used for spinal immobilization and are greatly inferior in their quality of immobilization. The VSB is proven to decrease complications associated with rigid boards, greatly improve the quality of immobilization, and thusly increase the quality of care.
Common relevant complications associated with spinal immobilization are:
• skin breakdown
• inadequate spinal immobilization and support
• pain and discomfort
• ventilatory compromise
• quality of radiological imaging
(Kwan & Bunn, 2005)
Research has shown that due to such complications, rigid boards placed in the prehospital environment should be removed in the ED immediately after the primary assessment and resuscitation phases (Vickery, 2001). The VSB negates this need by alleviating the complications associated with rigid boards and so allows patients to be left on the VSB much longer than on a rigid surface.
Skin complications
The human spine has natural curvature, and placing a human being on a rigid surface creates three main pressure areas: the occiput of the head, the scapular region of the thorax, and the sacral region. These areas are all associated with pressure sores, and studies show that prolonged time spent immobile on a rigid surface exacerbates longer-term skin breakdown (Mawson, Biundo, Neville, Linares, & Lopez, 1988). This is because the interface pressures created by the rigid surface impede circulation to the tissue area, and result in local hypoxia and necrosis. Other factors related to illness, trauma, and hospitalization do further complicate skin breakdown, but it is clear that time spent on a rigid board plays an integral role in the development of pressure ulcers. The VSB however conforms to the patient’s entire posterior surface area, eliminating these extreme pressure areas and decreasing the interface pressures on the skin which cause pressure sores (Main & Lovell, 1996; Sheerin & Frein, 1997).
Quality of immobilization
An experimental study proved that VSBs provide better immobilization than a rigid board and straps universally in all planes of motion, and showed a reduction of motion by about 75% on average (Luscombe & Williams, 2003). The VSB conforms to a patient’s unique anatomy and spinal curvature, reducing motion and allowing effective immobilization of patients with kyphosis and other spinal irregularities which cannot be effectively immobilized on a rigid board.
Pain
Luscombe and Williams (2003) demonstrated a 64% average reduction in pain while immobilized with a VSB versus a rigid board using a standard 0-10 numerical rating scale. Kwan and Bunn (2005) also indicated that the increased pain associated with spinal immobilization results in “multiple radiographs and unnecessary radiation exposure, longer hospital stays, and increased costs.” Further studies have concurrently supported the increased comfort of the VSB over the rigid board and the subsequent improvement in overall care (Johnson, Hauswald, & Stockhoff, 1996).
Ventilatory restriction
The VSB conforms laterally to the individual shape of a patient’s body from head to toe and restricts lateral motion as a solid unit. Equal motion restriction cannot be achieved with a rigid board and straps, and attempting such restriction requires uncomfortable tension on the straps and is proven to cause ventilatory restriction (Bauer & Kowalski,1988 ). This restriction is associated with impaired ventilation, significantly reducing forced vital capacity (FVC) and forced expiratory volume (FEV). Loosening straps to facilitate improved ventilation renders the already inferior rigid board system even less effective in immobilizing the spine than the VSB.
Radiography
The VSB contains no metal, and according to Med Tech Sweden, the manufacturer of the VSB, it is “both MRI compatible and X-Ray translucent”. There should hence be no need to remove the patient from the device during the initial assessment and resuscitation. The patient can be left on the VSB for initial radiographs taken as part of a trauma assessment and resuscitation. As aforementioned, VSBs eliminate the complications that warrant early removal from a rigid board, thus the patient can be left on the VSB much longer than on a rigid board.
When using the VSB the patient can still be log rolled with manual spinal immobilization to assess the back when necessary, just as one would with a rigid board. The VSB can be inflated (loosened) and released for the log roll, and then can be replaced and deflated (made rigid) to reinstate immobilization using standard wall suction.
Though rigid boards are useful for certain circumstances and applications, the overall conclusion, supported by medical research and field use, is that the VSB is a far superior device. It decreases complications, improves immobilization, offers unique splinting and extrication opportunities in the field, and so overall is an excellent treatment tool. Promoting its use is a benefit to quality of patient care, and so it is our hope that it will be embraced by our local emergency medicine community.
It has come to our attention that many hospital personnel have an aversion to VSBs and are perhaps uncomfortable with use of the devices. We feel that this is a result of a deficit of education and training with the devices, and we are enthusiastic to do all we can to help facilitate an understanding and appreciation of the benefits and use of VSBs. Please feel free to contact us to arrange training for your staff.
(signed)
References:
Kwan, I., & Bunn, F. (2005). Effects of prehospital spinal immobilization: A systematic review of randomized trials on healthy subjects. Prehospital and Disaster Medicine, 20(1), 47-53.
Vickery, D. (2001). The use of the spinal board after the pre-hospital phase of trauma management. Emergency Medicine, 18(1), 51-54.
Mawson, A., Biundo, J., Neville, P., Linares, , Wichester, Y., & Lopez, A. (1988). Risk factors for early occurring pressure ulcers following spinal cord injury. American Journal of Physical Medicine and Rehabilitation, 67(3), 123-127.
Main, P., & Lovell, M. (1996). A review of seven support surfaces with emphasis on their protection of the spinally injured. Journey of Accident and Emergency Medicine, 13(1), 34-37.
Sheerin, F., & Frein, R. (2007). The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: A trial of three surfaces. Journal of Emergency Nursing, 33(5), 447-450.
Luscombe, M., & Williams, J. (2003). Comparison of a long spinal board and vacuum mattress for spinal immobilization. Emergency Medicine, 20(1), 476-478.
Johnson, D., Hauswald, M., & Stockhoff, C. (1996). Comparison of a vacuum splint device to a rigid backboard for spinal immobilization. American Journal of Emergency Medicine, 14(4), 369-372.
Bauer, D., & Kowalski, R. (1988). Effects of spinal immobilization devices on pulmonary function in the healthy, non-smoking man. Annals of Emergency Medicine, 17(9), 915-918.
Friday, January 6, 2012
Wilderness Medicine Course
Wilderness Medicine Institute, a division of the National Outdoor Leadership School, offers a Wilderness Medicine for the Professional Practitioner course. It is not often offered, but there is one coming up in February in Sausalito, about 100 miles from where I live. I have been wanting to take this course for a long time. In 2008 I attended a wilderness medicine conference put on by UCSF. I learned a lot and enjoyed it very much, but I know I have a lot more of the basics to learn. The conference was mostly lectures by physicians on advanced topics, though there were workshops on practical skills. The WMI course is 16 hours including a lot of hands-on practical skills.
I am in the process of attaining a position as a volunteer paramedic in an area which will utilize wilderness medicine skills very much. I would almost never use the general skills at my paid job. Additionally I am a recreational backpacker, and enjoy taking others on hikes into the bush. I am always leery of emergencies happening in the backcountry, and I have read several books on the subject but there is no substitute for hands-on instruction.
I am a full-time college student, and receive no financial aid to assist with living expenses. I work a part-time ambulance job on the weekends. It is at a rural provider and the pay is not competitive, but it definitely helps pay the "big kid bills" that my wife and I share. I normally live about check-to-check, sometimes able to save very small amounts here and there for a cushion in case something expensive happens.
I recently took time off work to care for my mother and stepfather after they had surgery. My stepfather is in renal failure secondary to Polycystic Kidney Disease, and was on dialysis. My mother wanted to donate one of her kidneys to him but was not a match, however the transplant program at California Pacific Medical Center was able to arrange a 3-way closed loop trade which involved two other couples. The operation was in the San Francisco Examiner. Here's the article: http://www.sfexaminer.com/local/2011/11/triple-kidney-swap-san-franciscos-cpmc-has-unique-twist. They both needed care at home afterward, so I took time off to help them. Immediately following I also took time off to study for finals.
Money got even tighter through the holidays, and now I don't have any savings to pay for this class that I just recently learned about. I am trying to think of a way to pay for it, and though about asking for donations. It is really an educational expense, and will help me with volunteer opportunities. Not to say that it won't be fun, because I really love learning about what I do. I constructed a fundraising webpage, but haven't decided whether or not to publicize it and actually ask for donations. I really have no shame in being a "starving student" (I am definitely not starving), but I just don't know if this is an appropriate cause to ask for donations because it is personal and not specifically for an organization. Looking for suggestions.
Update: I decided to raise funds.
I am in the process of attaining a position as a volunteer paramedic in an area which will utilize wilderness medicine skills very much. I would almost never use the general skills at my paid job. Additionally I am a recreational backpacker, and enjoy taking others on hikes into the bush. I am always leery of emergencies happening in the backcountry, and I have read several books on the subject but there is no substitute for hands-on instruction.
I am a full-time college student, and receive no financial aid to assist with living expenses. I work a part-time ambulance job on the weekends. It is at a rural provider and the pay is not competitive, but it definitely helps pay the "big kid bills" that my wife and I share. I normally live about check-to-check, sometimes able to save very small amounts here and there for a cushion in case something expensive happens.
I recently took time off work to care for my mother and stepfather after they had surgery. My stepfather is in renal failure secondary to Polycystic Kidney Disease, and was on dialysis. My mother wanted to donate one of her kidneys to him but was not a match, however the transplant program at California Pacific Medical Center was able to arrange a 3-way closed loop trade which involved two other couples. The operation was in the San Francisco Examiner. Here's the article: http://www.sfexaminer.com/local/2011/11/triple-kidney-swap-san-franciscos-cpmc-has-unique-twist. They both needed care at home afterward, so I took time off to help them. Immediately following I also took time off to study for finals.
Money got even tighter through the holidays, and now I don't have any savings to pay for this class that I just recently learned about. I am trying to think of a way to pay for it, and though about asking for donations. It is really an educational expense, and will help me with volunteer opportunities. Not to say that it won't be fun, because I really love learning about what I do. I constructed a fundraising webpage, but haven't decided whether or not to publicize it and actually ask for donations. I really have no shame in being a "starving student" (I am definitely not starving), but I just don't know if this is an appropriate cause to ask for donations because it is personal and not specifically for an organization. Looking for suggestions.
Update: I decided to raise funds.
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