Airmail, Part 1

Responding to Reader E-mail from 30,000 Feet


 
 

Howard Rodenberg, MD, MPH, Dip(FM) | | Monday, November 26, 2007


Amarillo by mornin , up from San Antone.

Everything that I ve got, is just what I ve got on.

George Strait, Amarillo by Morning

I m writing this week s column somewhere over Amarillo, Texas. It s not morning, but night as in 10:30 p.m. my time, 9:30 in the Red River Valley and 8:30 in Salt Lake City, where I was supposed to be three hours ago at EMS Today 2004. Right now, I should be eating a free meal courtesy of the fine folks at Jems Communications. Instead, I m still in the great sardine tin in the sky. Turns out that weather is the great equalizer between first class and coach. We all get there at the same time.

This whole spiel is preface to noting that one of the blessings of air travel is that for a few hours, nobody can find you. This makes it an ideal time for rifling through the e-mail inbox and responding to your letters. I've had so many replies that I thought I'd share them, and my comments, over the next three weeks. Here's Part I.

Kids are adults

My comments regarding the concept that kids are little adults ( Sorry, But Kids ARE Little Adults ) prompted a host of supportive letters and (surprisingly) none in disagreement. Many, such as Brian MacDonald of Nova Scotia, Canada, note that they already espouse this philosophy in their local training programs to take away the mystery of caring for children. Michael Boyd says he has already integrated adult and pediatric lessons into common categories within his California paramedic training program. The idea of looking at the commonalities in care is echoed by Jim Cofer, who comments that too many pediatric protocols consist of, Do CPR in your arms while running to the ambulance.

Capt. James David of the Columbus, Ohio, Fire Division considers pediatric institutions part of the problem not from the knowledge they convey but because of the mode in which they deliver the message. I think this point is key and is related to the fact that adults and children learn differently. I ll be exploring this concept in a future column, but let s say, for now, that Capt. Davis hit the nail on the head.

Jeff Laabs observes that he has seen instructors get upset and stomp their feet when he disagrees with their contention that kids are not little adults. It seems that adults can do a pretty good job of acting like little kids. (My son, who is now six, has the best stomp in the world. He doesn t just stay in one place and stamp up and down, in the trip-trap, trip-trap way one would expect of the littlest Billy Goat Gruff. Instead, he flexes his muscles in an Ahnold -like pose, adopts a grim expression and spins in the opposite direction to stomp away from you the full force of his 30-some lbs. echoing with each little step across the floor. If he hasn t heard from you in a second or two, he gives you a hopeful glance to make sure you re watching and then resumes his march to the sea.)

Another writer considers that pediatricians probably feel the same way about adults that we do about kids, recalling that the wig factor hits warp factor six (I will be stealing this phrase) at a pediatric hospital when an adult develops chest pain or passes out on the floor. He also reminds us of the truism that a sick child usually looks sick. The trick, of course, is to see enough kids to know what a sick one looks like. A week of EMT-P school rotations in the local ED or playing with the nieces and nephews on holidays won t quite do it. You need volume.

Paul Matera, MD, of Washington, D.C., notes that the focus on children as a separate group of patients is a function of our culture of merit badge medicine. The segmentation of training and the need to acquire certifications in each course maintain special interests control over our standards of care and impede our overall efforts. He considers that the costs of time, money and effort in maintaining multiple certifications and the lack of distinct differences between them suggest that paramedic knowledge gaps might best be addressed by the medical director within the overall context of the local EMS system. (Another reader, Dolph Holmes, reinforces the idea that the best way to get acute care specialty advice is to contact your online medical direction. He also has a great tag line at the bottom of his e-mail: Paramedics save lives. EMTs save paramedics. )

I would echo Dr. Matera s thoughts and point out that even the American Board of Emergency Medicine concurred that board certification in emergency medicine is itself sufficient qualification for ED practice, irrespective of the number of ACLS, ATLS, PALS or other cards one holds. It s also of interest to me that most of these courses do not give out certifications, but rather certificates of course completion. They verify that you attended the course, but say nothing about your competency. It s a neat, yet eminently understandable, legal trick that makes you ultimately responsible for your own education and practice.

Mike Sherriff says that in some prehospital texts, measuring blood pressure is advised only for children older than three years. Apparently, capillary refill is advised as the best means to assess circulation for children younger than that age. I did a bit of homework and found that although the paramedic text I had on my bookshelf advised the assessment of vital signs in all age groups, the EMT-level book specifically instructs the student to take blood pressure only in children older than three years.

Although I think that the authors of the latter text realize that children younger than three years old do have a blood pressure, for some reason, they have little faith in the EMTs ability to measure it. Perhaps, they were familiar with an insightful study done by Gausche and colleagues. In a review of children younger than two years old, paramedics obtained all vital signs in only 37% of cases and none whatsoever in 10%. Paramedics were also asked to address those factors that frequently or always interfered with assessment of pediatric vitals. Reasons for not taking vitals included the usual culprits of uncooperative patients (59%) and excessive environmental noise (27%). More interesting reasons given for failure to assess pediatric vitals included child not sick enough for vitals (21%) and child too sick for vitals (12%). I don t think we let these reasons fly for adults.

It s true that it can be difficult to check the blood pressure of a squealing infant, but probably no harder than it is with a vocal, thrashing adult. One must recall that in young children, an appropriate systolic blood pressure is 80 mmHg plus 2 x (patient age). However, hypotension means more with a child than it does with an adult due to the youngster s limited cardiopulmonary reserve. That s why I think it s always worthwhile to try to get a BP or estimate a value based on the anatomic location of palpable pulses. Such variables as the dependent position of an extremity, crying and the clenching of fists may all make capillary refill tenuous as a definite marker of adequate perfusion. Objective measures, such as blood pressure, pulse oximetry and the future use of transcutaneous capnometry, in concert with close clinical observation, are probably the best sources of information regarding perfusion status.

Finally, a special thanks to Matthew Gratton, MD, medical director of MAST Ambulance in Kansas City, for his thoughts. Receiving kind words from someone you look up to means a lot.

EMS & faith

My article about the role of faith in EMS ( Does faith Have a Place in EMS? ) generated many replies. To be honest, I was a bit hesitant to write the piece. Faith is an intimately personal matter, and there is the old admonition to avoid talking in public about religion and politics. But given that what we do in prehospital care takes us so close to the edge of human experience life and death are as close to the root of faith as you can get I still thought it was a legitimate topic to discuss. Even after the column went out on the net, I still had a major case of pins and needles as I awaited what I thought would be an overall negative response.

I was floored by the number of encouraging e-mails I received. There were far too many to give them justice in a small sample, but no one had a negative word to say. It seems that for many EMS professionals, faith is a critical issue that has been long-ignored.

The United Kingdom s John Wilby notes that the spiritual dimensions of EMS may be best illustrated in the New Testament parable of the Good Samaritan. He contends that whatever s one s faith, or lack of it, it s undeniable that the patient s need for an EMS response is often a result of rejecting this fundamental principle. And, on a more concrete level, Stan Long reminds us that a patient s faith is not only placed in the divine: Do not minimize a patient s faith in you as a health-care provider. Ride with it, for you may be the only hope that person has faith in at the moment.

(I will share with you my favorite story concerning the Golden Rule. It comes from the Sefer ha-Aggadah, a Jewish book of tales and legends. A man came before Rabbi Hillel and asked him to teach him the entire Torah while standing on one foot. Hillel said simply, What is hateful to you, do not do to your fellow man. This is the Torah; all the rest is commentary. Go and study it. )

Given what we see in our practice of prehospital care, it can be difficult to find evidence of the divine in our professional lives. Maybe it takes a transition like death in our ranks to bring it to our attention. Roni Rosenberg recalls a ceremony for a fallen firefighter at which his colleagues and crew lined up to form the victim s name, then called it aloud. If that wasn t a message to the heavens, I don t know what is, Rosenberg says. Amen to that.

Rick Thompson writes from across the pond that he has started an EMS Pastoral Care Web site at www.emschaplainuk.com. It s an excellent site and a resource that s long overdue in this country. Bill LaMay suggests that the works of Dr. Dale Matthews at Georgetown University and Dr. Harold Koenig at Duke are also good references for understanding how faith helps people through troubled times. For my part, I d recommend the classic When Bad Things Happen to Good People by Rabbi Harold Kushner or just a good read (or reread) of the Book of Job.

On the lighter side, the Reverend Andrew Phillips of Gillett, Pa., and one of his ministerial colleagues are both volunteer First Responders. He relates that some patients laugh at the fact that they re in such bad shape that they require two pastors to take them to the hospital. If I were the patient, it would probably spook me. These two people, who are undoubtedly closer to God than I am, must know something in advance.

Many of the replies were intensely personal, and I don t feel right sharing them on the Internet. I am, nonetheless, indebted to the writers for letting me share a bit of their lives. But taken as a whole, it seems plain that faith remains a core issue in what we do. Despite our attempts (wholly endorsed by me) to elevate EMS to a logical science, it is, at heart, a human endeavor. As long as we depend on the human touch to provide care, we ll continue to wrestle with issues of faith and hope in our lives. As Mike Smith of Durham, N.C., says, You have to have faith to believe in what you do and how you do it. It s difficult to do this kind of job if you do not have faith. Tom Butler notes that it s not just about faith because Faith without hope is nothing.

And, finally, as one unknown correspondent writes, Just one person s opinion, but I couldn t do what I do if I couldn t unload on God.


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