All posts by Mike Schadone

Academia, Health Care, Technology

Implementing an EMR system

Electronic records streamline the flow of many of the components of patient care. EMRs and ePCRs are very useful in lowering costs, simplifying business processes, and increasing patient safety, as well as overall efficiency, if implemented correctly (Smith, 2003).

Currently, I work as a critical care paramedic providing patient care in acute settings, whether prehospital of interfacility. Within this capacity, I also teach classes to other health care providers, including first responders, emergency medical technicians, paramedics, nurses, physicians, and allied health personnel. I am familiar with the concepts of electronic patient care reporting (ePCR) and the importance and utility of electronic medical records (EMR); however, the only means of electronic reporting available in my capacity as a paramedic is poorly developed ePCR software coupled with intermittent network connectivity, so I still choose to utilize paper reporting. My part-time job with a local municipal ambulance provider relies on a widely available third-party ePCR system that seems to work well. I do utilize this ePCR system when working for this provider.

I have also gained experience with information technology and object-oriented programming concepts while developing platform-independent, client-server distributive applications designed for the internet and intranets. I also have experience with Windows and Unix/Linux platforms.

References

Smith, P. D. (2003). Implementing an EMR system: One clinic’s experience. Family Practice Management, 10(5), 37-42. Retrieved from http://www.aafp.org/fpm/2003/0500/p37.html

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

Physician-assisted Suicide

I have always maintained that the best thing that I have ever done for a patient was to hold their hand as they died; however, there are few scenarios that I can posit where I would ever cause the death of another, and I would never do it in my capacity as a medical professional. In the State of Connecticut, assisting a patient in their suicide is illegal (Kasprak, 2003; Saunders & Smith, 2010). Saunders and Smith (2010) describe the use of “semantic ploys” (para. 3) in arguing for physician-assisted suicide and how the court deemed the “issue rests with the legislature, not with the court” (para 4).

Two states have laws permitting physician-assisted suicide, Oregon and Washington (Death with Dignity Act, 1997; Death with Dignity Act, 2008). The other 48 states either have laws forbidding assisted suicide, such as Connecticut, rely on common law, or have no laws permitting or forbidding the practice (Kasprak, 2003). Personally, my thoughts on the matter are clearly reflected in my opening statement. More compelling, however, is a recent discussion on the discontinuation of implanted cardiac devices in patients with a desire to “refuse continued life-sustaining therapy” (Kapa, Mueller, Hayes, & Asirvatham, 2010, p. 989). Many of the respondants to this study viewed the discontinuation of pacemakers akin to physician-assisted suicide, whereas less felt the termination of cardioverter-defibrillator therapy was an ethical issue. Oddly, lawyers indicated less problems discontinuing therapy than did physicians.

There are conditions that are so intractably painful and wrought with suffering that I would not even consider thinking less of a person suffering such a malady who took their own life. Death, for many people, is a fear beyond fear, and for a person (of considerable sound mind) to choose death as a viable alternative to such suffering, I commend their bravery and choose not to judge them negatively. No physician or other health care provider should cause the death of a person directly, but acknowledging the patient’s will to die is another matter. In lieu of providing a chemical means of ending life, a physician could, in my mind, counsel a patient on the means and methods that might be viewed as more effective and humane than other means which might result in unwanted suffering. I do believe that a person has the right to choose an alternative to a surely painful and agonizing death, regardless of the presence of depression. If a person is suffering from depression because of a terminal illness that is causing physical suffering, it is hard to imagine this person will resolve the depression before succumbing to the causal disease process. In these cases, the person has the right to choose a more dignified death. For those cases where the person is incapacitated and cannot make health care decisions, I feel that any friend or family member, or a consensus of available friends and family members, should be able to make the decision to continue or discontinue life-sustaining measures. Even if the decision is wrong for the patient, most of the time the decision is for the benefit of the family and friends and lacks medical relevance aside from resource management, though there are spiritual, emotional, and moral considerations that the next of kin may face which are no less relevant.

Personally, I grant any person permission to end my life if they see me engulfed in flame or if taken on the battlefield by an enemy known for public torture. Beyond these two circumstances, I will always choose to live so long as I have my thoughts. I have heard some people intimate that they would wish to die if they were conscious but perpetually paralyzed (i.e. locked-in syndrome); however, I am not so sure that I would want to die just for lacking the ability to communicate with others. I would want to view the world, though, perhaps by television or radio. I am too curious as to what comes next for the world. As we interfere with the dying process, it does make sense that we address the morality in which we do this. It does not seem right to have brain dead patients connected to ventilators and feeding tubes forever. It’s Orwellian.

References

Death with Dignity Act of 1997, O.R.S. 127.800 et seq. (1997).

Death with Dignity Act of 2009, R.C.W. 70.245 (2008).

Kapa, S., Mueller, P. S., Hayes, D. L., & Asirvatham, S. J. (2010). Perspectives on withdrawing pacemaker and implantable cardioverter-defibrillator therapies at end of life: Results of a survey of medical and legal professionals and patients. Mayo Clinic Proceedings, 85(11), 981-990. doi:10.4065/mcp.2010.0431

Kasprak, J. (2003, July 9). Assisted suicide (OLR Research Report No. 2003-R-0515). Retrieved from http://www.cga.ct.gov/2003/olrdata/ph/rpt/2003-R-0515.htm

Saunders, W. L. & Smith, M. R. (2010, June 21). Assisted-suicide advocates fail in Connecticut. National Review Online. Retrieved from http://www.nationalreview.com

Academia, Health Care

Community Health Centers

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

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

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

References

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

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

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

Academia, Health Care, Society

Henrietta Lacks

Grady (2010) offers the circumstances of Henrietta Lacks for discussion as it pertains to medical ethics. Henrietta Lacks was a young woman who succumbed to cervical cancer in the early 1950s at Johns Hopkins Hospital (Grady, 2010; Sorrell, 2010). Grady describes Henrietta Lacks and her family as “poor, with little education and no health insurance” (para. 10), yet she was cared for and her cancer was treated with radium, the standard treatment of the day. Despite treatment, Henrietta passed away. During the course of her treatment, however, a small sample of cancer cells were removed from her cervix for testing, and they continue to be tested to this day (Grady, 2010; Sorrell, 2010). Additionally, this line of cells, now known as the HeLa cells, has become commercialized, as they are bought and sold for millions on the biomedical research market (Grady, 2010).

Assuming no consent was given by Henrietta or her family, this raises a few questions. Did the physicians at Johns Hopkins have a right to these cancer cells? Did they have a right to transfer ownership to third parties? Does the estate of Henrietta Lacks require royalties be paid when others profit from what amounts to a donation to the public domain?

No person can own another person (or, a part thereof). This is consistent with the moral society of the United States. However, Henrietta Lacks presented herself to Johns Hopkins hospital with the express desire to rid herself of the cancer cells causing her illness. This alone could mean that the cells are refuse and able to be salvaged, and according to Fost (2010), this is agreed to be the law of the land. Fost describes the circumstances surrounding the HeLa cells as normal course of medical business, and I agree for the most part: “If tissue removed during an operation is about to be thrown out with the garbage and has no identifying information, it should be permissible to use it for research without the patient’s consent” (2010, para. 1). In this case, however, the researchers later approach the Lacks family to obtain DNA samples to discriminate between HeLa cell cultures and non-HeLa cell cultures. This mere fact offers evidence that the tissue is identifiable with Henrietta Lacks and her lineage, and I feel, as does Fost, that this is where the researchers erred, in asking for continued support of the cells by obtaining further comparative specimens for analysis yet not clarifying the misconceptions of the family. The researchers should not have requested further tissue (i.e. blood) donation without obtaining informed consent from the donors. Further, the cell line were given a name representative of Henrietta Lacks, HeLa, and she was named as the donor and widely known as such throughout the biomedical research community. Ergo, there were certainly identifying data linking Henrietta Lacks to the specimen.

Remuneration

Certainly under normal circumstances the cells should be made available for research purposes, but they should not be sold for profit, only for the costs of storage and maintenance. Any tissue freely used for medical science should be in the public domain. Further, if a specimen is found to have financial worth, I feel that the custodial researchers should set aside a royalty account allowing a small percentage of the proceeds to be returned to the donor’s estate. I also feel that if researchers have any special interest in further donation, then those donors should be offered remuneration for their donation which should be commensurate to the gains assumed to be made by their donation.

I find no issue with how the cancer cells were used initially, however, the sample should not have been attached in name to the donor. Though not required, it would have been nice if the researchers provided a royalty to the estate of Ms. Lacks, however, to thank her for her contribution to medicine and science.

References

Fost, N. (2010). A cell’s life: The immortal life of Henrietta Lacks. Issues in Science and Technology, 26(4), 87+. Retrieved from http://ic.galegroup.com.ezp.waldenulibrary.org

Grady, G. (2010, February 1). Second opinion: A lasting gift to medicine that wasn’t really a gift. The New York Times. Retrieved from http://www.nytimes.com

Sorrell, J. M. (2010). First do no harm: Looking Back to the Future [Editorial]. Journal of Psychosocial Nursing & Mental Health Services, 48(9), 2-3. doi:10.3928/02793695-20100730-07

Emergency Medical Services, Public Health

A Tertiary Care Transfer

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

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

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

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

Academia, Health Care

Quality in Interdisciplinary Critical Care Medicine

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

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

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

References

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

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

Codes of Ethics

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

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

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

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

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

References

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

Academia, Health Care, Society

Understanding Cultural Disparities

Social programs are just that… social. In fact, the basis of any social program is to take part in society, both philanthropists and recipients. I think that we have forgotten what it means to be social. I like to think of a well-designed social program as an invitation extended to a marginalized community to partake in society as an equal member. Only when we see ourselves as equal in title and domain can we ever think to overcome racial and ethnical biases (not to mention other more generic stereotypes).

The Lakota Nation has certainly met with strife, both on and off the various reservations. I have always understood that they have unique problems stemming from our early misunderstandings and stereotypes of savage people. In fact, not all of us were victim to this view. It was the Iroquis, after all, after whom we modelled our constitutional governement, and it was a majority of the tribes of every Nation that have assisted us in battle even when feeling oppressed.

The Cheyenne River Sioux are affected by a poor economy, including poverty, elevated rates of unemployment, and a stagnant workforce. In addition, many Native Americans living on reservations are also prone to mental disorders, such as depression, substance abuse, and suicide. Native Americans certainly have it tough, and though many are able to find their way within and without the majority culture, whether through acculturation or community-wide boons such as gaming and resource development, many falter.

The fact that Native Americans are genetically prone to alcoholism, are sociologically prone to depression, and are overall prone to health disparities, suicide, and homicide reveals that there needs to be a solid and comprehensive approach to their problems. The Cheyenne River Sioux, however proud they might be of their culture, are not immune.

So, how do I help? First, examining the cultural and genetic aspects of Native Americans in the context of substance abuse allows me to educate myself on cultural specifics that may assist me in treating a Native American patient. Also, understanding their plight allows me to consider them politically, even from afar.

As much as I would like to hop on a plane (actually, I would probably drive, anyway) and assist the Cheyenne River Sioux hands-on, it is not practical. I do believe in charity, but I certainly do not have the resources to make a meaningful contribution. I will, however, remain a proponent from within the majority culture. I believe awareness of the problems that they face will be a key in allowing others to offer them the assistance to rise above their plights to seek happiness.

Academia, Politics, Society

Precedence of Social Change in Print Media

An Analysis of the Precedence of Social Change in the Print Media

In a society as grand, as robust, and as diverse as America enjoys, it would be naïve to suggest that as a society we are perfect. Thus, change is necessary and inevitable. As a society, we not only have a right to pursue happiness, but arguably, an ethical responsibility to do so (Kymlicka, 2001; U.S. Const. amend. I). Although personal improvement is important, many times we achieve this through positive social change.

Positive social change indicates an effort by an individual or a group of individuals who attempt to influence a representative group of society to promote civic responsibility in a manner that might propagate beyond the initial effort to create a civic philosophy that improves the overall happiness of some percentage of society.

Emily Groves (2010), a writer for the Norwich Bulletin, wrote a recent article about the efforts of local community leaders, including Rep. Joe Courtney, to inspire civic responsibility and instill a greater understanding of the history surrounding the Constitution, the Bill of Rights, and the guiding principles and influences of the Founding Fathers. The program, “We the People: The Citizen and the Constitution” is a part of a national project of The Center for Civic Education.

In this front page article, Groves (2010) describes the positive impact that both Courtney and the program had on the participants. The high school students who participated were quoted to say that they have a higher appreciation of government and the role that they play as individual citizens.

Perhaps Rep. Courtney’s presence played a part in the article’s placement on the front page, but usually only the most dramatic of news stories find a home here, relegating good will stories to the back sections of the paper (Groves, 2010). The Norwich Bulletin, however, finds its readership located in what is commonly referred to the quiet corner of Connecticut. Good will articles are probably appreciated more here over the common drama of most mainstream newspapers. The Groves (2010) article shares the front page with a child welfare piece reporting an effort on improving conditions for children under the auspices of the Department of Children and Families (Rabe, 2010) and an article about a fundraiser to benefit a Catholic school that was closed (Scirbona, 2010). The Norwich Bulletin is certainly a community-centered newspaper.

If I were a regular subscriber to this newspaper, I would have read this article for a number of reasons. It is well written, well placed, and covers a subject of my interest. I am not, however, a regular subscriber to this or any other newspaper. Lately, I have found more value in searching for newsworthy topics on my own.

As I stated above, change is necessary and inevitable. Print media outlets, in my opinion, would serve their readership well by focusing on more of the positive strides that we take as a community and as a society. Just as we have a responsibility to pursue happiness along with the right to be able do so, the press has a responsibility to report truth, whether fact or opinion, along with the freedom to do so (Kymlicka, 2001; U.S. Const. amend. I).

References

Groves, E. (2010, September 18). Education: Courtney gives mock Congress real feel. Norwich Bulletin, 150(261), pp. A1, A7.

Kymlicka, W. (Ed.). (2001). The virtues and practices of democratic citizens. In Author, Contemporary political philosophy (2nd ed.; pp. 287-293). New York, NY: Oxford.

Rabe, J. (2010, September 18). Child welfare: Report: Abused children failed by DCF. Norwich Bulletin, 150(261), pp. A1, A7.

Scirbona, C. B. (2010, September 18). St. Mary Church fair: School closed, but Circle of Fun lives on. Norwich Bulletin, 150(261), pp. A1.

U.S. Const. amend. I.

Academia, Politics, Society

Facing Alcoholism:

The Socioeconomic Survival of the Cheyenne River Sioux

 Contributers:

  • Belinda Floyd
  • Monique Madison
  • Lisa Meador
  • Cheryl Nelson
  • April Oldenburg
  • Michael F. Schadone
  • Caprise Snyder
  • Melissa Torrey
  • Carlos Vargas

 

Alcoholism is an individual and social disease that affects people all over the world. It has varying degrees of severity based on the amount and length of consumption. There are risks associated with the use of alcohol that vary from social consequences to physical health risks (World Health Organization [WHO], 2010). Alcoholism has been linked to various acts of crime more often than illicit drugs (Lovekin, 2002). The causes of alcoholism vary, and include poverty, use as an escape mechanism, genetics, and societal pressure. Some people choose to use alcohol because of pressure from family and friends, and some just want to experiment. There are also some that just want to get away from painful emotions (Medicine.Net, Inc., 2010). Poverty is also often cited as a leading cause of alcoholism (Cedra, 2010).

Because of their ability to negatively impact those around them, those addicted to alcohol should not be ignored but rather, to be socially responsible, we must recognize the fact that their illness needs to be treated as a disease . World wide alcohol is related to the cause of 2.3 million pre-mature deaths, and is the 5th leading cause of premature disability and death. It is also the causative factor in over 4 percent of the worlds burden of disease (WHO, 2010).

Very few communities are immune to the problem of alcoholism and the Cheyenne River Sioux Tribe is no exception. Many tragedies have occurred from their alcohol addiction, including homicide, suicide, motor vehicle fatalities, and increased violence (Shepard, 2007). We will explore the causes and effects of alcoholism and its impact on the Cheyenne River Sioux Tribe. We will then make recommendations, and propose solutions to minimize the occurrence and negative effects of alcoholism in the community.

The Situation Today

The Cheyenne River Sioux Tribe is a Native American tribe located in South Dakota. They have a history thousands of years old, and great pride in the traditions of the community. They honor Mother Nature and the land that they live on, which has been a part of their culture from its beginnings. Like most Native American tribes they have had their ways of life tested by the world around them, and have uncountable injustices thrust upon them (Milbrodt, 2002; Swenson, 1994; White, 1978). The Cheyenne River Sioux Tribe has built a history and a homeland that they would like to preserve long into the future. While they fight to keep traditions alive and remain solid as a culture they also fight the modern difficulties that ensue (French & Hornbukle, 1980; Mizrach, 1999).

According to a report by the Department of Interior, Ziebach County, which is home to the Cheyenne River Indian Reservation, has a poverty rate of 54% (as cited in Ortman, 2010). The jobless rate among tribal members is 88% (Ortman, 2010). This tribe, like many others, is plagued by “alcoholism, suicide, crime and a sense of abandonment” (Ortman, 2010). This area was also hit by devastating storms during the past winter. The Chairman of the tribe, Joe Brings Plenty, questions why it must take a disaster of this magnitude to get the attention of a government that he feels has “broken its treaty obligations to care for Indians who gave up their land to make way for white settlers” (Ortman, 2010, para. 3) . It is our aim to investigate conditions and issues that surround this tribe. These very conditions and issues may well be at the root of the high rate of alcoholism among the members of this tribe. Alcoholism is a large social problem in the tribe, and finding ways to alleviate and educate members is an important need. Alcoholism is not a singular disease; it affects the culture and traditions as a whole (French & Hornbukle, 1980). It can compromise the future success of a person and the group they belong to (A.D.A.M. Inc, 2009).

It will be our goal to determine what conditions led to the alcoholism problem now experienced by the tribe, and what information, help, and programs are available, and to build upon that knowledge to provide whatever assistance we can with the disease of alcoholism in the tribe.

Poverty

Poverty is both the cause and consequence of many of the problems that Native American communities face, like alcohol addiction. It is a vicious cycle which the current economic climate only makes worse. The standard response to poverty is economic development. However, poverty in Native American communities cannot be separated from its historical context. Native Americans live in places chosen for them by the American government, the result of an invasion designed to take over their lands. The Cheyenne Sioux Tribe website refers to the creation of the American West as we know it “after most Native American peoples were ‘safely confined’ on reservations” (Cheyenne River Sioux Tribe, 2009, para. 1). In time that overt hostility has turned into neglect, while poverty has become severely entrenched. Contrary to popular belief, most tribes are not wealthy from gaming.

While history may be a root cause of poverty in Native American communities, we are powerless to change history. We can only address the present and future, while acknowledging the past. Therefore, the development solutions that we recommend acknowledge the unique traditions and history of the Cheyenne River Sioux tribe. In Development as Freedom, economist Amartya Sen (2000) talks about freedom as an end and a way to create development. In this context, freedom is more than being free of negative circumstances, like freedom from oppression. Also critical to his notion of development, is the development of capabilities within individuals and communities – the freedom to do. In this case, our recommendation is based on economic development that permits the Sioux the freedom to live consistently within their beliefs and traditions.

Connection to the land is essential to Native American thought (Rodgers, n.d.). Creating economic development opportunities that are consistent with this connection allows the Sioux to live a holistic life, break out of the cycle of poverty and escape some of the pressures that lead to alcoholism. We recommend an initiative to support Sioux businesses that uphold traditional principles, such as the creation of a line of organic food products, the manufacture of biodegradable packaging or the marketing of solar energy. Also critical to the success of this effort would be encouraging education in relevant fields, and the establishment of high wage jobs that persuade young people to stay on the reservation.

Escape

When people talk about escaping from things that are going on in their lives, there’s only so far that they can get away from those things or problems. That is, people can physically remove themselves from a stressful area, like a home fraught with arguing family members, but they cannot physically remove the memories of those arguments from their mind. Many experiences make people want to escape or run away from or forget about those experiences, and there are a variety of ways that people attempt to do this. Those methods of escape can be both positive and negative; some people meditate to relieve stress, while others exercise. Unfortunately, one of the most common, yet severely negative escape routes involves the use and abuse of alcohol. Because of its effects on the person consuming the alcohol, such as lowered inhibitions and the euphoric effect which can seem to alleviate stress and worry, alcohol often succeeds in providing an escape that some people look for, but only temporarily. Afterwards, however, the stress and worry can return, propelling the user to consume more alcohol to prolong the escape, which often progresses alcohol use to alcohol abuse.

Native American communities are beset with a multitude of problems, which include poverty, racism and discrimination, high rates of unemployment, issues maintaining their ethnic identity in a country with a different dominant culture, depression, and suicide (Martins, Widoe, Porter, Chebon, & McNeil, 2006). While the aforementioned social problems do not constitute an exhaustive list of problems faced by many Native Americans, they certainly provide insight into the kinds of problems that some Native Americans may attempt to escape from when using or abusing alcohol. With poverty topping the list of social conditions that plague Native American communities, it is not surprising that between 2005 and 2008 36% of Native Americans aged 18 or older living in poverty binged on alcohol compared to the national average of 25% (Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2010). Unfortunately, the Cheyenne River Sioux Tribe is not immune to these social problems.

Attempting to reduce the high rate of alcohol abuse as a means of escape within the Cheyenne River Sioux Tribe, requires one to tackle the problems that the members of this community are seemingly attempting to escape from. Poverty, unemployment, and discrimination seem like insurmountable obstacles to overcome when trying to eradicate those social conditions that tend to lead to alcohol abuse as a means of escape or relief from stress and worry. With the current U.S. economy being unstable, poverty and unemployment have stricken several U.S. communities, not just Native Americans. With that said, solutions like creating jobs and improving the economy will take years for the positive effects to be felt. While this is a long-term goal, which will prove to eradicate poverty, alternative means of combating this problem are available, and may produce good results that are not contingent upon something that is out of the individual’s control, such as the economy. Promoting Alcoholics Anonymous programs, psychological counseling, and group therapy are some options for the Cheyenne River Sioux Tribes. The concern, however, is whether these solutions, typical of the dominant American culture, will be accepted or rejected by a community, which strives hard to maintain its separate and historical identity. Certainly, culture and tradition will have to play a role.

Pressure

The disease of alcoholism can begin for many reasons (A.D.A.M. Inc., 2009). Factors range from genetics, poverty, familial and family patterns, and pressure from outside sources, such as peer pressure. In this section we will look at the link between outside pressure, and alcoholism in the Native American.

A person’s environment can have a dramatic link to the cause of alcoholism (A.D.A.M. Inc., 2009). A child may grow up with alcohol around them and see family members drinking and it may become familial (Milbrodt, 2002). A child may feel like it is a normal thing that adults do, and grow up emulating that family picture. It can make a child more prone to becoming an alcoholic later in life, because they have not been exposed to something different, and the peer pressure is harder to ignore. As a child growing up around the over- consumption of alcohol, it becomes harder to ignore peer pressure as they get older, even if it is something they have seen as a negative family pattern (Milbrodt, 2002). A article in the Journal of American Indian Education, linked peer pressure, alcoholism and family structure to illustrate the problem.

They are products of a society where alcohol abuse is not considered deviant behavior […] where poverty is the norm, where teenage pregnancy is sanctioned, where parents and relatives are often in trouble with the law, and where peer pressure takes the form of family pressures as well. (Bowker, 1992, “Results of the study” para. 5)

Although the causes of alcoholism are complex, there is a great deal of research determining how societal and peer pressure develop into such a damaging condition (A.D.A.M. Inc., 2009). Many of the factors that cause a dependence on alcohol include anger and dissatisfaction in life, unrelieved stress, and emotional difficulties, as well as social and peer pressure (A.D.A.M. Inc., 2009). Some people choose to use alcohol because of social factors such as pressure from their family, and others may feel peer pressure from their friends. Parents and family members may not realize the damage that alcohol can do, and how it can affect their family relations. Sometimes family has the power to make people feel the need for alcohol. Sometimes family members tend to criticize their own family members, which may lead the person to drinking. Sometimes consistent arguments, as well as influence from friends may lead to heavy drinking. The factors are numerous, but in the arena of stimulus from an outside source, the causes stem from pressure around the person deciding to drink.

Alcoholism is a serious problem. It is the leading cause of unintentional deaths (French & Hornbuckle, 1908). Children are affected by the alcoholic parent’s behavior. Sometimes this may lead to child abuse or child negligence (ChildAbuse.com, 2010). Family members of alcoholics often feel embarrassment, sadness and fear of their love one (Parsons, 2003). Children of alcoholic parents struggle with depression and confusion, often not knowing if their loved one is somewhere hurt (Parsons, 2003). There are times that family members become fearful of their love ones. Alcoholics may become violent to their family members. Children sometimes blame themselves for their parent’s drinking (Parsons, 2003).

Anxiety of Identity

In a historical overview of Native Americans it can be seen that loss of cultural identity, leading to low self esteem and identity anxiety, is a contributing factor in the high rates of alcoholism among this culture (French & Hornbuckle, 1980). Teresa Milbrodt (2002) writes that “Native Americans have been put at high risk for alcoholism due to a history that they cannot forget” (p. 7). She shows that the Lakota people have suffered a loss of culture through abuses of Native Americans by white settlers and governmental policies spanning hundreds of years. Current conditions are a result of past events that have created a breakdown of the traditional structure of the tribe. Changes such as federally run boarding schools that the children were required to attend, changes in the traditional gender roles, and shifts in family traditions have left the tribe culturally adrift.

Many of the students who were sent to these federal boarding schools returned to the reservations feeling ashamed of their cultural heritage. They then migrated to urban areas where they felt equally out of place. In their eyes they “had no place in any society” (Milbrodt, 2002, p. 8).

Gender roles also underwent severe changes when the Native Americans were forced onto reservations. Men were no longer able to hunt, and the government even tried to outlaw spiritual practices such as ceremonies, dances and warrior societies. Men felt unable to provide for their families. The hunt and the ceremonies also determined a man’s status within the tribe. Again, the changes in tribal structure left members feeling unsure of their place in society. Confined to the reservations, men “lost their status and cultural identity” (Milbrodt, 2002, p. 10).

Government policies also effected the family traditions. Policies were implemented to restrict travel and tribal members were unable to visit family and friends, which was an important way of keeping traditional stories and history alive, as well as reinforcing kinship identity. These family traditions provided an important support system. Tribal members note that when the family system is not strong enough, members do not get the support they need; “with the loss of family came the loss of the identity” (Milbrodt, 2002, p. 12).

History has, through the destruction of the social system, led to a lack of identity within the Lakota culture. It has been noted that “this loss of cultural identity is also one of the major contributions to the high rates of alcoholism on reservations” (Milbrodt, 2002, p. 14).

Underlying Issues

Alcoholism and related disorders are directly impacted by socioeconomic status, educational level and rates of unemployment (Shiraev & Levy, 2010). The Cheyenne River Sioux Reservation is an impoverished reservation in Zwiebach and Dewey Counties in South Dakota. The U.S. Census Bureau shows that Zwiebach’s poverty rate in 2008 was 54%, while the rate for Dewey was slightly lower at 38% (as cited in Ortman, 2010). The are many possible factors that contribute to this high rate of poverty.

The unemployment rate is extremely high at 88% (as cited in Ortman, 2010). Jobs are scarce in these counties, which are located some distance from urban areas. The infrastructure, the water and electrical systems, throughout the reservation are outdated and failing. This limits new growth, and therefore also limits new job opportunities. This infrastructure has been further impacted by the severe storms of the past winter, leaving the community even more distressed. Unlike many other reservations the reservation does not offer gambling, which provides many job opportunities for other reservations (Ortman, 2010).

According to Education Officials the extreme poverty of the reservations is impacting student success. The graduation rate among Indian students is only about 30%, as compared to the overall graduation rate throughout South Dakota of 75%. This is attributed to the poor physical condition of schools. Also of concern is the lack of qualified teachers, as well as outdated texts and limited supplies (Brokaw, 2010).

While all of these may be contributing factors in the issue of alcoholism, it is also important to look at the correlation aspect of this cycle. It is hard to determine which factor is causing which. Alcoholism is a vicious cycle that is hard to break. Does the poverty rate lead to alcoholism or does the alcohol rate contribute to the poverty level? Black Elk (2010), of the Oglala Lakota, describes the values of the Lakota nation as a circle:

You have always noticed that everything an Indian does is in a circle and that is because the Power of the World always works in circles, and everything tries to be round…The sky is round, and I have heard that the earth is round like a ball, and so are all the stars. The wind, in its greatest power, whirls. Even the seasons form a great circle in their changing, and always come back to where they were. The life of a man is a circle from childhood to childhood, and so is everything where power moves. (p. 6)

The cycle of poverty and alcoholism is one which we would like to help break.

Solution Proposal

According to Martins et al. (2006), “Native Americans have endured social, racial, and economic oppression but have persevered despite these struggles” (para. 39). Native Americans have experienced discrimination, oppression, disease, enslavement, and war, since the first European settlers arrived in North America. The negative treatment that Native Americans have been exposed to has created negative psychological effects that tend to be transmitted across generations, which creates a stronger cultural bond but promotes isolationist attitudes towards the majority culture, causing separation and marginalization. Co-opting the stresses of previous generations when they themselves are faced with oppression or marginalization, Native Americans, because of their unique cultural history, may suffer a form of intergenerational post-traumatic stress disorder. Some, however, are able to succeed in assimilation and integration, but this outcome requires effort and energy to maintain the acculturation. Native American youth who leave home to attend college tend to exhibit generalized anxiety, more so than those youths who attend college closer to home. This may be a manifestation of anxiety of identity when relating to the majority culture (Allen, 1973; Bowker, 1992; Martins et al., 2006, Milbrodt, 2002).

Native Americans are prone to certain health problems more than are other segments of the population. For example, there are high rates of type 2 diabetes, heart disease, obesity, and alcoholism among Native Americans. The rate of type 2 diabetes is four times the national average for American Indian elders, affecting one in five. Consistent with the general population, however, heart disease is the leading cause of death for Native Americans. In comparison to that of other racial and ethnic groups, the life expectancy of Native Americans is appreciably lower. According to the work of Everett Rhoades, reasons for this discrepancy may include poverty, greater risk of interpersonal violence, increased abuse of substances, vehicular accidents, and greater rates of disease (e.g. diabetes). (Martins et al., 2006, para. 19)

Native Americans share several mental health risks due to common sociocultural factors, such as poverty, poor health care access, and the isolation and lack of opportunity felt living on some of the reservations (Han et al., 1994; Martins et al., 2006, Milbrodt, 2002). The most common mental disorder among both children and adult Native Americans is depression, raising the risk of suicide tremendously, especially with concomitant substance abuse (French & Hornbuckle, 1980; Martins et al., 2006; Milbrodt, 2002; Ogden, Specter, & Hill, 1970).

Although the strong cultural and ethnic identity shared by Native Americans may contribute to stress and depression, participation in cultural and ceremonial activities may prove to be protective against the same stress and depression (Martins et al., 2006). Additionally, Martins et al. (2006) describes how the strong family emphasis that many Native Americans value may prove protective against psychological distress.

Substance abuse may also be combated with traditional cultural treatments, such as sweat lodges, the Red Road, and the Recovery Medicine Wheel (a 16-step program that utilizes a culturally important facet of circular attribution rather than linear progression; Martins et al., 2006). However, it is important to note that the problem is not entirely socioeconomic. According to growing genetic research, Native Americans are known to posses certain genetic variations that raise their risk of alcohol dependency (Edenburg et al., 2006; Ehlers, 2010; Mulligan et al., 2003; Spillane & Smith, 2007; Wall, Carr, & Ehlers, 2003; Wall, Garcia-Andrade, Thomasson, Carr & Ehlers, 1997). This fact may be detrimental to any substance abuse counseling if neither the counselor nor the patient understand the ramifications.

Economically, Vinje (1996) finds that although, focusing on governmental and private employment rates and promoting natural resource management and manufacturing typically fall short of economic goals, education is a sustainable mainstay requirement for reducing poverty levels. Gaming is certainly a viable option (Feinstein, 1994; Pommersheim, 1984), but as Vinje points out, it frequently “falls short in its objective” (p.427). Expandinging the economy should certainly remain a high priority goal as it will not only create a more comfortable life for those living on the reservation, but it will also decrease the psychological burdens to allow more happiness in their lives (Pickering, 2000; Pommersheim, 1984; Vinje, 1996).

Conclusion

The Sioux are a great people with a rich culture and expansive history. Unfortunately, some of the reservations, specifically the Cheyenne River Sioux reservation, find themselves battling elevated incidences of alcoholism, interpersonal violence, depression, and suicide. We feel that there is no singularity in this problem, and the focus and solution need to be comprehensive in order to be effective.

The Sioux tend to be marginalized, which is a lasting symptom of the intolerances and mistreatment that have been thrust upon them since the European settlement of North America. As the Sioux have been relegated to reservations of land that the United States government felt were of little use to the nation, it is understandable that the Sioux had a difficult time finding economic value in the land that was kept separate from the majority European culture. This, in addition to the misguided attempts at forcing the Sioux into acculturation, has continued to marginalize the Native American tribe to a point where a negative psychology is so pervading as to be transmitted from generation to generation. Depression is now prevalent throughout the Sioux tribe.

In order to provide an escape from the daily strife of a poor economy and lower sense of self, some may feel the need to turn to mind-altering substances. This reliance on drugs and alcohol may provide the psychological relief sought, but it does nothing to better the community and increases the incidences of violence, whether aimed at others or self-directed. Additionally, recent findings have suggested that Native Americans have a predisposition, genetically, to alcoholism. The addiction of alcohol in the company of mental distress usually leads to a singular conclusion: suicide.

As stated, the Sioux have a rich cultural history, and should rely on their knowledge of nature and the traditional values to create comprehensive programs which address these issues holistically (i.e. involving the whole person and their community). These programs, however, should not focus on preventing negative issues so much as they should promote a reacceptance of the traditional values, leading to a maximal appreciation of the life skills required to reinvest themselves in their community. The Sioux concept of family is one that promotes health and stability by encouraging a reliance on not only the community but themselves as well.

With more of the community involved in creating a better life on the reservation, there is a better chance of individual members creating their own personal economies, which in turn will better the economy of the reservation and other reservations surrounding them.

The answer is circular.

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