Category Archives: Emergency Management

Academia, Clinical, Emergency Medical Services, Health Care, Public Health, Technology

Scrutinizing the Literature of EMR

 As I scrutinize Dimitropoulos and Rizk (2009) for possible inclusion in a literature review for my research, I find it both promising and troubling. The article appears to be pertinent to my research question of how various laws and practices might adversely affect shared access of electronic health records; however, it is important to understand if this article is a documentation of primary research or a review of existing research, and as I describe below, this is unclear. This lack of clarity obscures other facets of the article that important to a researcher. These are also described below.

Initially, the work of Dimitropoulos and Rizk appears to be pertinent to my research based on the title and the publication in which it appears. Health Affairs is a respected journal within the realm of public health research, practice, and instruction, and it is ranked seventh of all health policy and service journals by Journal Ranking (http://www.journal-ranking.com). Publication within Health Affairs does not degrade the reputation of the authors and serves only to promote their work to their peers. As my research is within the realm of public health, Health Affairs is an obvious avenue to pursue for relevant work, and as this article by Dimitropoulos and Rizk appears to reflect a specific focus on the relationship between privacy laws and the ability, or lack thereof, to share health information, it appears to have relevance.

According to the abstract, Dimitropoulos and Rizk (2009) examine how variations is state (and, territorial) privacy laws might inhibit sharing health information via an central exchange, or repository. Though it would seem plausible for Dimitropoulos and Rizk to conduct their own research, the abstract seems to imply that they are merely reporting on the findings of a committee charged with examining such irregularities in privacy laws amongst the states and territories, presumably, of Canada. After reading the report, though, I find a disconnect between the abstract and the article. In the abstract, it appears more as if the authors are detached reporters, but within the body of the article, it seems as though they appear to take ownership of the primary research. This is confusing as it was plainly stated that the research was conducted by a large consortium of state officials: “the project initially engaged organizations in thirty-four … and later … forty-two jurisdictions. This collaborative work is commonly referred to as the Health Information Security and Privacy Collaboration (HISPC)” (p. 429).

This report is confusing to read as the perspective shifts frequently between first- and third-person. Additionally, the authors describe opinions formed and emotions felt during the primary research (opinions and emotions that only the primary researchers could know), yet it is unclear if these were transmitted through other writing or if the authors formed and felt these themselves. It is unclear whether the authors, Dimitropoulos and Rizk (2009), were participating researchers or merely reporters.

Both authors are noted to work for RTI International’s Survey Research Division, yet this corporation is not credited with any of the original research (Dimitropoulos & Rizk, 2009). I would have to conduct further research into the authors, their employer, and the project, itself, in order to make a final determination of the credibility of this article. This research would, hopefully, give the authors’ words better context, also. Complicating this is the absence of clearly delineated references, although a few appear within the Notes section that appear to be worth investigating.

Dimitropoulos and Rizk (2009) describe an effort to create a cohesive environment that will enhance the ability to share health information throughout a number of jurisdictions. As such, there is no scientific inquiry and it follows that adherence to the scientific method would be inappropriate. Again, however, it is unclear if this research is original or not.

In closing, it appears that Dimitropoulos and Rizk (2009) are credible in their writing; however, as each article must be able to stand on its own, and the article is lacking in form and perspective, I question the origination, application, and utility of this article, at least as it pertains to my original research question. Privacy in computing has been a major concern in the past two decades (Johnson, 2004). I feel that I could find more pertinent literature by expanding my search beyond this article.

References

Dimitropoulos, L. & Rizk, S. (2009).A state-based approach to privacy and security for interoperable health information exchange.Health Affairs, 28(2), 428-434. doi:10.1377/hlthaff.28.2.428

Johnson, D. G. (2004). Computer ethics. In L. Floridi (Ed.), The Blackwell guide to the philosophy of computing and information (pp. 65-75). Malden, MA: Blackwell.

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

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, 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, Politics, Public Health, Society

Addressing Health Disparities

It is troubling to many people to see any person suffering in our society. It is even more troubling to see inequality extend to whole ethnic and racial groups within our society. We certainly do not want to be an unjust society, and we certainly want every member of our society to benefit from the technological gains made in the last century.

One of the more troublesome areas that many view as unjust is health and health care. It is unfortunate that some members of our society suffer from disparities in health. For instance, immunizations and vaccines for most of the common deadly pathogens are readily available, yet many people fail to immunize themselves or their family.

Immunization and vaccination programs have eradicated smallpox and polio and have all but eliminated the threat of measles in the United States (U. S. Department of Health and Human Services [DHHS], 2000). With influenza and pneumonia causing 30,000 to 41,000 deaths in the U. S., annually, the importance of vaccinating against these diseases is quite evident. Obviously, lacking immunity to a deadly pathogen is a disparate condition of health status, and Hispanic and African American populations are vaccinated with less frequency than Whites. How are these issues being addressed?

On the international level, the United Nations (2009) is addressing health disparities by attempting to eradicate poverty on a global scale. Unfortunately, many of these global initiatives have created an environment rife with economic turmoil that we are just now starting to see and understand. Though the premise of helping people out of poverty is very noble, the reality seems to be that we can only offer means for people to help themselves. Otherwise, we risk thrusting whole populations into a world they know nothing about, setting them up for failure. Poverty is based on local economy, and I believe that these interrelated problems are best addressed on the local levels with assistance from states, nations, and global endeavors. The people must direct their own path for a successful transition. They must take responsibility for their own successes and failures.

The United States addresses these concerns on a federal level, offering guidance to states and municipalities in ways to address them. One of these methods is a report from the U. S. Department of Health and Human Services. Healthy People 2010 (DHHS, 2000) has two stated major goals: 1) to increase quality and years of healthy life, and 2) to eliminate major health disparities. There are also 467 objectives in 28 focus areas designed to further these two major goals. Immunization is one of these focus areas.

According to the CDC’s National Center for Disease Statistics (2010), the goal of achieving a 90% immunization rate for children 19-35 months of age is close to being reached. The combination diphtheria, tetanus, and pertussis (DTP) vaccine (85%) and pneumococcal conjugate vaccine (75%) are the only two recommended childhood vaccines that are not being administered at least 90% of the time. According to DHHS (2000), the goal for DTP vaccination was 80% in 2000. It appears that this goal has been reached and exceeded.

Conversely, older adults, age 65 and greater, are at an increased risk of contracting illnesses that could be prevented by vaccination. “In 1999 approximately 90 percent of all influenza and pneumonia-related deaths occurred in individuals aged 65 and older” (Centers for Disease Control and Prevention, Office of Minority Health and Health Disparities, 2007, para. 2). DHHS (2000) does not state a quantitative goal for vaccinating noninstitutionalized older adults, though it does mention a need to “increase the proportion of noninstitutionalized adults who are vaccinated annually against influenza and ever vaccinated against pneumococcal disease” (p. 42). In 2000, 46% of the population in the U. S. were vaccinated against pneumococcal disease, and 64% were vaccinated against influenza (DHHS, 2000). In 2009, pneumococcal disease vaccinations increased by 15%, whereas influenza vaccinations increased by only 3% (Centers for Disease Control and Prevention, National Center for Health Statistics, 2010).

Striving to eliminating health disparities is a noble endeavor; however, the mere fact of attaining this goal contributes to the increase of health care disparity. By increasing the health care delivery model for one at-risk population, we must accept negative gains in the delivery of health care for all other populations. This is an example of the law of conservation describing the divisional nature of finite resources: when an isolated system undergoes change, its change in entropy will be zero or greater than zero (Negi & Anand, 1985). This concept is better stated as it applies to the zero-sum game of our economics today. Kathleen Madigan (2010), in a Wall Street Journal blog post, stated, “More spending in one area has to be financed by less purchases elsewhere” (para. 5).

Two conclusions can be drawn from observing this phenomena in health care. First, if people are spending their health care dollars on other staples, such as food, clothing, and shelter, then we should see a decline in the health of individuals that are making these choices. Second, within health care, in order to increase a focus on one population, an equal negative effect will be seen in all other population groups.

In all aspects of health care delivery, care should be taken to ensure just and equitable delivery of care regardless of socioeconomic factors, race, gender, religion, or creed. All people should have access to the minimum required care in order to maintain a healthy and productive life. We can counsel and educate our patients and clients to best health practices, but we cannot, however, force people to choose health over other facets of their lives.

References

Centers for Disease Control and Prevention, National Center for Health Statistics. (2010). Immunization. FastStats. Retrieved from http://www.cdc.gov/nchs/fastats/immunize.htm

Centers for Disease Control and Prevention, Office of Minority Health and Health Disparities. (2007). Eliminate disparities in adult & child immunization rates. Retrieved from http://www.cdc.gov/omhd/AMH/factsheets/immunization.htm

Madigan, K. (2010, August 3). With wallets thin, consumers face zero-sum game. Real time economics: Economic insight and analysis from the Wall Street Journal. Retrieved from http://blogs.wsj.com/economics/2010/08/03/with-wallets-thin-consumers-face-zero-sum-game/

Negi, A. S. & Anand, S. C. (1985). The second law of thermodynamics. A textbook of physical chemistry (pp. 241-289). Retrieved from http://books.google.com/

United Nations. (2009). The millenium development goals report: 2009. Retrieved from http://www.un.org/millenniumgoals/pdf/MDG_Report_2009_ENG.pdf

U.S. Department of Health and Human Services. (2000, November). Healthy People 2010: Understanding and improving health (2nd ed.). Washington, DC: U. S. Government Printing Office.

Academia, Health Care, Public Health, Society

Cultural Influences on Health Disparities

Disparities in the availability, access, and delivery of health care are a great and growing concern. Some of the factors leading to disparite health include race, socioeconomic status, and gender (Chen, Martin, & Mattews, 2006). Chen et al. describes how race and socioeconomic status are major factors in the United States, based on the Healthy People 2010 data (U.S. Department of Health and Human Services, 2000). According to the results of this study, our public health efforts seem to be misguided. As the researchers of this study indicate, “race and SES effects on child health are best understood in concert, rather than separately” (p. 705). The differences in race and socioeconomic status are a factor only to White and Black children when looking at prevalence rates for activity limitations and circulatory conditions, as illustrated by Chen et al. in Figures 1 and 2. These figures show that higher education actually has a small but negative effect on the health status of Asians and Hispanics while having a dramatically positive effect on Blacks. Additionally, in Figure 3, Chen et al. show a significant negative effect of education on incidence rates for acute respiratory conditions. There is no significant relationship for the same with regards to Whites or Blacks.

This study shows that there are certainly correlations between race, economic status, and differences in the health status of children in America, but these factors might only be relative. We need to understand if other factors can be identified as causative. In order to explain how Whites and Blacks share correlations while Asians and Hispanics share correlations, we might consider the length of time each population has been exposed to American culture. Whites and Blacks have been in America for over 300 years while Asians and Hispanics have migrated more recently. In addition, there is also evidence of attitude and preference differences for minorities towards health care, though the Institute of Medicine (2002) marginalizes this phenomena in their study.

As a health care provider and regardless of the causes of disparities in health status, it is advisable that I understand these causes so that I may better direct a patient’s care with a holistic understanding of the patient.

References

Chen, E., Martin, A. D., & Matthews, K. A. (2006). Understanding health disparities: The role of race and socioeconomic status in children’s health. American Journal of Public Health, 96, 702-708. doi:10.2105/AJPH.2004.048124

Institute of Medicine. (2002). Unequal treatment: What healthcare providers need to know about racial and ethnic disparities in health. Retrieved from http://www.nap.edu/html/unequal_treatment/reportbrief.pdf

U.S. Department of Health and Human Services. (2000). Healthy people 2010: Understanding and improving health. Washington, DC: Author.

Academia, Emergency Management, Health Care, Public Health, Society

Immunization and Infectious Disease Mitigation

Cultural Models of Immunization and Infectious Disease Mitigation

The members of some communities, such as Puerto Rico, do not understand the scope and severity of some infectious diseases until they become infected (Pérez-Guerra, Zielinski-Gutierrez, Vargas-Torres, & Clark, 2009). The lack of a basic understanding of illness and infection poses a roadblock to mitigating disease transmission within the community. For Pérez-Guerra et al., the perception of severity and mitigation is important as they investigate the difference in attitudes towards dengue infections because dengue cannot be controlled by vaccine and must be mitigated by community participation in mosquito abatement activities. Other infectious diseases, however, can be controlled by vaccine, but efforts to limit infection are met with ignorance or misconceptions (Lau, Griffiths, Choi, & Tsui, 2010; Leask, Sheikh-Mohammed, MacIntyre, Leask, & Wood, 2006).

Public health officials, in concert with community leaders, should seek to educate affected communities about the infectious diseases they face along with effective mitigation strategies and the importance of vaccination, if available. Coreil (2010) describes the importance of cultural models in “[gaining] a deeper understanding of the cultural context of behavior” (p. 83). If behaviors are not understood, then it will be difficult to redirect them. Reaching out to community leaders has the added effect of allowing the leaders to alter the message just enough so that it might be effectively communicated to the community.

Providing a cultural health model allows for a larger scope of audience while effectively tailoring the message so that most of the target audience will appreciate the nature of the message. Approaching health behaviors from a cultural stand-point also offers the advantage of allowing peer support to propagate messages through out the community. This might be especially true when dealing with a multitude of subcultures where the message might better be disseminated via interpersonal means. Eventually, the message will be received by many individuals who will begin to have discussions with others in the community. For communities where individuals are not likely to speak to each other regarding personal health-related matters, the cultural health model allows a general message to reach each individual.

References

Coreil, J. (Ed.). (2010). Social and behavioral foundations of public health (2nd ed.). Thousand Oaks, CA: Sage.

Lau, J. T. F., Griffiths, S., Choi, K. C., & Tsui, H. Y. (2010). Avoidance behaviors and negative psychological responses in the general population in the initial stage of the H1N1 pandemic in Hong Kong. BMC Infectious Diseases, 10(139), 1-13. doi:10.1186/1471-2334-10-139

Leask, J., Sheikh-Mohammed, M., MacIntyre, C. R., Leask, A., & Wood, N. J. (2006). Community perceptions about infectious disease risk posed by new arrivals: A qualitative study. The Medical Journal of Australia, 185(11/12), 591-593. Retrieved from http://www.mja.com.au/public/issues/185_11_041206/lea10999_fm.pdf

Pérez-Guerra, C. L., Zielinski-Gutierrez, E., Vargas-Torres, D., & Clark, G. G. (2009). Community beliefs and practices about dengue in Puerto Rico. Pan American Journal of Public Health, 25(3), 218-226. doi:10.1590/S1020-49892009000300005

Academia, Emergency Management, Health Care, Public Health, Society

Social Ecology of Immunization and Infectious Diseases

Vaccines are very useful as preventive medicine in public health to reduce morbidity and mortality due to communicable diseases, though they are not a substitute to safe drinking water, sanitation, nutrition and environmental health in the long run.
(Madhavi et al., 2010, p. 618)

In dealing with infectious diseases, two primary methods of prevention are worthwhile: immunization and avoidance. Avoidance is nearly impossible as valence for various pathogens vary so greatly and community network structure influences (Ciccaroneet al., 2010; Salathé & Jones, 2010). Immunization, on the other hand, allows for proximal contact with a specific pathogen without the likelihood to effective transmission, or active infection. Immunization, or innoculation, is the process of introducing the immune system to potential future pathogens so that it may form lifelong antibodies that can readily attack the pathogen if infected in the future (Centers for Disease Control, 2009). Immunization is gaining stronger support in the face of a growing number of antibiotic-resistant pathogens and pathogens with a propensity for recombination under heavy environmentally selective pressures, and though antibiotic therapy is a reliable and effective secondary prevention method, it seems to be true that antibiotic therapy is becoming less effective the more we rely on it as a prophylaxis (Laxminarayan & Brown, 2001). Additionally, antibiotics are only effective in the treatment of bacterial infections and have no effect on viral infections. Antiviral medications are typically more expensive and less available.

Luckily, when speaking about infectious processes, there is little need for continuous care after the acute presentation (Ciccarone et al., 2010). The pathogen is typically eradicated from the host by means of the natural combative effects of the immune system in combination, when required, with pharmacological assistance, and there is only a small chance of the host suffering any lasting effects. Unfortunately, there are some pathogens that continue to cause harm well after the acute phase of infection. Pathogens, such as the human immunodeficiency virus, ravage the immune system making the host susceptible to a number of other opportunistic infections that can become life-threatening. Other pathogens, such as hepatitis, can damage the natural filtration system of the host’s body that other deleterious effects surface creating a chronic disease process of the organs. In these, and other, cases, tertiary prevention strategies can help to offer the host a meaningful quality of life with the presence of the disease process. Some effective tertiary methods include medications aimed at improving the function of certain organs or systems. Diet and exercise also plays a major role in tertiary prevention strategies (Stokols, 1992).

Depending on the particular pathogen, infection might not affect me as much as others. As a paramedic, I have a comfortable knowledge of infectious disease processes, and I understand that a simple regimen of antibiotic medication, along with rest and fluid intake, will cure most of the infectious bacterial diseases that I might face, albeit some drug-resistant pathogens are not so easy to manage. Additionally, I have isolation equipment at my disposal that allows me to create a barrier from these and other infectious diseases. Ciccarone et al. (2010) further describe many of the psychosocial barriers Asian and Pacific Islanders face when confronted with the early stages of some infections. “Psychosocial issues such as depression, embarrassment, and shyness were reported to have influenced time to seeking medical attention” (Ciccarone et al., 2010, p. 143). Although I accept that I may suffer one or more of these barriers, my education, along with mandatory workplace reporting requirements, empower me to seek medical care when needed.

Addressing prevention strategies, Stokols (1992) introduces a model using the social ecology of health. Though he does not categorize primary, secondary, and tertiary means, he does hint at prevention strategies being proximal or distal. Further, Stokols outlines a variety of means related directly to an understanding of environmental roles and pressures. Understanding how an individual relates to, from, and within his or her ecology allows the health practitioner to provide more focused means of prevention and education.

References

Centers for Disease Control. (2009). Parent’s Guide to Immunizations [Excerpt]. Retrieved from http://www.cdc.gov/vaccines/vac-gen/downloads/pg_how_vacc_work.pdf

Ciccarone, R. M., Kim, M., Tice, A. D., Nakata, M., Effler, P., Jernigan, D. B., … & Sinkowitz-Cochran, R. L. (2010). Prevention of community-associated methicillin-resistant staphylococcus aureus infection among Asian/Pacific Islanders: A qualitative assessment. Hawai‘i Medical Journal, 69(6), 142-144. Retrieved from http://web.ebscohost.com.ezp.waldenulibrary.org/

Laxminarayan, R. & Brown, G. M. (2001). Economics of antibiotic resistance: A theory of optimal use. Journal of Environmental Economics and Management, 42(2), 183-206. doi:10.1006/jeem.2000.1156

Madhavi, Y., Puliyel, J. M., Mathew, J. L., Raghuram, N., Phadke, A., Shiva, M., … & Banerji, D. (2010). Evidence-based national vaccine policy. Indian Journal of Medical Research, 131, 617-628. Retrieved from http://web.ebscohost.com.ezp.waldenulibrary.org/

Salathé, M. & Jones, J. H. (2010). Dynamics and control of diseases in networks with community structure. PLoS Computational Biology, 6(4), e1000736. doi:10.1371/journal.pcbi.1000736

Stokols, D. (1992). Establishing and maintaining healthy environments: Toward a social ecology of health promotion. American Psychologist, 47(1), 6-22. doi:10.1037/0003-066X.47.1.6

Politics, Public Health, Technology

Conquest of Indigenous Populations

The native Americans of the Great Lakes region were thankful for the opportunity to trade fur with the multitude of nations that presented themselves in friendship from the 14th to the 17th centuries (Reader’s Digest, 1978, p. 149). It was the conquest of land, ordered by King James I and King Charles II, that negatively affected the indigenous populations (p.149). It was this progressive agenda that marginalized the native Americans and ultimately caused King Philip’s year long war as well as other campaigns against the white settlers of the east coast (p. 152). Throughout this time, many tribal nations were decimated by other nations while competing for trade of the more powerful weapons the white settlers could provide. The tattered tribes would move and join in alliances with other defeated tribes to minimize the possibility of a recurrence and to ensure procreation and ultimate tribal survival (p. 152). This intermingling surely had an effect on the biological make-up of the various tribal nations. I feel that much of the negativity could have been avoided with a simple sense of respect.

Currently, there are many indigenous peoples facing a number of problems with colonization. The aborginal women of Ontario, Canada, are a specific example of how an overall lack of respect leads to the marginalization of a whole culture. “Aboriginal women have a lower life expectancy than non-aboriginal women, and higher incidences of diabetes, HIV/AIDS, tobacco addiction, and suicide (up to eight times the rate experienced by other women)” (as cited in Ontario Native Women’s Association [ONWA], n.d., p. 4). To address these concerns, the community has formed organizations like ONWA and the Native Women’s Association of Canada to provide a unified voice to advocate for improved status for aboriginal women in Canada. As their position paper states, “the ONWA makes recommendations for future actions to begin the process of initiating the necessary changes with a special focus on the need for grassroots control, activism, and leadership development for Aboriginal women” (p. 1). In addition to advocating for the equality of aboriginal women, the ONWA also advocates for the environment recognizing the increasing levels of waterway pollution and other environmental concerns.

Thus far, the ONWA has developed programs to address health concerns, gambling addictions, workforce development, housing and justice (ONWA, 2010). As a grassroots activist organization, the ONWA appears to be gaining ground for the equality of aboriginal women in Ontario.

References

Ontario Native Women’s Association. (n.d.). Contemporary issues facing aboriginal women in Ontario: An Ontario Native Women’s Association position paper. Thunder Bay, ON: Author.

Ontario Native Women’s Association. (2010, May 27). About us. Retrieved from http://www.onwa-tbay.ca/aboutus.htm

Reader’s Digest. (1978). In J. A. Maxwell’s (Ed.), America’s fascinating Indian heritage. Pleasantville, NY: Reader’s Digest Association.

Emergency Medical Services, Politics

Conversations in the Back of the Ambulance

MS: So, we have about a half-hour ride to the other hospital. Would you be willing to help me out with a project for my anthropology class?

AP: Sure, we’ve been having quite a conversation so far.

MS: Okay, for the record and because of medical privacy concerns I will acknowledge your participation with the initials AP for Anonymous Participant. Also, I have to make sure that I note the generational differences between us.

AP: Well, that shouldn’t be too hard to do.

MS: No, certainly not. For documentation sake, let us say that you are in your 70’s, and we can leave it at that.

AP: I’m closer to eighty, though?!

MS: Wow, can’t even do a guy a favor!

AP: HA! So, what are these questions? I imagine it’s how to pick up the ladies, right?

MS: Yeah, sure, let’s start there! Actually, I wanted to ask more about your views growing up. Politics, religion, et cetera.

AP: Well, let’s start with religion. I think that will be the easiest.

MS: Okay, religion.

AP: Well, let’s see… I grew up in a fairly Protestant family. I mean, we went to church every Sunday and all, but we were never overly religious.

MS: Would you say that you were tolerant of other religions, or did you view your religion as the true religion of your god?

AP: Oh, no! We were very tolerant. We would never look down on anyone else because of their beliefs, especially their religious ties. The only problems that I have ever had with people were, well, the neighborly scuff – whose fence is on whose property – and, of course, mechanics. $1000 to install a $25 part… highway robbery for sure! And, I am sure I won’t like you too much after I get your bill!

MS: Obama will take of that, though, right? Actually, I do want to talk about your political views here in a minute, but let’s keep on religion for now. Do you think your views of religion have changed much over the years?

AP: Well, that’s tough to say. I’m pretty old, and I know that I’m gonna die pretty soon. It makes you think, you know? I mean, I know I want to make sure that I get a chance to tell the kids and the grandkids how proud I am of them, and I pray to God every day that I will get that chance. They all live in different States, so it’s tough to get them all together, lately. But, I find myself talking to God a lot more these days, but I am not sure if I believe in Him any more than I used to, as an adult, I mean. As a kid, he’s like Santa Claus or the Tooth-fairy; you believe in Him for no other reason than you were told to.

MS: Yeah, that’s kinda where I’ve been. I can understand that there might be a consciousness that is ultimately responsible for our creation, but I am not sure if I believe he knows what exactly he has created. Accidental or otherwise, we do exist, and it would only make sense that something put this in motion. Maybe I’m a theist, but mostly I don’t think about it. I’m usually agnostic or atheistic. Perhaps, I’m an agnostic theist?!

AP: Well, when you get as old as me, you want to make sure you are on the good-boy list.

MS: That’s Santa?!

AP: Close enough.

MS: Alright, let’s talk politics. I’ll keep it simple at first. George Washington, good or bad?

AP: Good, no great! He was a great man, Washington.

MS: Tyler?

AP: Who?

MS: Abraham Lincoln?

AP: Great!

MS: Wilson?

AP: What? Woodrow Wilson? Ungh… That was an evil man. Let me tell you about Wilson. Wilson is why this country is the way it is. I imagine that others before him wanted to do some of the things that he did, but sheesh, Wilson was the one that got it done. And, done, indeed, it is.

MS: What was so bad about Wilson?

AP: Have you ever heard of the Great Depression? That was Wilson’s work, there. Yeah, it happened a few years after he died, but the framework was his alone. Who were those other two guys? They came after Wilson…. I can’t think.

MS: Harding and Coolidge?

AP: That’s them. I remember my father telling me that if it weren’t for those two, Hoover wouldn’t have had a chance. Hoover was actually in office during the start of it, the depression. Lucky for me, I don’t remember it. In fact, don’t remember him. I think the first President that I can remember was F.D.R. He was the war President. As far as I recall, though, I think Hoover just ran with the Wilson plan, killing everything Harding and Coolidge did to fix the problems.

MS: So, I’m guessing you are a Conservative? A Republican, perhaps?

AP: I remember waving the flag for Roosevelt, so I guess I was a Democrat, then, you know, at twelve years old, or however old I was then… probably more like nine or ten. But, as I got older, especially from the time the war ended, I started paying attention to politics. I’ll tell you, it makes not one lick of difference if the guy is black, brown, yellow or white; if he’s a politician, he’s both a liar and a thief! We have had very few politicians that were honorable men, very few. And, these Progressives, well, they are the worst of them. This Obama is one of them.

MS: Yes, I believe Obama is a self-proclaimed Progressive.

AP: And, it shows. Wilson was a Progressive. Too many of them are. And, they don’t tell you! That’s the worst of them. They tell you what you want to hear, you elect them, then they do this about-face and spend, spend, spend us into oblivion. Looking back, this is certainly not my father’s country anymore. Ford was good, though. He never gets any recognition.

MS: So, Ford, good; Wilson, bad. Is that right?

AP: Yup!

MS: Interesting. I’m going to have to read up on Ford a bit more. You mentioned something about race a minute ago: “Brown, black, yellow, white”, something. What are your views on race relations in the United States?

AP: Oh, no… You aren’t gonna like me much after this conversation, but I’ll be honest. I always try to be honest.

MS: Okay, Ben Franklin, let me have it.

AP: Ha! Well, I can honestly… heh, honest… say that I have no problem doing business or maintaining friendships with anyone of any race, nationality, or creed. The problem that I have is the laziness and the sense of entitlement that many people have today. Fifty years ago, you didn’t see that, not like today, anyway. It’s just unfortunate that the minorities tend to have this attitude, this air of you’re not better than me, so give me money so I don’t have to work.

MS: Ahh, so the Progressives rear their ugly heads once again!

AP: Exactly! And, that’s what I was talking about. It’s this idea that if we give them money, they will use it to rise up and overcome poverty or something. Almost magical thoughts of levitation, if you will. One day, they will learn that if you keep giving people stuff, there will come a time when they forget how to earn it. Same with me. I’m sure that if the government sent me a check every week for not working, at some point, I would become complacent and not work. I doubt it, but it is possible I guess.

MS: Is it the government’s place to give out all of these entitlements?

AP: Again, I’m old, but I’ve made a pretty decent living for myself over the years. Medicare is a horrible system, but between that and my other insurance, at least you’ll get paid!

MS: Well, I’m not too worried about that. You sign my form, and that’s all I care about for payment. We have people!

AP: Yeah, tough guys always have people. But, community… community and family is what we need to get back to. That used to be enough. Granted, there were times that were really tough, especially for my family when I was born and right before. We had tough times, but we got through them. We were smart about it. We trusted that it couldn’t last too long, and it never did.

MS: Well, one thing that I’ve noticed is the propensity of my generation to move away from family. I think we rely on the internet for communication and planes, trains, and automobiles to visit from time to time.

AP: Well, we had a farm. When the family has a farm, you help run it. Actually, I think it was the farm that kept our heads above water all those years.

MS: I always wanted a farm. Is it still in the family?

AP: Nah. None of the kids wanted to keep it up. It is hard work running that farm, but we sold it off, paid our debts, and invested the rest. Pretty much been living on that after we retired.

MS: So, what was life like on the farm? I mean, family life specifically.

AP: Well, our farm was a part-time venture, so to speak. I would wake up, do some chores, have breakfast, go to work, come home, do some chores, eat dinner, do some chores, go to bed, and repeat. Don’t get me wrong, I enjoyed the hell out of it. The kids helped out when they were old enough, but the wife kept the whole ship running smooth. If it weren’t for her… well, let’s just say I wouldn’t still be here.

MS: Television and movies about years ago seemed to marginalize women. The wives cooked, cleaned, did the laundry, had babies… you’re laughing?

AP: My wife cooked, cleaned, did the laundry, had babies, sure, but I cooked, I cleaned, I did laundry, and I was very involved in the raising of our children. Don’t let those programs fool you. Family was family. We did it all. In fact, we both left for work at about the same time, though she would get home sooner than me. She only worked around the corner.

MS: You are describing a very concerted effort at keeping house and home.

AP: If you find a young woman to love, you take good care of her, and she will take good care of you. I remember a few guys that would mistreat their ladies, but back then, well, back then, we took care of things like that. Times get tough, but don’t mistreat your lady.

MS: Speaking of your wife, she said that she would meet us up here. So, I should give her all the respect in the world?

AP: Anything less, and I’ll smack you one!

MS: It seems chivalry ain’t dead!

AP: Not as long as I’m around, and I ain’t going anywhere, yet!

MS: No, it seems that you will be around to cause her grief for a little while longer, at least, but not with me. It seems like we’ve arrived. It was absolutely great hearing your story. I am honored. Is there anything that you would like to add?

AP: Yeah, tell the driver not to hit so many bumps next time!

MS: He’ll be opening the doors here in a minute. You can tell him yourself. Thank you again.

AP: Anytime, but next time, come by the house. I don’t need another ambulance bill!

MS: Understood.

As a paramedic, I enjoy many benefits. The single best benefit is certainly the ability to meet new people and talk to them. For this assignment, I felt it best to rely on the random nature of my job to gain the perspective of someone I have never met before. There are limitations, though, to this method of choosing a potential informant for this interview. Paramedics are bound by confidentiality, and though the informant granted express permission to use his words and his story, I could not ask him to waive his rights under the Health Insurance Portability and Accountability Act (1996). I felt that the limitation was not an undue hardship, and the benefits of gaining such a random perspective far outweighed the benefits of identification of the informant.

The informant that I interviewed was a 70-something year-old gentleman who was more than eager to share his story with someone so interested in listening. The most important discovery of the entire interview was that we all have interesting life lessons to share. If only more people would stop to listen, important lessons could be taught.

It is very important to note that this interview was conducted during a time when the informants mortality was in question. I feel that this opportunity is unique in the honesty and conviction of the responses to my questions. We started the interview by talking about religion.

The informant and I feel that we have quite the same religious background and beliefs (personal communication, June 2010). When I approached the topic of religious tolerance, he seemed to be more cognizant of character and overall morals separate from specific religious practices. This thought reinforced some of my core beliefs about the human condition, about how we are moral creatures.

Discussing politics gave me some real insight into how earlier Americans might have viewed the progressive versus conservative debate originally (Anonymous, personal communication, June 2010). I am sure that the informant is not an exemplar of all twentieth century American political thought, but he was able to draw some parallels with the current political environment. Tough times arise and people tend to get nervous about economic survival. It is easy to conceive that an incomplete understanding of politics and economics fuels the debate on both sides of the issues.

From politics, we moved on to discuss his view of race relations in the United States. Interestingly, it seems as though my informant might have been resigned to accept that he might have some racist tendencies until I asked him his thoughts and understanding of race (personal communication, June 2010). It turns out that he was slightly mistaken. My informant realized, during our conversation, that it was not racial differences that he was upset about but a general lack of motivation seen in many people over the years. It is just an unfortunate twist that he associated this laziness with racial stereotypes. Though we changed the subject quite abruptly, I could sense a rebuilding of his understanding of racial differences. It was good to see such a thing take place.

Family was strong throughout my informants life (personal communication, June 2010). Whether we were speaking of being raised by post-depression era parents or farm life with his own family, there was always cooperation to make the family structure work. I took exceptional notice during this portion of the interview. In the contemporary United States, I have noticed a disintegration of family and community. In childhood, I recognized the meaningfulness of family bonds and community spirit. I wonder how this changed. My informant describes a time that was not particularly easy on him or his wife, but they remained loyal to each other and to the family, specifically. Today, it outwardly appears to makes more sense for some to seek a better alternative at the first hint of difficulty or trouble. This is not what family means to either of us, and I am glad to see an example of how things work out pleasantly in the end.

Our interview ended with a particularly entertaining joke about him protecting his wife from any irresponsible comments that I might make (Anonymous, personal communication, June 2010). I am sure that he did not feel that he had to actually protect her from me, but I think he felt that he needed to make me understand how much he cared for his wife. Man to man, an idle threat seems to convey a universal understanding between men, whether serious or joking. I am glad to have witnessed this show of strength. I am sure that he is contemplating the fact that he will not be around much longer. I hope that he understands that he would leave his wife with good people in the world. I believe that this discussion was the impetus for my patient to realize that the world outside of [his neighborhood] is not a hostile or unfriendly world. I also think he realized that he will not be here forever, and his wife will be taken care of by the community that he supported for so long. I am glad to be a part of that community.

References

Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, §1177, 110 Stat. 2029 (1996).