Παρασκευή, 17 Ιουνίου 2016

Tips to prevent, manage EMS scene disagreements

While much of the care provided in EMS is governed by protocols, providers are being given more latitude when deciding how best to treat a patient. In this way, protocols are being used to define a specific scope of practice, but medical care in the mobile environment is much more of a reflection of the individual provider than it once was.

With this shift towards individual practice the chances of an on-scene disagreement between providers increases. No longer can everyone simply point to a rigid protocol for guidance.

While increasingly common, not all disagreement is a bad thing. Several skilled, well-informed providers discussing possible treatment options for a complex patient is an effective and desired approach to medical care.

The most important aspect, however, is to develop a treatment plan in a collaborative fashion with the patient's best interests in mind.

Why we do what we do
Most EMS providers have been asked during a job interview some variation of the question: "What made you choose a career in EMS"" Many answered with some variation of, "To help people."

The fact that this answer is common, though, doesn't make it any less true. Most providers of EMS, volunteer or career, started in the industry to help people.

That pledge to your patient, however, goes beyond just "helping." More specifically, that pledge is to be an advocate for your patient.

While that often means simply providing good medical care, it may also mean ensuring that a patient is comfortable prior to transport, is being seen quickly in the emergency department or is removed from an unsafe home situation.

In the context of an on-scene disagreement about how best to treat a patient, the best approach is to start from a position of patient advocacy and to proceed from there to a resolution.

How to manage differences of opinion
It is important to realize that loud, emotional disagreements between providers does not inspire patients' and bystanders' confidence in the EMS system. Alternatively, starting from a position of patient advocacy, both parties can calmly explain why their approach is most advantageous to the patient.

It's not about being right. It's about doing the right thing for the patient.

Above all else, keep the conversation civil and appropriate. Additionally, realize that while providers may disagree, they are both motivated by good intentions. The two treatment options likely aren't that far apart in most cases.

The myth of rank
Local rules vary, but generally the agency with investigative jurisdiction has ultimate authority on the scene of emergency calls. This is relatively clear cut on a vehicle crash (police jurisdiction) or a structure fire (fire jurisdiction), but becomes muddy on medical calls that may involve police or fire agencies responded with an EMS agency.

As a result, many medical directors have a protocol that states that the individual with the highest level of licensure on a medical call has command of the scene. But what if a fire captain from a BLS engine and a firefighter paramedic from an ALS ambulance disagree on patient care"

Ultimately, sorting out rank is an operational function for each department and system to determine. On scene is not an appropriate time to have a discussion about the merits of rank versus licensure level. Save the operational questions for before or after a call.

Every EMS system has the provision to speak with a physician in real time when needed. If on scene medical providers are unable to reach a consensus about patient care, involving medical direction is a great option.

Doing so brings a third, likely unbiased party into the discussion who can make a decision based on the patient's presentation and available treatment options.

Conclusion
Feeling strongly that Sarah, a soccer player with a leg injury, should receive pain management before splinting, you ask to speak with the paramedic for a moment while his partner goes to get the stretcher.

"Here's the thing," you say. "We tried to apply direct pressure to the open wound before we placed her leg in the splint and she seemed like she was in incredible pain. She has obvious deformity and her vital signs certainly demonstrate her level of distress.

"Since we need to splint that leg tightly to control the bleeding and then wheel the stretcher across the field, I thought it would be better for her to be as comfortable as possible before we did that. I just don't want to cause her anymore pain than we have to."

The paramedic thinks for a moment and says, "No, you're absolutely right. Thanks for the suggestion. I wanted to get her to the hospital quickly knowing that she's going to need surgery, but it's worth taking a few minutes to make her comfortable"

He radios to his partner and asks her to bring the intravenous kit and narcotics box along with the stretcher.

Sarah receives 100 mcg of fentanyl before her leg is splinted and she is loaded on the stretcher for transport. En route she receives repeat doses of fentanyl every five minutes until her pain is well managed.



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Tips to prevent, manage EMS scene disagreements

You were asked to assess and treat a 22-year-old woman with an obvious leg fracture and there was a disagreement about how to proceed; did you make the right call?

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Clinical scenario: Soccer player with a leg injury

You are dispatched to a local park for an adult with a traumatic extremity injury

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Ramp-up tones used by Beloit Fire Department



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Ramp-up tones used by Beloit Fire Department



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Veterinary Hospital Dissemination of CTX-M-15 Extended-Spectrum Beta-Lactamase–Producing Escherichia Coli ST410 in the United Kingdom

Microbial Drug Resistance , Vol. 0, No. 0.


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First Detection of VIM-4-Producing Pseudomonas aeruginosa and OXA-48-Producing Klebsiella pneumoniae in Northeastern (Annaba, Skikda) Algeria

Microbial Drug Resistance , Vol. 0, No. 0.


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Early High-Dose Caffeine Increases Seizure Burden in Extremely Preterm Neonates: A Preliminary Study

Journal of Caffeine Research , Vol. 0, No. 0.


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Multicentre experience using daclatasvir and sofosbuvir to treat hepatitis C recurrence after liver transplantation - The CO23 ANRS CUPILT study

Journal of Hepatology

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Factors influencing recurrence following initial hepatectomy for colorectal liver metastases

British Journal of Surgery

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Mortality trends in U.S. adults with septic shock, 2005-2011: A serial cross-sectional analysis of nationally-representative data

BMC Infectious Diseases

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Long-term effects of a randomized, controlled, tailor-made weight-loss intervention in primary care on the health and lifestyle of overweight and obese women

American Journal of Clinical Nutrition

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Comparing characteristics of sporadic and outbreak-associated foodborne illnesses, united states, 2004-2011

Emerging Infectious Diseases

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Statins associated with decreased risk of new onset inflammatory bowel disease

The American Journal of Gastroenterology

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Antibiotics use pattern and appropriateness among children in the treatment of cough/cold and diarrhea

Value in Health

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The autophagosomal snare protein syntaxin 17 is an essential factor for the hepatitis c virus life cycle

Journal of Virology

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Prediction of clinically significant bleeding following wide-field endoscopic resection of large sessile and laterally spreading colorectal lesions: A clinical risk score

The American Journal of Gastroenterology

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Laparoscopic versus open distal gastrectomy for locally advanced gastric cancer after neoadjuvant chemotherapy: Safety and short-term oncologic results

Surgical Endoscopy

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Evidence-based clinical practice guidelines for liver cirrhosis 2015

Journal of Gastroenterology

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New paradigms in clonal evolution: Punctuated equilibrium in cancer

The Journal of Pathology

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Development and validation of a risk scoring system for severe acute lower gastrointestinal bleeding

Clinical Gastroenterology and Hepatology

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Online platform to embrace wide community of people affected by genetic diseases



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Table of Contents, Volume 170A, Number 7, July 2016



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Elastins from patients with Williams–Beuren syndrome and healthy individuals differ on the molecular level

Williams–Beuren syndrome (WBS) is a congenital disorder, which involves the heterozygous deletion of the elastin gene and other genes on chromosome 7. Clinical symptoms that are associated with hemizygosity of the essential extracellular matrix protein elastin include premature aging of the skin and supravalvular aortic stenosis. However, only little is known about the molecular basis of structural abnormalities in the connective tissue of WBS patients. Therefore, for the first time this study aimed to systematically characterize and compare the structure and amount of elastin present in skin and aortic tissue from WBS patients and healthy individuals. Elastin fibers were isolated from tissue biopsies, and it was found that skin of WBS patients contains significantly less elastin compared to skin of healthy individuals. Scanning electron microscopy and mass spectrometric measurements combined with bioinformatics data analysis were used to investigate the molecular-level structure of elastin. Scanning electron microscopy revealed clear differences between WBS and healthy elastin. With respect to the molecular-level structure, it was found that the proline hydroxylation degree differed between WBS and healthy elastin, while the tropoelastin isoform appeared to be the same. In terms of cross-linking, no differences in the content of the tetrafunctional cross-links desmosine and isodesmosine were found between WBS and healthy elastin. However, principal component analysis revealed differences between enzymatic digests of elastin from healthy probands and WBS patients, which indicates differing susceptibility toward enzymatic cleavage. Overall, the study contributes to a better understanding of the correlation between genotypic and elastin-related phenotypic features of WBS patients. © 2016 Wiley Periodicals, Inc.



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Publication schedule for 2016



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In this issue



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Autism variants can influence behavior, communication traits in general population



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Cover Image, Volume 170A, Number 7, July 2016

Thumbnail image of graphical abstract

The cover image, by Alfredo Brusco et al., is based on the Original Article Whole exome sequencing is necessary to clarify ID/DD cases with de novo copy number variants of uncertain signifi cance: Two proof-of-concept examples, DOI: 10.1002/ajmg.a.37649.



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Delayed diagnosis in a house of correction: Smith–Magenis syndrome due to a de novo nonsense RAI1 variant

We report a 25-year-old female confirmed to have Smith–Magenis syndrome (SMS) due to a de novo RAI1 variant. Her past history is significant for developmental and intellectual delay, early and escalating maladaptive behaviors, and features consistent with significant sleep disturbance, the etiology of which was not confirmed for over two decades. The diagnosis of SMS was initially suspected in 1998 (at age 12 years), but that was 5 years before the initial report of RAI1 variants as causative of the SMS phenotype; cytogenetic fluorescence in situ hybridization studies failed to confirm an interstitial deletion of 17p11.2. Re-evaluation for suspected SMS was pursued with RAI1 sequencing analysis in response to urgent parental concerns of escalating behaviors and aggression with subsequent incarceration of the subject for assault of a health professional. Genetic analysis revealed a de novo RAI1 (NM_030665.3) nonsense variant, c.5536C>T; p.Q1846X. This case illustrates the importance of confirming the SMS diagnosis, which is associated with cognitive and functional impairment, as well as significant psychiatric co-morbidities and behavioral problems. The diagnosis was particularly relevant to the legal discussion and determination of her competence to stand trial. As other similar cases may exist, this report will help to increase awareness of the possibility of a very late diagnosis of SMS, with the need for re-evaluation of individuals suspected to have SMS who were initially evaluated prior to the identification of the RAI1 gene. © 2016 Wiley Periodicals, Inc.



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