The ethics of small-town medicine

Jim, a farmer in rural Wyoming, is having trouble with a stiff, swollen elbow that feels hot to the touch. The physician, Dr. Burke, thinks it might be the patient’s arthritis flaring up but can’t rule out the possibility of an infection.

She’s had minimal experience with aspirating fluid from a joint. Although she has done the procedure a couple of times during her family practice residency, it’s more typical to refer the patient to a rheumatologist. Dr. Burke isn’t sure she has the expertise to handle Jim’s situation – and besides, what if there are complications?

But when she suggests sending Jim to a specialist, the patient balks. He doesn’t know if he can get away from the farm. His wife would have to drive him, and miss a day of work. Can’t Dr. Burke handle the procedure herself?

This fictional scenario, and the ethical quandaries it raises, appears in the May edition of Virtual Mentor, an online ethics journal by the American Medical Association. Nearly a dozen essays explore the ethical and professional challenges that surround rural medicine, from patient privacy to physician workforce.

Is rural health care really that different from everywhere else? On the surface, perhaps not. But the underlying differences, although subtle, are quite clear, Kathleen Miller writes in an introduction:

In a small town, one’s physician is often a friend, coworker, or even family member; in such an environment, the range of privacy concerns spans reproductive rights, the stigma still associated with psychiatric care, and the medical treatment of friends and family. When specialists are geographically distant, physicians are often placed in the difficult position of performing procedures that may be outside of their comfort zone in order to provide optimal patient care. Frequently, rural physicians must cope with being the sole medical resource for a community, creating the potential for isolation and burnout.

Most people who live and work in rural communities probably recognize many of these issues, and maybe even have firsthand experience with some of them. Although we may not think of them as ethical issues, they do sometimes create moral dilemmas at least partially defined by their rural context.

There can be comfort in knowing everyone at the doctor’s office but at times it’s socially and emotionally awkward, both in the clinic and outside of it. In smaller towns where everyone knows everyone else, the doctor might have a better understanding of what the patient’s life is really like, but at the cost of a loss of privacy for the patient – and possibly for the doctor as well.

Some of the issues surrounding rural medicine pose larger societal questions. Does it create inequalities when those living in rural areas have access to fewer health care services? Is it acceptable public policy to rely on mid-level clinicians as the solution to rural doctor shortages? What is the burden of forcing rural residents to travel for specialty care? Is it financially feasible or even realistic for rural communities to have a wider range of health care services locally available?

Statistically, rural populations tend to have some important health factors in common with inner-city residents: Both are more likely to be poor; both are more likely to live with chronic conditions; both face more obstacles in gaining access to health care. Does the medical community have a social responsibility to do more for the underserved? Should medical schools be required to invest more diligently in preparing students for careers in rural practice?

It’s not clear what the answers should be. Heightened awareness of the moral aspects of rural health care would be a good start, however, argues Virtual Mentor.

“Rural” and “quality” are not mutually exclusive. Many rural providers and facilities are very good at what they do and have a deep understanding of the communities they serve. But the dynamics of rural health care can be very different from their suburban and city counterparts, and it’s a mistake to think otherwise. Solutions that work well in larger settings can’t necessarily be successfully or effectively applied in a rural setting. Do those who set policies and make decisions at the state and national level truly understand this? I’m not convinced they always do.

West Central Tribune file photo

Zombie apocalypse? Get your preparedness on!

 I did a double-take when I came across the CDC’s Public Health Matters blog a couple of days ago and saw one of the latest entries: “Social Media: Preparedness 101: Zombie Apocalypse.”

Zombie apocalypse? Seriously? What have those straitlaced public health folks been drinking?

In just two or three days, the blog post has gone viral. Web traffic was so heavy that the CDC’s server crashed. Everyone, it seems, wants to know how to prepare themselves for a zombie invasion.

As it turns out, the CDC isn’t entirely off its rocker. The message may be tongue in cheek but it has a purpose. Ali S. Khan, assistant surgeon general, writes, “You may laugh now, but when it happens you’ll be happy you read this, and hey, maybe you’ll even learn a thing or two about how to prepare for a real emergency.”

Preparations such as: maintaining a home emergency kit stocked with food, water, soap, towels, first-aid supplies, prescription and non-prescription medication, clothing and blankets. You should have a tool kit containing a utility knife, duct tape and a battery-powered radio. And don’t forget important documents such as your driver’s license, passport and/or birth certificate.

OK, your emergency kit is ready. Now what you need is a plan. If zombies invade, which evacuation route will you take to escape the city? Do you have a couple of alternate routes? Have you identified a meeting place where your family can be reunited if you somehow get separated? Do you have a list of emergency contacts?

The CDC even outlines its role in the event of a zombie apoc…  uh, disease outbreak or other public health emergency:

CDC would provide technical assistance to cities, states or international partners dealing with a zombie infestation. This assistance might include consultation, lab testing and analysis, patient management and care, tracking of contacts, and infection control (including isolation and quarantine). It’s likely that an investigation of this scenario would seek to accomplish several goals: determine the cause of the illness, the source of the infection/virus/toxin, learn how it is transmitted and how readily it is spread, how to break the cycle of transmission and thus prevent further cases, and how patients can best be treated. Not only would scientists be working to identify the cause and cure of the zombie outbreak, but CDC and other federal agencies would send medical teams and first responders to help those in affected areas (I will be volunteering the young nameless disease detectives for the field work.)

Here in Minnesota, the most likely emergency scenarios are weather-related – a tornado, flood or blizzard. I’d also add fire and family medical emergency to the list. And as we’ve seen in recent years, pandemic influenza is a potential public health emergency too.

Local agencies put a lot of work into being prepared, but when it comes right down to it, most individuals will be forced to cope on their own during at least part of an emergency. It’s better to be prepared than to sit waiting for a rescue that might not come, or to place an added strain on resources that should be directed toward those who need them the most.

Zombie apocalypse? I don’t think I’m going to worry about it happening anytime soon but hey – the message got my attention.

Images: Top – West Central Tribune; bottom, U.S. Centers for Disease Control and Prevention

When the dog bites

Back when I was in seventh grade or thereabouts, I was riding my bike one summer day when a large black dog came running after me. His owner was nowhere in sight. He growled and snapped at my heels as I pedaled like crazy, terrified I would be knocked off my bike and mauled.

Fortunately I managed to outdistance him (or else he lost interest in the chase, I’m not sure which). But the story doesn’t end as well for the thousands of Americans each year who sustain serious dog bite injuries.

Every year during the third week in May, the American Veterinary Medical Association and the U.S. Centers for Disease Control and Prevention co-sponsor National Dog Bite Prevention Week to call attention to this public health problem.

The numbers are a little frightening: An estimated four million to five million Americans were bitten by a dog last year. Nearly one million of these bite injuries were severe enough to require some form of medical attention. Every so often, news reports surface of horrific injuries – some of them fatal – involving a victim attacked by one or more dogs. What’s especially concerning is that more than half of dog bite injuries involve children, although recently this has been decreasing.

There seems to be a profile for households where dog bite injuries are more likely: namely, the presence of a dog in the household. The risk apparently goes up with the number of dogs; adults with two or more dogs in the home are up to five times more likely to be bitten than individuals who don’t have a dog.

Among occupations, letter carriers face some of the highest risk. The U.S. Postal Service reported last week that there were dog attacks on 5,669 postal employees in 2010. The worst city in the U.S.: Houston, where 62 incidents took place last year. Minneapolis was seventh on the list, tied with Portland, Ore., at 35 dog attacks on letter carriers in each city.

An analysis by the U.S. Agency for Healthcare Research and Quality contains some more details: Rural areas have higher rates of dog bite injuries requiring emergency-room treatment or a hospital stay. Elderly people make up a small proportion of those bitten by a dog each year but are among the most likely to be hospitalized. The average cost associated with inpatient hospital treatment for a dog bite is $18,200.

Does this mean all dogs are dangerous and we shouldn’t share our lives and homes with them? Any dog, given the right circumstances, will bite, notes Dr. Janet Tobiassen Crosby, a veterinarian. But the dog isn’t invariably to blame; aggressive canine behavior sometimes can escalate when humans fail to correctly interpret the clues. She writes:

Proper training and socialization of puppies and dogs is crucial to avoid dog bites, as is training the humans how to recognize dog body language and approach dogs in a non-threatening manner.

In other words, dog bite injuries don’t have to be inevitable. Here’s some basic advice to lower your risk:

– Before bringing a dog into your home, do your research to choose a breed that’s best suited to your lifestyle. Spend time getting to know the dog before adopting or buying. Reputable shelters and breeders should disclose whether the animal has any known history of aggression.

– Spaying and neutering can greatly reduce the tendency toward aggression, as can appropriate socialization and training.

– Never leave infants or young children alone with a dog.

– Don’t approach an unfamiliar dog. Don’t pet a dog without first allowing it to see and sniff you.

Although rabies is often the first concern that springs to mind when someone is bitten by a dog, the bigger issue is the skin and deep-tissue damage that serious bite injuries often entail. In serious cases, reconstructive surgery might be necessary. Infection is another significant risk.

Dogs do many wonderful things for the human species but they’re still dogs and they think, behave and react like dogs. It’s up to the people in their lives to understand this and to handle the relationship accordingly.

I can’t end this blog without adding a few words about cats. We don’t hear very much about cat bites, probably because they’re much less common than dog bites. A Medscape article puts cat bites at 5 to 15 percent of the yearly total of animal bite wounds seen at emergency rooms in the U.S. Dog bites, on the other hand, make up 80-90 percent of the annual total.

Cats don’t possess the size or strength to inflict the crushing-type injuries typical of dog attacks. Their sharp pointed teeth are capable of serious puncture wounds, however, that drive bacteria deep into the tissue. These wounds might look small on the surface but can lead to serious infection without appropriate evaluation and treatment. Overall, cat bites are more likely than dog bites to become infected, and infection also tends to develop more rapidly than with dog bites – good reasons for why cat bites ought to be taken seriously.

Photo: Wikimedia Commons

An invitation to Grand Rounds

Grand Rounds, n. A formal conference in which an expert presents a lecture concerning a clinical issue intended to be educational for the listeners. In some settings, grand rounds may be formal teaching rounds conducted by an expert at the bedside of selected patients. – Mosby’s Medical Dictionary

Each Tuesday the health care blogging community holds Grand Rounds, a weekly collection of the best of the blogosphere. This week’s edition is hosted by the Center for Advancing Health of Washington, D.C., and includes a post that recently appeared in this blog.

Grab yourself a cup of coffee and head over there for a few hours of excellent reading from a diversity of writers/bloggers. And be sure to browse through the CFAH site itself to learn more about the Prepared Patient Forum, the Good Behavior! series, the Health Behavior News Service and other tools and information found on the site.

Photo: Wikimedia Commons

Everyday heroes

When you’re a member of an ambulance crew, you never quite know what your day will bring. These are medicine’s everyday heroes – the emergency medical technicians and paramedics whose work is stressful, demanding, exacting, skilled, professional and rewarding.

What is it like to spend a day in their shoes? To mark National Emergency Medical Services Week, we’re taking readers behind the scenes today with live guest-blogging by the Willmar Ambulance Service at Rice Memorial Hospital. Follow us from 7 a.m. to 7 p.m. and see how the day unfolds as entries are live-blogged continuously throughout the day. Readers are invited to ask questions or provide feedback via the comment section below; the paramedics will try to answer as many of your questions as possible. Be sure to check out the links posted above to learn more – and visit us often during the day for live updates.

7:03 a.m.: Good morning, everyone, this is Brad Hanson, the operations manager for the Willmar Ambulance Service. I will be blogging with you today as we respond to calls and bring you up to speed on a day in the life of a Willmar paramedic.

I am just heading into the office after helping my wife get the kids up for the day and off to school and day care. As the manager, I have a take-home paramedic vehicle so I can always be available if there is a major incident or have to cover call in town due to our crews being busy on other calls.

Our service responded to over 2,600 calls last year, so we have some very busy days where all five of our ambulances are being utilized. You may have seen one of our big blue ambulances in the community!

I am looking forward to giving you an inside look today, so let me know if you have any questions!

7:34 a.m.: Well, looking back over the night shift we have already been a bit busy. As I was saying earlier, I am on call pretty much 24/7. As I was making breakfast for my wife with my 8-year-old daughter this morning (we decided we were going to serve breakfast to her in bed since today is our 14th wedding anniversary), my wife Michelle was awakened by my cell phone ringing. One of the crews called regarding a transfer to St. Cloud, as they were just finishing up an intercept call to Atwater. I will explain intercepts more later. S0 much for the perfect surprise breakfast in bed…

Oh well, we had a good breakfast, and in reviewing the night I remember hearing several pages for the crews since 11 p.m. I counted five with the transfer. It makes for a long night and morning for the crew that started last evening at 7 p.m. Looks like it’s going to be a 16-hour shift for Jim and Keith. This also leaves us a bit short in town so only one crew now until 9 a.m., then back to two. Let’s see how the rest of this day goes.

7:59 a.m.: Checked in with the new 0700 crew, Lonnie and Jim B., today, having a bite of breakfast, then on to rig checks.

Our mornings start out fairly typical with equipment checks to make sure everything is on board and ready and the narcotics are counted and signed off. We are also going to be getting ready for our open house tomorrow as it is National Emergency Medical Services Week, so if you get a chance, say thanks to anyone in public safety that does medical work, from 911 dispatchers, First Responders, EMTs, paramedics, emergency room physicians and nurses.

8:36 a.m.: Sure is nice to see the sun, it can get to be a HUGE downer to do ambulance calls when the weather is nasty. I can remember many calls over the years where I was sure glad I had extra winter gloves and hats in my vehicle to hand out to crews on accident calls when it was below zero. Brrrr!

Having nice days just makes you even more excited about how you can help. It’s kind of like an unknown adventure, waiting for the pager to start blaring about an emergency. Are we going to be going to a major accident, transporting a pleasant elderly lady from a nursing home to the hospital, or something else?…  It seems some days you can just sense that it’s going to be busy and some days you wonder if you’re ever going to get a call.

I mentioned intercepts in a previous blog. Since Willmar Ambulance is an Advanced Life Support Ambulance Service, or ALS, we provide advanced care services to all the Basic Life Support Services around Willmar. In Kandiyohi County there are a total of five ambulance services: New London, Atwater, Raymond, Lake Lillian and Willmar. We also work with services outside of our county like Kerkhoven, Clara City, Brooten, Cosmos and others.

We are automatically sent out on calls anywhere in our county if the 911 call is for things like chest pain, major trauma or someone that is considered unconscious or unresponsive. We have a great working relationship with all our surrounding services and always look forward to working with them to help take care of their patients.

9:30 a.m.: We are back to full crews in town. We have two crews on street duty during the day Monday through Friday, with another crew on call either from home if they live in Willmar or at our ambulance quarters located within the Kandiyohi County Rescue Squad building just north of the E. Highway 12 Burger King on Lakeland Drive (very nice facility).

Our two duty crews have assigned tasks to keep them busy during their shifts, like getting the garage ready today for our open house, or working on any number of assigned tasks like data reports, CPR training or just making sure the trucks are looking good. I always remind our staff that we live in a fishbowl and we are driving large blue billboards, so we always need to look and be professional as we are serving the public 24/7!

10:22 a.m.: With our crews today is Jesse. He is a new casual paramedic hired recently by Willmar Ambulance and is doing his field training today. When we hire new staff, we look for candidates that will fit well within our organization and that are already trained to the National Registry EMT standards.

The Willmar Ambulance field training program trains new members how to be an EMT or paramedic on our service. Field training is done by our seasoned Field Training Officers, or FTO staff. Depending on any previous experience in EMS, this training can last up to 30 days. In this time, we schedule the new hire with FTOs for a number of shifts. They spend the day working with the duty crews going through the equipment on the trucks, checking off on a number of different competency tasks during their FTO time.

As they go on calls with us, they initially start by just watching and getting used to our process, paperwork and how we handle calls, as well as learning our medical protocols and working on mapping of the city. As time goes on and runs are accomplished, they move to being the care provider while the FTO watches their care. After each event and the end of every shift, they are evaluated on the day to see where they are at and asked how they are feeling about the position.

Quality assurance is a large part of our work and we always evaluate and make sure our protocols are being followed and reviewing our runs to maintain the best care possible!

12:09 p.m.: Hello, my name is Shar. I have been an EMT with Willmar Ambulance Service for just over eight years. Also a member of Kandiyohi County Rescue for the past 10 years. I got into this profession a little later than most of my co-workers.

At the time I decided to become an EMT I was looking at doing something different with my life, needed a career change and this was something I had wanted to do but didn’t have the opportunity, due to having small children at home.

Yes, we all start out as adrenaline junkies and get a little excited when the pagers start to go off and we hear the sirens, see flashing lights, just like little kids do whenever they see us.

A typical day for myself and my medic partner Carrie is Mon.-Fri. 9-5. We start our day with rig checks, making sure all equipment is stocked and everything is in full working condition.

After that we head into the EMS office which is located in the emergency room where we have a lot of other assigned duties to do each day. My typical duties other than 911 and back-up calls consist of entering all ambulance billings into the computer for the business office, entering our statistics into the computer, maintaining the casual and full-time schedules for all of our staff, ordering equipment and uniforms for all of our staff, making sure we have staff to cover open shifts, fill liquid O2 tank on our truck, assist ER when needed, of course cleaning of trucks, lots of paperwork and all other duties as assigned.

The 9-5 shift is also called the power shift because we cover the hours of the day when we are usually the busiest and we handle most of the daytime transfers that are sent out to other hospitals. We also do some casual calls where you don’t have to be in the office but respond if a call comes in for a third rig.

As EMTs we do a lot of patient care with our medic partners but we also do most of the driving. We have to go through a driving program and must maintain current certification and also clean driving records. We have continued education to keep our skills and certification.

Like all jobs, we have some bad days. Sometimes you have a call that just hits home, but I wouldn’t trade this job for any other out there.

12:57 p.m.: Hi, my name is Carrie Yungerberg. I am a critical care paramedic with Willmar Ambulance.

Every day I come to work, I don’t know what to expect. I may be sitting in the office working on projects, I could be transferring a patient to another facility or responding to ambulance calls in the community. The best part of the job is that each day is different, but the same. I can respond to two chest pain calls and the symptoms for each person, the heart rhythm, and history for each are different.

I initially started college to be an ER nurse, but met a paramedic who told me to become an EMT to see if I liked that type of work. After less than a year of being a paramedic I knew that I loved EMS and would be in it for a long time. After being an EMT for nine years I went to paramedic school at South Central College in Mankato. I was fortunate to be able to continue to work with Willmar Ambulance after graduation. I have been with Willmar Ambulance now for 14 years.

Being a paramedic requires you to think on your feet. For example, when you are treating a patient and the heart rhythm changes, you need to be able to change your thinking and “go down another path” to treat the patient appropriately. Another way you have to think on your feet is to change what you think might be wrong with the patient. For example, if we respond to a car accident we need to determine if the patient had an underlying condition that might have caused the accident – for example, a heart attack or chest pain, or did the car accident cause the heart attack/chest pain.

There are days that we don’t have calls during our shift. On those days we have projects that we do in the office. Some of the projects that I work on are bike helmet safety, CPR classes, Sonshine First Aid tent volunteers, maintenance/coordination of patient care reports for the ambulance and maintaining supplies, handouts for community events as well as setting up staff to attend community events and community education such as taping a segment for the WRAC-8 show, “Willmar 911.”

The hospital has CPR classes once a month for their employees. I coordinate the instructors for teaching. Also if a business, church or community organization needs a CPR class, we work with them to set up a class. Along with CPR, I am part of the AED coalition of Kandiyohi County which helps place AEDs in the community at businesses and churches.

Sonshine Music Festival arrives in Willmar every July. Willmar Ambulance maintains the tent with volunteers from Kandiyohi County and throughout the state of Minnesota. We have over 150 volunteers who take time to help in the first aid tent. We use all types of medically trained staff, from paramedics, EMTs, RNs, LPNs and CNAs. There also are doctors and non-medically trained staff that volunteer.

All of our patient charting is now done on computers. We have a specially designed report that we use to document everything from the ambulance call. Part of my job is to make sure these reports make it to the patient medical chart at Rice Hospital. Also to make sure the reports get sent to the Emergency Services Regulatory Board.

Community education and events are also part of the job. We attend events such as National Night Out, Healthy Kids Day, and Family Fun Night and Safety Days. We give tours of the ambulance to Boy/Girl Scouts, daycare centers and preschools.

If it’s not ambulance calls keeping us busy, it’s the boss!!

1 p.m.: Just got a 911 call to a local restaurant, working with the crews right now.

1:25 p.m.: A large percentage of Willmar Ambulance calls are cardiac-related. Signs and symptoms of cardiac events can vary from males to females, but some typical clues are pain or heaviness in the chest that lasts longer than five minutes, pain radiating into arms and/or jaw. Other signs and symptoms can include unexplained shortness of breath, unexplained sweating and nausea.

Willmar Ambulance, along with the other services in Kandiyohi County, has the ability to detect significant cardiac events by being able to perform a 12-lead EKG and transmit the data directly to a physician in the emergency room. Having EMS involved early in a cardiac event has shown up to a 45-minute decrease in time when a person needs to be taken to a higher level of care like a catheterization lab in St. Cloud or the metro.

How 12-lead EKGs came to Kandiyohi County

2:18 p.m.: Our work today continues as we prepare for our open house events tomorrow. Sounds like the weather is going to be great! We hope to see a lot of families come out and enjoy the evening with us!

Oh, and since it’s going to be soooo nice, we will even cook for you!

So reminder, Wednesday 4-7 p.m. at the Willmar Ambulance garage. See more at

3:14 p.m.: Hello, my name is Dr. Scott Abrams, emergency physician at Rice Memorial Hospital.

For the last couple of years, I have provided medical direction for the Willmar Ambulance Service. I basically help with the medical decision-making process or “protocol” that we follow in providing care to the community.

I have come to greatly appreciate the level of care provided by Willmar’s emergency medical technicians and paramedics. They consistently provide excellent care to the community and are always working and training to become better. As medical director and as someone who calls Willmar home, I want to know that when I call 911, I’ll be getting rapid, appropriate care. I can say that we absolutely have that kind of care here in Willmar, thanks to everyone who works with the Willmar Ambulance Service.

I’ve also had the privilege of providing medical direction for several of Willmar’s surrounding communities (Sunburg, Kerkhoven, Atwater, Lake Lillian and Raymond). While Willmar has a professional or “paid” service, these communities rely on volunteers to staff their ambulance services. I have been consistently amazed by the number of people that volunteer their time and efforts to be trained and to work on their local ambulance service. It is a credit to them and to their community that these towns have such excellent services. They truly are wonderful people volunteering to do a tough job and I’ve been fortunate to work with them.

3:36 p.m.: Hi, I’m Jim Kroona and the reason the surprise breakfast wasn’t a surprise. Sorry about that, boss, and congrats on 14 years.

I’ve been an EMT with Willmar Ambulance for 13 years and on the County Rescue Squad for 16 years so the pager is always on. A shift for me is on call from 7 a.m. to 7 p.m. and on duty from 7 p.m. to 7 a.m. Twenty-four hours can go so fast and yet seem so long.

My partner Keith and I started last night with a transfer to Hutch and ended it with a transfer to St. Cloud (which went about 10 minutes before our shift was to end). We had a call where the police assisted us with a patient and did an intercept with Atwater Ambulance. So hardly time to take a lunch break. You learn early on to eat and sleep when you can because you might not have the chance if you wait.

For me it’s about giving back to my home town. Born and raised here and enjoy the sacrifice we make to help those in need.

I have had the joy/terror of delivering a baby in the front seat of a car and the sadness of extricating a relative from his truck as he died.

Please be safe in your day and with what you do. Finally off to bed!! Hope I can fall asleep.

3:51 p.m.: With over 2,600 calls per year, our crews have days of what feels like controlled chaos and some days where it feels like we are just working in the office or the garage.

It typically takes our crews one hour to respond to, transport and do the paperwork on a routine ambulance call. Our service covers 137 square miles within the county and has a response time standard of having to be enroute to calls once dispatched within 90 seconds 90 percent of the time and to be on scene within 10 minutes 90 percent of the time as well.

We use electronic patient care reports so our information about a patient is recorded and uploaded via a secure system where our records are stored and accessible to our hospital health information department as well as our quality control staff. Having the ability to do electronic reports has tremendously helped our service see and respond to our data, from staffing levels to quality assurance.

I tend to still write information on my gloves; old habits are hard to break. Oh, I still enter the data into the electronic system, but other staff members are way better at it than me.

4:33 p.m.: Being paged to a local clinic where someone has fallen, crew responding code 3 now!

4:39 p.m.: Sometimes, depending on the situation, we need to ask for a second ambulance to help on a call. This could be a need for lifting assistance, or because the patient is severely injured and extra hands are required to take care of the patient safely and without causing more harm. We are very fortunate to have backup when we need it to better take care of our patients and help prevent staff injuries when lifting or moving patients in difficult situations.

We communicate with our emergency department nurses and physicians via radio when we are on scene to give them a heads up of what we are dealing with so they can better prepare for the patient coming in. We use portable radios or mobile units within the ambulances. Cell phones are also sometimes used, but radios are simple and are quick access to medical control when needed.

Our reports are quick, with basic important information relayed to the ED about the situation, background and treatments given, as well as asking for any further questions or orders from the doctor in the ESD. We always assess our patient’s vital signs, and depending on the call, may use our cardiac monitor, oxygen, medications or other equipment as needed to make our patient as comfortable as possible and to help ease any pain they have.

4:47 p.m.: Well, as of this posting we have had six calls since midnight, with four of the calls before 7 a.m. It is typical that we have streaks where our main volume of calls comes in on the night shift and some where they come on the day shift.

Our data tells us our busiest times are M-F from 0900-1700 but calls are not always predictable, so to have 24/7 coverage is a must for a town our size.

I will keep you posted until 7 p.m. on what is yet to come. Hope you’re enjoying the weather and the day with the great crews of Willmar Ambulance.

5:41 p.m.: Hello, my name is Jim Bode and I have worked for Willmar Ambulance Service since 1998. I am currently employed as a casual paramedic and also have critical care certification.

Today was kind of a quiet day around here for an ambulance service. When we got to work at 7 a.m. we checked over all the trucks to make sure everything is stocked and ready to go for the day (and night). After truck checks it was time to get something to eat from the cafeteria. Sometimes this does not go as planned; today we got to sit down and enjoy our meal.

After breakfast we went to the garage again and started cleaning it up for the upcoming event tomorrow (come get some hot dogs and see some really cool stuff). After cleaning the garage and running errands around the hospital, we finally decided on lunch, a local pizza joint that is very understanding when we gotta run out the door.

At last we get a call, problem unknown at another restaurant in Willmar. After the run it’s time to restock supplies and clean up the truck for our next run. This usually takes about 15 minutes to get everything in order.

This afternoon was more prep time for tomorrow and enjoying the sunshine which has been missing for some time now. We got a call from the primary crew that they could use some help with a patient they had, so we assisted them on the scene with their requests.

At this time there is nothing more to report on, so everybody stay safe and come see us tomorrow at the ambulance garage.

6:53 p.m.: Well, everyone, not a crazy day and that’s OK! Thanks for hanging out with us and stay safe! This is Brad Hanson signing off for the day.

Thanks to Rice Memorial Hospital for agreeing to participate in a live blog; to Sandra Schlagel, communications coordinator at Rice Hospital, for facilitating this project and providing photos; and most of all to Brad Hanson and the rest of the Willmar Ambulance Service for making it all happen.

Framing the osteoporosis discussion

Some of the latest clinically relevant findings in preventing, diagnosing and treating osteoporosis will be presented this week as the National Osteoporosis Foundation holds its ninth international symposium in Las Vegas.

It looks as if the agenda will cover a wide range of topics: drug therapy, nutrition, communicating with patients about drug side effects, and the emerging science on clinical practice and therapeutic issues related to osteoporosis. The week will wind up with a session co-sponsored by the American Society for Bone and Mineral Research on what’s new in bone research.

I always sort of assumed that most adult Americans know at least a little bit about osteoporosis, or thinning of the bones, a condition that’s often age-related and can increase the risk of fractures. After all, ads for prescription drugs to stave off osteoporosis seem to be everywhere these days. So I was a little surprised when a recent survey, conducted by the National Osteoporosis Foundation and Harris Interactive, found that 34 percent of the respondents had never heard of the condition.

Although 70 percent of the survey participants believed osteoporosis can be prevented, half didn’t know that exercise can make a difference, and almost three-fourths were unaware of the role nutrition can play. (Since I’ve been unable to find any information on how the survey was conducted or how many people participated, take these findings with a slight grain of salt.)

Poor bone health can be a big deal. Individuals with osteoporosis are more vulnerable to breaking a bone, leading to pain, disability, medical expenses and, in the most serious cases, loss of independence and/or shortened lifespan. Some people never truly recover. It’s thought that as many as two out of every 10 older adults who break a hip die within a year, due to problems either associated with the injury itself or the surgery to fix it.

Figuring out the best screening and prevention strategies hasn’t been easy, though. Do we screen everyone past a certain age? How do we identify other at-risk populations? What are the important risk factors? How often should people be screened? How aggressive should we be about prescribing medication to prevent osteoporosis? Which people are the best candidates for medication and how long should they take a drug?

The U.S. Preventive Services Task Force, the main body for developing evidence-based screening guidelines for clinical practice, issued new recommendations back in January on screening for osteoporosis. The gist of the task force’s recommendations: Women who are over age 65 and women who are younger but have the same or higher fracture risk as a white woman over age 65 should be screened.

The panel concluded there was “convincing evidence” that bone density measurement with DXA, or dual-energy X-ray absorptiometry, can effectively predict the short-term risk of a fracture and appears to be more reliable than questionnaire forms of screening. Overall, the USPSTF concluded that for these two populations of women, “there is moderate certainty that the net benefit of screening for osteoporosis by using DXA is at least moderate.”

So what about drug therapy to lower the risk of osteoporosis? Here the evidence becomes rather murky. In a guest essay published online last week at Kevin MD, Dr. Juliet K. Mavromatis notes that she sees many women who “are left on these drugs for years and years,” despite limited clinical knowledge about the long-term safety.

It’s an area that’s ill-defined, she wrote:

Many questions remain about how to approach the treatment of aging bones to prevent the debilitating outcome of bone fracture. Seasoned clinicians have seen the problems that may occur in some cases with treating large populations of well patients for normal life processes (postmenopausal estrogen replacement therapy). Let’s hope that future research will address the question of when to treat with medication and for how long with further precision. Until then let’s use appropriate caution when prescribing medicine for normal senior bones.

The USPSTF recommendations do in fact call for more research on several issues: how often women should be screened for osteoporosis, the extent to which screening truly has an impact on long-term health outcomes, and the impact of osteoporosis on women of color. More studies also need to be designed for men, who can get osteoporosis too although their risk is lower than that of women.

Given the swelling numbers of Americans who are getting older and the likely rise in the number of people with osteoporosis, this seems to be an area of study that calls for some serious attention.

Image: Wikimedia Commons

Don’t forget – live guest-blogging tomorrow with the Willmar Ambulance Service!

Linkworthy 3.1: Friday the 13th

A roundup of some noteworthy reading encountered on the web in recent weeks:

– I can’t believe I missed this story last month, but here it is, from the Wall Street Journal: The Battle of the Office Candy Jar. Summed up in three words: Proximity + temptation = ruination. My favorite quote from the article: “Even for a person with the greatest resolve, every time they look at a candy dish they say, ‘Do I want that Hershey’s Kiss or don’t I? At the 24th time, maybe I’m kind of hungry, and I just got this terrible email, and my boss is complaining – and gradually my resolve is worn down.”

I hope my newsroom colleague who brought in the leftover Peeps and jellybeans after Easter is reading this.

– Speaking of food, The Atlantic published an article today that takes an interesting look at supermarket design and its influence on what, and how much, we buy – and whether stores can be redesigned to help consumers make different purchasing choices. It may smack of social engineering but it seems to be backed up by some intriguing research.

Engaging the Patient is hosting a series of guest blogs during Patient Experience Month that explores the line between rhetoric vs. action. Is health care truly becoming patient-centered, or is “patient-centered” just a buzzword?

When it comes to the things that patients care about and that deeply affect their lives, health care often seems to be missing the mark, observes Alexandra Drane, president and co-founder of Eliza, a patient engagement firm.

Dr. Davis Liu wonders: Do patients even want to become empowered? “They simply want to have convenient and personalized care, whether in office, telephone, video or email,” he writes.

Other installments in the series address the current state of patient engagement and the role of health care executives in fostering patient engagement.

– For some serious reading, check out “Neglected to Death,” a series reported in the Miami Herald that uncovers violations and abuses in Florida’s assisted living facilities. Although it focuses on the worst of the worst rather than facilities that are well-run, it’s a cautionary reminder for families to do their research before choosing an assisted living home and to remain informed and vigilant about their loved one’s care.

– Several new entries have been posted in an ongoing series at the Cost of Care blog, exploring some of the difficulties patients encounter in trying to manage the cost of their health care. The entries were submitted last year as part of a national essay contest and include the story of a knee surgery patient who ran into a brick wall while trying to get an estimate of what the procedure would cost, a student who received an unexpected bill, and a man who was both uninsured and catastrophically ill.

– HUMS, or High Utilizers of Medical Services, aren’t always well understood. Indeed, they’re often blamed and criticized for abusing the health care system. The reality, however, is that there’s more to this subgroup of patients than meets the eye. They’re often mentally ill, addicted and/or homeless, and existing public health safety nets fail them all too frequently.

Dr. R. Jan Gurley, who writes about urban health, describes an effort in San Francisco to identify these individuals and the challenges of providing care that’s less costly and more effective. It’s daunting but it’s not an issue that cities can afford to ignore, she writes: “The big question is what we all, collectively, are going to do to address their suffering and premature death – and their inefficient and costly use of safety-net services.”

– Here’s an initiative I can get behind: The Society for Participatory Medicine has embarked on a glossary project to compile the many abbreviations and acronyms used in health care and help the consumer decode them.

An example from a typical medical chart:


HPI: This is a 52-year-old black female with a long history of CAD and COPD who presents wit SOB of several days’ duration. She has had some DOE but no chest pain or diaphoresis. She has had an MI in the past with CABG in 1999 of 4 occluded vessels.

Although patients are often encouraged to obtain copies of their medical record, one can’t help wondering how much good this will do if they don’t understand the alphabet soup.

The SPM has created an online form (linked above) allowing people to submit abbreviations, acronyms and an explanation of each. The information will be compiled into a glossary that can be used by patients to help decipher and better understand the technicalese in their medical record.

If this is a project you can help with, check it out and consider adding your own entry or two. This is one of those cases in which the more entries, the better.

Photo: Wikimedia Commons

Live-blogging next week!

Watch this blog next week and follow me on Twitter for a day of live guest-blogging by the everyday heroes of the Willmar Ambulance Service.

Date: Tuesday, May 17.

Time: Entries will be posted from 7 a.m. to 7 p.m., giving readers a glimpse of what it’s like to be an emergency medical technician and the role of the ambulance service in providing health care to the community.

The occasion: Emergency Medical Services Week, May 15-21.

I’ll be the blog host but the real stories will come from the ambulance crew as their day unfolds. Check back often as new entries are posted throughout the day. The EMTs would love to have many readers following this behind-the-scenes look at who they are and what they do.

West Central Tribune photo

Rating the weight-loss plans

In the world of diets, apparently not all are created equal. Consumer Reports recently evaluated seven of the most popular diet plans and picked a winner: Jenny Craig. The commercial program edged out Atkins, Ornish, Weight Watchers and Slim Fast as the most successful at helping people shed pounds.

The diet plan ratings, which were issued this week, inject some facts into the often confusing and hyped-up discussion about which diets work best for whom.

The Consumer Reports health team based its rankings on the published evidence from reputable medical journals: Were people able to stick with the diet? Did they lose weight? Was the diet supported by current science on nutrition and weight loss?

Jenny Craig, which combines counseling with a regimen of prepackaged, portion-controlled foods, rose to the top on the basis of a study, published last October in the Journal of the American Medical Association, that found participants achieved an average 8 percent weight loss over two years. The study involved 332 people. In what Consumer Reports called “a remarkable level of adherence,” the majority of the participants – 92 percent – stayed with the diet plan for the entire two years of the study.

Impressive as this might sound, it doesn’t necessarily mean people who want to lose weight should rush to sign up for Jenny Craig, Consumer Reports cautioned: “It’s obviously worth considering, but if you don’t like the idea of eating prepackaged meals, it might not be for you.”

In the long run, the best diet is the one you can live with, Kathleen Melanson, Ph.D., associate professor of nutrition and food sciences at the University of Rhode Island and director of the university’s Energy Balance Laboratory, told Consumer Reports. “If you’re forcing yourself on a diet you hate, it’s going to be really hard to stick with long term,” she said.

More food for thought from the Consumer Reports ratings:

– No matter what kind of diet you’re on, you won’t lose weight unless you burn more calories than you take in. But the evidence is beginning to show that some types of calories are more filling than others. Diet plan creators are increasingly incorporating this knowledge into how they design their menus – higher in protein, fiber, fruits and vegetables that fill people up and reduce hunger pangs without upping the calorie count.

– The evidence is growing that refined carbohydrates, such as those found in white bread and potatoes, contribute to weight gain and type 2 diabetes because of how they affect blood sugar and insulin levels.

– Fat appears to be less detrimental to health than commonly believed. Although it’s still “a subject of vigorous scientific debate,” saturated fat doesn’t seem to raise the risk of cardiovascular disease or stroke, according to Consumer Reports.

– Some studies suggest that dieters are better off if they replace the saturated fat in their diet with unsaturated fat rather than refined carbs.

– A dietary middle ground, suggested by Dr. Michael L. Dansinger, assistant professor of medicine at Tufts University and a weight-loss researcher: “a low-ish carbohydrate diet that’s high in vegetables and lean protein, including dairy; moderate in fruit; with nonsaturated fat from sources such as olive oil, nuts, avocados and fish.”

– Emotional support systems can make a difference. Jenny Craig offers both telephone and in-person counseling. Support group meetings also are one of the foundations of the Weight Watchers plan, which came in third in the Consumer Reports ratings, and the Ornish diet.

Update: As the ratings are further analyzed, some criticism and caveats have been emerging. The most notable objection: The study on which Consumer Reports based its rankings didn’t reflect diet conditions in the real world. Consumer Reports is defending its evaluation of the diet plans, pointing out that it was based on current science.

Is Jenny Craig really the best? It depends. For people who have difficulty with portion control or menu planning, or simply don’t like to cook, the prepackaged food may be an approach that works for them. Other people might have better success with a different strategy.

What the debate seems to underscore is that there’s no single approach that objectively works for everyone – and that losing weight, let alone sustaining weight loss over the long term, is extremely difficult for many of us.

Photo: Wikimedia Commons

Ticked off

There tends to be a yearly rhythm to some of the health care news: flu shots in fall, Lyme disease in spring, West Nile virus in summer. Every so often, though, something new comes along to keep things interesting.

This time around, it’s the emergence of anaplasmosis as one of the leading tickborne diseases in Minnesota.

Figures released last week by the Minnesota Department of Health were quite surprising: The incidence of human anaplasmosis more than doubled in 2010. Most years, there are about 300 confirmed cases statewide; last year there were 720. About 30 percent of them resulted in hospitalization, and one person died. In some north central counties of Minnesota, anaplasmosis now rivals Lyme disease as one of the most common tickborne illnesses.

Most people probably haven’t heard much about anaplasmosis, so here’s a primer: It is a bacterial disease transmitted to humans through the bite of a deer tick, the same way Lyme disease is transmitted. Symptoms of infection include fever, severe headache, muscle aches, chills and shaking. There might also be nausea, vomiting, loss of appetite, weight loss, abdominal pain, diarrhea, joint pain and changes in mental status.

People who are aging or immune-compromised can be more vulnerable to severe disease. Among the serious complications of anaplasmosis are respiratory failure, kidney failure and secondary infections.

Treatment consists mainly of antibiotics.

Overall, potentially serious tickborne diseases are on the rise in Minnesota, a development that has state health officials concerned. Dave Neitzel, an epidemiologist who specializes in these diseases, calls it a “continuing and troubling trend.”

Cases have been popping up of Powassan virus disease and a new form of ehrlichiosis, both carried by the black-legged (or deer) tick. Neither of these diseases was seen in Minnesota before 2008.

The incidence of babesiosis, a tick-transmitted protozoan infection, also rose rather sharply last year, from 31 reported cases in 2009 to 56 last year.

The arrival of tick season doesn’t mean we should all be cowering indoors to stay safe. It should be noted that most of these diseases are still relatively uncommon. Prevention is the best medicine, though, and it starts with avoiding tick habitat as much as possible from late spring through midsummer, the time of year when ticks are most active. For those who need to spend time outdoors, repellents can help reduce their risk of being bitten by an infected tick.

The Minnesota Department of Health has more detailed information here and here.

Photo: Wikimedia Commons