tag:theconversation.com,2011:/us/topics/emergency-medicine-26454/articlesEmergency medicine – The Conversation2024-02-11T19:05:40Ztag:theconversation.com,2011:article/2219792024-02-11T19:05:40Z2024-02-11T19:05:40ZA new emergency procedure for cardiac arrests aims to save more lives – here’s how it works<p>As of January this year, Aotearoa New Zealand became just the second country (after Canada) to adopt a groundbreaking new procedure for patients experiencing cardiac arrest.</p>
<p>Known as “double sequential external defibrillation” (<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9907872/">DSED</a>), it will change initial emergency response strategies and potentially improve survival rates for some patients.</p>
<p>Surviving cardiac arrest hinges crucially on effective resuscitation. When the heart is working normally, electrical pulses travel through its muscular walls creating regular, co-ordinated contractions.</p>
<p>But if normal electrical rhythms are disrupted, heartbeats can become unco-ordinated and ineffective, or cease entirely, leading to cardiac arrest.</p>
<p>Defibrillation is a cornerstone resuscitation method. It gives the heart a powerful electric shock to terminate the abnormal electrical activity. This allows the heart to re-establish its regular rhythm.</p>
<p>Its success hinges on the underlying dysfunctional heart rhythm and the proper positioning of the defibrillation pads that deliver the shock. The new procedure will provide a second option when standard positioning is not effective.</p>
<h2>Using two defibrillators</h2>
<p>During standard defibrillation, one pad is placed on the right side of the chest just below the collarbone. A second pad is placed below the left armpit. Shocks are given every two minutes.</p>
<p>Early defibrillation can dramatically <a href="https://pardot.stjohn.org.nz/l/182252/2023-02-08/63fwb2/182252/1675908603ZVeUnZBf/Hato_Hone_St_John_OHCA_Summary_Feb23.pdf">improve the likelihood</a> of surviving a cardiac arrest. However, around 20% of patients whose cardiac arrest is caused by “<a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/ventricular-fibrillation">ventricular fibrillation</a>” or “<a href="https://my.clevelandclinic.org/health/diseases/23254-pulseless-ventricular-tachycardia">pulseless ventricular tachycardia</a>” do not respond to the standard defibrillation approach. Both conditions are characterised by abnormal activity in the heart ventricles.</p>
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<a href="https://theconversation.com/cardiac-arrests-in-young-people-what-causes-them-and-can-they-be-prevented-or-treated-a-heart-expert-explains-163276">Cardiac arrests in young people — what causes them and can they be prevented or treated? A heart expert explains</a>
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<p>DSED is a novel method that provides rapid sequential shocks to the heart using two defibrillators. The pads are attached in two different locations: one on the front and side of the chest, the other on the front and back.</p>
<p>A single operator activates the defibrillators in sequence, with one hand moving from the first to the second. According to a recent <a href="https://pubmed.ncbi.nlm.nih.gov/36342151/">randomised trial</a> in Canada, this approach could more than double the chances of survival for patients with ventricular fibrillation or pulseless ventricular tachycardia who are not responding to standard shocks.</p>
<p>The second shock is thought to improve the chances of eliminating persistent abnormal electrical activity. It delivers more total energy to the heart, travelling along a different pathway closer to the heart’s left ventricle.</p>
<h2>Evidence of success</h2>
<p>New Zealand ambulance data from 2020 to 2023 identified about 1,390 people who could potentially benefit from novel defibrillation methods. This group has a current survival rate of only 14%.</p>
<p>Recognising the potential for DSED to dramatically improve survival for these patients, the National Ambulance Sector Clinical Working Group updated the <a href="https://cpg.stjohn.org.nz/tabs/guidelines">clinical procedures and guidelines</a> for emergency medical services personnel.</p>
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Read more:
<a href="https://theconversation.com/arrested-development-can-we-improve-cardiac-arrest-survival-in-hospitals-100079">Arrested development: Can we improve cardiac arrest survival in hospitals?</a>
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<p>The guidelines now specify that if ventricular fibrillation or pulseless ventricular tachycardia persist after two shocks with standard defibrillation, the DSED method should be administered. Two defibrillators need to be available, and staff must be trained in the new approach.</p>
<p>Though the existing evidence for DSED is compelling, until recently it was based on theory and a small number of <a href="https://www.sciencedirect.com/science/article/abs/pii/S0300957220302446?via%3Dihub">potentially biased observational studies</a>. The Canadian trial was the first to directly compare DSED to standard treatment.</p>
<p>From a total of 261 patients, 30.4% treated with this strategy survived, compared to 13.3% when standard resuscitation protocols were followed.</p>
<p>The <a href="https://link.springer.com/content/pdf/10.1007/s00134-023-06993-1.pdf">design of the trial</a> minimised the risk of other factors confounding results. It provides confidence that survival improvements were due to the defibrillation approach and not regional differences in resources and training.</p>
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<a href="https://theconversation.com/how-do-pacemakers-and-defibrillators-work-a-cardiologist-explains-how-they-interact-with-the-electrical-system-of-the-heart-217429">How do pacemakers and defibrillators work? A cardiologist explains how they interact with the electrical system of the heart</a>
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<p>The study also corroborates and builds on existing theoretical and clinical scientific evidence. As the trial was stopped early due to the COVID-19 pandemic, however, the researchers could recruit fewer than half of the numbers planned for the study.</p>
<p>Despite these and other limitations, the international group of experts that advises on best practice for resuscitation <a href="https://pubmed.ncbi.nlm.nih.gov/37937881/">updated its recommendations</a> in 2023 in response to the trial results. It suggested (with caution) that emergency medical services consider DSED for patients with ventricular fibrillation or pulseless ventricular tachycardia who are not responding to standard treatment.</p>
<h2>Training and implementation</h2>
<p>Although the evidence is still emerging, implementation of DSED by emergency services in New Zealand has implications beyond the care of patients nationally. It is also a key step in advancing knowledge about optimal resuscitation strategies globally.</p>
<p>There are always concerns when translating an intervention from a controlled research environment to the relative disorder of the real world. But the balance of evidence was carefully considered before making the decision to change procedures for a group of patients who have a low likelihood of survival with current treatment.</p>
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<a href="https://theconversation.com/anyone-can-save-a-life-including-kids-heres-why-they-should-learn-cpr-and-basic-life-support-200337">Anyone can save a life, including kids. Here's why they should learn CPR and basic life support</a>
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<p>Before using DSED, emergency medical personnel undergo mandatory education, simulation and training. Implementation is closely monitored to determine its impact.</p>
<p>Hospitals and emergency departments have been informed of the protocol changes and been given opportunities to ask questions and give feedback. As part of the implementation, the St John ambulance service will perform case reviews in addition to wider monitoring to ensure patient safety is prioritised.</p>
<p>Ultimately, those involved are optimistic this change to cardiac arrest management in New Zealand will have a positive impact on survival for affected patients.</p><img src="https://counter.theconversation.com/content/221979/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vinuli Withanarachchie is a Clinical Research Assistant at Hato Hone St John. </span></em></p><p class="fine-print"><em><span>Bridget Dicker is Head of Clinical Audit and Research at Hato Hone St John. She is a member of the International Liaison Committee on Resuscitation Basic Life Support (BLS) Task Force.</span></em></p><p class="fine-print"><em><span>Sarah Maessen is a Clinical Research Fellow at Hato Hone St John.</span></em></p>New Zealand is just the second country to approve a novel defibrillation procedure for some patients. With current survival rates very low, it is hoped the new method will save many more lives.Vinuli Withanarachchie, PhD candidate, College of Health, Massey UniversityBridget Dicker, Associate Professor of Paramedicine, Auckland University of TechnologySarah Maessen, Research Associate, Auckland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2189912024-01-08T13:34:33Z2024-01-08T13:34:33ZEmergency medicine residencies more likely to go unfilled at for-profit and newly accredited programs<p>The number of unfilled positions in emergency medicine residency programs surged in 2022 and 2023, with the trend most pronounced at programs that were recently accredited or under for-profit ownership. That’s the key finding of <a href="https://doi.org/10.1002/aet2.10902">my team’s recent study</a> of the past two match cycles.</p>
<p>A match cycle is when medical students choose a specialty and learn where they will train. It starts when fourth-year medical students interview at residency programs at hospitals around the country. Then, the students rank their preferred training programs, and the programs rank the students. An <a href="https://www.nrmp.org/intro-to-the-match/#:%7E:text=NRMP%20uses%20a%20mathematical%20algorithm,possible%20match%20for%20all%20participants.">algorithm makes matches</a>.</p>
<p>The proportion of medical students applying for emergency medicine residencies dropped by <a href="https://www.acep.org/news/acep-newsroom-articles/joint-statement-match-2023">16.8% from 2021 to 2022</a> and declined another 18.1% from 2022 to 2023. This abrupt decline may degrade the three-to-four-year clinical training experience of emergency medicine residents and affect how the health care system provides emergency care in the future.</p>
<p>But this waning in demand is only half of the story. Deepening the problem is the fact that the number of emergency medicine residency programs has grown at the same time. </p>
<h2>No checks on the for-profit sector</h2>
<p>Over the past five to eight years, <a href="https://www.npr.org/sections/health-shots/2023/02/11/1154962356/ers-hiring-fewer-doctors">more for-profit and private capital-backed firms</a> have bought emergency medicine facilities, taken over staffing contracts in existing hospitals and <a href="https://doi.org/10.1001/jamanetworkopen.2023.12457">created emergency residency programs</a>.</p>
<p>Since they are for-profit entities, these companies have a responsibility to return money to investors. They have been shown to achieve this by <a href="https://doi.org/10.1002/aet2.10786">paying residents less</a> and charging <a href="https://www.bmj.com/content/382/bmj-2023-075244">higher prices</a> on services like imaging and hospitalization.</p>
<p>Currently, there are no limits on the number of residency programs or positions in emergency medicine. The Review Committee for Emergency Medicine <a href="https://www.acgme.org/specialties/emergency-medicine/overview/">automatically approves all proposals for new residency programs</a> that meet requirements. Despite the fact that positions are already going unfilled, <a href="https://apps.acgme.org/ads/Public/Reports/Report/1">eight new emergency medicine residency programs were accredited</a> during the 2022-23 academic year. This accreditation system is currently under review, but any changes will take years to go into effect.</p>
<h2>More positions, lower demand</h2>
<p>I am a physician <a href="https://scholar.google.com/citations?user=KVEHBakAAAAJ&hl=en&oi=ao">who studies the state of emergency care</a>. In our recent paper, my team and I calculated the number of emergency medicine residency programs that filled all positions in the past two match cycles. </p>
<p>Our <a href="https://doi.org/10.1002/aet2.10902">study shows that</a> in 2022, 277 emergency medicine residency programs offered 2,921 positions and had 219 unfilled positions. In 2023, 287 emergency medicine programs offered 3,010 positions and 554 went unfilled. In each of these years, about 30 programs had primary clinical training sites under for-profit ownership. </p>
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<p>The drop in interest in emergency medicine may be driven by well-circulated <a href="https://doi.org/10.1016/j.annemergmed.2021.05.029">forecasts predicting a surplus</a> in the emergency physician workforce by 2030 and <a href="https://doi.org/10.1016/j.annemergmed.2021.05.029">escalating levels of burnout</a> among emergency physicians. </p>
<p>By examining where residents chose to go when there were more than enough programs to choose from, we learned three things. </p>
<p>First, more established programs did better. Emergency medicine residency programs accredited within the past five years had more than double the likelihood of not filling all positions compared with those accredited for more than five years.</p>
<p>Second, in 2023, more opportunities were offered in several metropolitan areas, including Detroit, Miami and Philadelphia, but these programs ended up with many unfilled positions.</p>
<p>Third, emergency medicine residency programs with for-profit clinical sites were less likely to fill all residency positions. These programs had a 50% greater chance of not filling all positions when compared with nonprofit or government-run sites. </p>
<h2>Possible solutions</h2>
<p>It’s not clear whether these trends will continue. In 1996, <a href="https://www.nrmp.org/match-data-analytics/archives/">the anesthesiology specialty</a> saw the proportion of filled residency positions drop to 45%, an all-time low. Yet the specialty rebounded to fill nearly 100% of available positions by 2002.</p>
<p>While it is possible the past two years for emergency medicine are part of the natural ebb and flow of specialty interest among medical students, our findings, the historical literature and the recent <a href="https://www.wsj.com/articles/kkr-backed-envision-healthcare-plans-chapter-11-bankruptcy-filing-2fff4382">bankruptcy filing of Envision</a> – a large, for-profit emergency medicine group that staffs <a href="https://emworkforce.substack.com/p/state-of-the-us-emergency-medicine">several clinical sites and residency programs</a> – all suggest medical students may be recognizing the disadvantages of for-profit emergency medicine residency programs. </p>
<p>There is little data on the quality of these programs. No research yet has evaluated board exam pass rates of emergency medicine residents graduating from newly accredited or for-profit clinic sites. However, <a href="https://doi.org/10.4300/JGME-D-21-01097.1">residents in pediatric programs</a> with a corporate affiliation had lower board exam pass rates.</p>
<p>In addition to reconsidering the persistent opening of new programs, now may be the time for organizations like the <a href="https://www.emra.org/">Emergency Medicine Residents’ Association</a> and the <a href="https://www.acep.org/">American College of Emergency Physicians</a> to address issues that affect recruitment of emergency medicine residents. </p>
<p>Physician burnout could be addressed by reviewing hospital policies designed to maximize profits. For example, many patients are admitted to the hospital, yet <a href="https://www.acep.org/patient-care/policy-statements/boarding-of-admitted-and-intensive-care-patients-in-the-emergency-department">“board”</a> in the hallway of an emergency department for hours. These patients have routinely been shown to have <a href="http://doi.org/10.1001/jamainternmed.2023.5961">worse outcomes</a>, yet hospital leadership frequently attempts to <a href="https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0217">prioritize revenue-generating</a> surgeries and procedures in lieu of assigning beds for admitted patients from the emergency department.</p>
<p>Loan forgiveness and increased salaries could draw more residents to emergency medicine, especially in rural areas where distinct physician shortages exist. And more female residents would be drawn into emergency medicine if disparities in pay and concerns over violence in emergency rooms were systematically resolved.</p><img src="https://counter.theconversation.com/content/218991/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cameron Gettel receives funding from the National Institute on Aging (NIA) of the National Institutes of Health and the American Board of Emergency Medicine / National Academy of Medicine Fellowship. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation or approval of the manuscript.</span></em></p>A new study finds more emergency medicine residencies are available, but hundreds of the positions are going unfilled.Cameron Gettel, Assistant Professor of Emergency Medicine, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2116082023-08-15T09:30:07Z2023-08-15T09:30:07ZSurf group found safe after days at sea in Indonesia. A sea survival expert on what it takes to survive being lost at sea<figure><img src="https://images.theconversation.com/files/542760/original/file-20230815-17-5xb8yc.jpg?ixlib=rb-1.1.0&rect=17%2C8%2C5734%2C3224&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>News that four Australians and two Indonesian crew members have been <a href="https://www.abc.net.au/news/2023-08-15/four-australians-found-after-going-missing-on-aceh-surf-trip/102730976">found alive</a> after going missing on Sunday from a boat trip off the coast of Aceh in Indonesia has made headlines around the world. </p>
<p>The group, which was on a surfing trip, was found “bobbing around on their surfboards”, according to media reports <a href="https://www.abc.net.au/news/2023-08-15/four-australians-found-after-going-missing-on-aceh-surf-trip/102730976">quoting</a> the father of one of the Australian surfers.</p>
<p>Our research in the Extreme Environments Laboratory at the University of Portsmouth focuses on how humans survive and respond to adverse environments. </p>
<p>So what does it take to survive such gruelling conditions? </p>
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<a href="https://theconversation.com/your-first-emotion-is-panic-rips-cause-many-beach-drownings-but-we-can-learn-from-the-survivors-210982">'Your first emotion is panic': rips cause many beach drownings, but we can learn from the survivors</a>
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<h2>A hierarchy of survival</h2>
<p>There is an established <a href="https://www.researchgate.net/publication/270283180_Essentials_of_Sea_Survival">hierarchy of survival</a>.</p>
<p>Without air you only survive for a matter of minutes. Without sufficient warmth you only survive hours. Without sufficient drinking water you can <a href="https://www.researchgate.net/publication/270283180_Essentials_of_Sea_Survival">survive</a> up to <a href="https://wellcomecollection.org/works/v9h44s6v">six or seven</a> days in a maritime environment. Without food you can survive 40–60 days.</p>
<p>So, those who survive more than a few hours are almost always in warm air or water. </p>
<p>Because you can eventually cool even in water that is relatively warm, you are better off out of the water than in it. Being on top of a surfboard is a step in the right direction.</p>
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<a href="https://theconversation.com/why-is-extreme-frontier-travel-booming-despite-the-risks-208201">Why is extreme 'frontier travel' booming despite the risks?</a>
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<h2>Dealing with dehydration</h2>
<p>When the water and air are warm, the primary problem is dehydration.</p>
<p><a href="https://wellcomecollection.org/works/v9h44s6v">Death</a> due to dehydration occurs when you lose about 15–20% of your body weight in fluid. </p>
<p>Even at 5% dehydration you can get headaches, become irritable and feel lightheaded. At 10% you may be dizzy, feel faint, have a rapid pulse and rapid shallow breathing. Thereafter, hallucinations and delirium are common.</p>
<p>To survive longer than six or seven days, when dehydration is your major threat, you must do two important things.</p>
<p>First, try to find fresh water. The absolute <a href="https://pubmed.ncbi.nlm.nih.gov/13368838/">minimum</a> you need to find is 110–220 millilitres a day, although 400mL per day is safer.</p>
<p>If you were prepared, you may have taken water with you as you embarked on your survival voyage.</p>
<p>If you are lucky, it might rain and you may be able to collect some rainwater in suitable, uncontaminated containers.</p>
<p>Surfers are unlikely to have devices such as a solar still or a reverse osmosis pump available to purify water for safe drinking. But other sources of useful fluids include <a href="https://researchportal.port.ac.uk/en/publications/essentials-of-sea-survival">fish “lymph”</a> squeezed from the flesh of fish. This has about the same salt concentration as human body fluid (0.9%), so is only helpful if you are very dehydrated.</p>
<p><a href="https://researchportal.port.ac.uk/en/publications/essentials-of-sea-survival">Fish eyes, spinal fluid and turtle blood</a> can also help when desperate.</p>
<p>What you must not do, despite what becomes an overwhelming urge, is drink the seawater that surrounds you. </p>
<p>Seawater has an average salt concentration of 3.5%, so drinking it adds to the salt load of the body.</p>
<p>You should also not <a href="https://researchportal.port.ac.uk/en/publications/essentials-of-sea-survival">drink urine</a> in this situation, because it will also contribute to salt building up in your body.</p>
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<span class="caption">Bobbing around on a surf board is better than paddling in it and getting hot and sweaty.</span>
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<h2>Conserving fluids</h2>
<p>The second important factor is to conserve body fluid. </p>
<p>The body of a 75kg person contains nearly 50 litres of water, and in a survival situation where dehydration is your greatest threat, conserving this water is crucial.</p>
<p>The body helps. With a body fluid loss of 1% of body weight and consequent decrease in blood volume and increase in salt concentration, the body increases the production of the anti-diuretic hormone that lowers urine production by the kidneys.</p>
<p>You can provoke this response by drinking nothing in the first 24 hours of a survival voyage. </p>
<p>At the same time, it is important to do as little as possible. Try to minimise heat production by the body, which will mean less sweating.</p>
<p>So “bobbing around” on a surfboard is better than paddling it and getting hot and sweaty. </p>
<p>Normally, you would seek or make shade on your survival craft and rest during the hottest parts of the day. This is not possible on a surfboard, but periodic wetting from waves may keep you cool and help reduce sunburn (which can impair your ability to control your body temperature) by cooling the skin and covering it periodically. </p>
<p>The longer-term challenge is starvation – but this is a less pressing problem than dehydration.</p>
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<span class="caption">Waters off Aceh Province, Indonesia.</span>
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<h2>Staying calm in a crisis</h2>
<p>Survival at sea depends on knowing <a href="https://www.physoc.org/">how your body works</a> and what it needs, and then doing the right things. </p>
<p>Experience helps. Being used to the sea means you remain more relaxed in a crisis and are less likely to <a href="https://physoc.onlinelibrary.wiley.com/doi/full/10.1111/j.1469-7793.2001.00619.x">become seasick</a> (which can accelerate dehydration, impair body temperature regulation and destroy morale). </p>
<p><a href="https://www.bps.org.uk/psychologist/survival-psychology-wont-live">Being with others</a> helps morale and decision-making. Young and fit people, such as many surfers, are less likely to have other health-related problems that may compromise their survival prospects. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/alone-in-a-dark-cave-what-can-we-learn-from-extreme-survival-experiments-208300">Alone in a dark cave: what can we learn from extreme survival experiments?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/211608/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mike Tipton is affiliated with the Extreme Environments Laboratory University of Portsmouth, UK.
</span></em></p>When the water and air are warm, the primary problem is dehydration.Mike Tipton, Professor of Human and Applied Physiology, University of PortsmouthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2028442023-06-07T02:23:49Z2023-06-07T02:23:49ZHow to treat jellyfish stings (hint: urine not recommended)<figure><img src="https://images.theconversation.com/files/530469/original/file-20230607-30115-psgkb.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/box-jelly-fish-photographed-aquarium-68332459">Shutterstock</a></span></figcaption></figure><p>If you have been stung by a jellyfish at the beach, you’ll know how painful and unpleasant it can be. But how best to treat jellyfish stings has been debated over the years.</p>
<p>Is it best to use hot water or an ice pack? How about pouring on vinegar or rubbing with sand? Then there’s the popular myth about urinating on your leg, which health professionals have <a href="https://www.scientificamerican.com/article/fact-or-fiction-urinating/#:%7E:text=Back%20in%201997%20all%20the,the%20treatment%20and%20it%20worked.">debunked</a> <a href="https://health.clevelandclinic.org/pee-jellyfish-sting/">many times</a> but seems to resurface regardless.</p>
<p>We looked at the evidence for popular treatments and have <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009688.pub3/full">just published</a> our analysis in a Cochrane review. This is what we found.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/when-we-swim-in-the-ocean-we-enter-another-animals-home-heres-how-to-keep-us-all-safe-193457">When we swim in the ocean, we enter another animal's home. Here's how to keep us all safe</a>
</strong>
</em>
</p>
<hr>
<h2>Why do jellyfish stings hurt so much?</h2>
<p>Jellyfish are common in coastal regions around the world. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/524541/original/file-20230505-29-u5skut.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Warning sign for marine stingers" src="https://images.theconversation.com/files/524541/original/file-20230505-29-u5skut.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/524541/original/file-20230505-29-u5skut.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/524541/original/file-20230505-29-u5skut.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/524541/original/file-20230505-29-u5skut.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/524541/original/file-20230505-29-u5skut.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/524541/original/file-20230505-29-u5skut.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/524541/original/file-20230505-29-u5skut.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Watch out, jellyfish about.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/yellow-black-warning-sign-dangerous-marine-168106508">Shutterstock</a></span>
</figcaption>
</figure>
<p>They have tentacles covered with tiny stinging cells called nematocysts. When these cells touch your skin, they release venom that can cause burning, redness, swelling and sometimes more serious reactions, such as heart issues.</p>
<p>Fortunately, most jellyfish stings are not life-threatening. Symptoms differ depending on the species. And the best treatment for one species is not always the best for another.</p>
<p>By knowing which treatment works and which doesn’t, you can reduce your discomfort and avoid complications.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/want-to-avoid-a-bluebottle-sting-heres-how-to-predict-which-beach-theyll-land-on-179947">Want to avoid a bluebottle sting? Here's how to predict which beach they'll land on</a>
</strong>
</em>
</p>
<hr>
<h2>What we did</h2>
<p>We found nine trials involving treatments for two types of jellyfish:</p>
<ul>
<li><p><strong>bluebottles</strong> or Portuguese man o’ war (<em>Physalia</em>)</p></li>
<li><p><strong>box jellyfish</strong> (<em>Cubozoa</em>), which are considered the most dangerous jellyfish. Some box jellyfish can cause Irukandji syndrome (a condition that may lead to severe pain, heart problems, and very occasionally death).</p></li>
</ul>
<p>These trials, involving 574 people, tested various treatments such as vinegar, hot water, ice packs, isopropyl alcohol, methylated spirits, ammonia and sodium bicarbonate.</p>
<p>The trials also looked at Adolph’s meat tenderiser (a powder thought to break down proteins) and Sting Aid (an over-the-counter treatment thought to help ease pain after a variety of stings).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/welcome-to-australia-a-land-of-creatures-out-to-kill-you-maybe-71490">Welcome to Australia, a land of creatures out to kill you... maybe</a>
</strong>
</em>
</p>
<hr>
<h2>So what works?</h2>
<p>Regardless of the jellyfish species, it’s reasonable to first remove any visible tentacles with tweezers or a gloved hand. What to do next depends on the species.</p>
<p><strong>For bluebottles, try heat</strong></p>
<p>The data in our included studies provides what’s described as low-certainty evidence for soaking the affected area in water about 45°C to ease the pain. This is thought to denature the venom protein. At the beach, you could apply a heat pack or take a hot shower.</p>
<p>There was not enough evidence to show whether other treatments, such as ice packs, were effective for bluebottle stings.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/524542/original/file-20230505-27-3vrruw.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C648&q=45&auto=format&w=1000&fit=clip"><img alt="Bluebottle on sandy beach" src="https://images.theconversation.com/files/524542/original/file-20230505-27-3vrruw.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C648&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/524542/original/file-20230505-27-3vrruw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=390&fit=crop&dpr=1 600w, https://images.theconversation.com/files/524542/original/file-20230505-27-3vrruw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=390&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/524542/original/file-20230505-27-3vrruw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=390&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/524542/original/file-20230505-27-3vrruw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=490&fit=crop&dpr=1 754w, https://images.theconversation.com/files/524542/original/file-20230505-27-3vrruw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=490&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/524542/original/file-20230505-27-3vrruw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=490&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Stung by a bluebottle? Try warm water or a heat pack.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/bluebottle-portuguese-man-o-war-on-413370460">Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>For box jellyfish, try vinegar</strong></p>
<p>For box jellyfish stings, the evidence was more limited. Our review did not find sufficient evidence to support <a href="https://resus.org.au/download/guideline-9-4-5-jellyfish-stings-july-2010-43-kib/?wpdmdl=13756&masterkey">current</a> <a href="http://www.ilsf.org/wp-content/uploads/2012/07/MPS-05%20Envenomation.doc">recommendations</a> to apply vinegar to inactivate the nematocysts.</p>
<p>Nevertheless, it’s reasonable to try vinegar. That’s because <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/j.1326-5377.1980.tb134566.x">evidence</a> not considered as part of our review shows vinegar inactivates nematocysts when tested in the laboratory.</p>
<h2>When to seek medical care</h2>
<p>Most symptoms can be managed at the beach or at home. But always seek medical attention if you or the person you’re looking after has symptoms such as:</p>
<ul>
<li><p>difficulty breathing</p></li>
<li><p>chest pain</p></li>
<li><p>nausea</p></li>
<li><p>vomiting</p></li>
<li><p>weakness, or </p></li>
<li><p>drowsiness.</p></li>
</ul>
<p>Such severe symptoms mean monitoring and treatment in hospital may be needed. If the person stops breathing or has a heart attack, they need immediate basic life support.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-cases-of-cardiac-arrest-time-is-everything-community-responders-can-save-lives-126491">In cases of cardiac arrest, time is everything. Community responders can save lives</a>
</strong>
</em>
</p>
<hr>
<h2>What not to do</h2>
<p>Do not rub or scrape the area with sand or a towel because this might cause more nematocysts to release their venom.</p>
<p>When it comes to treatments, our review found some may be harmful or ineffective, so should be avoided. </p>
<p>These included ammonia, methylated spirits and fresh water, as they may cause burns on the skin or trigger more venom to be released from nematocysts. </p>
<p>Avoid pressure immobilisation bandaging (wrapping a bandage tightly around the limb) as this may also trigger more venom release from nematocysts. </p>
<p>We found vinegar, sodium bicarbonate, Sting Aid or meat tenderiser have no proven benefit and may cause irritation or infection.</p>
<p>Perhaps not surprisingly, there were no published trials looking at the effectiveness of urine as a treatment and so it’s not recommended.</p>
<h2>Prevention is best</h2>
<p>Remember, prevention is better than cure. Keep an eye on safety announcements from lifeguards, monitor the water for jellyfish and wear protective clothing to prevent stings where possible.</p><img src="https://counter.theconversation.com/content/202844/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hot water, cold water, rubbing with sand? What our new review says works best to treat jellyfish stings.Richard McGee, Senior lecturer in Paediatrics, University of NewcastleMichelle Welsford, Professor and Director of the Division of Emergency Medicine , McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1979002023-01-31T19:20:29Z2023-01-31T19:20:29ZParamedics could sound early warnings of child abuse or neglect – but they need support and more training<figure><img src="https://images.theconversation.com/files/507013/original/file-20230130-18-9wh9lh.jpg?ixlib=rb-1.1.0&rect=34%2C34%2C4559%2C3414&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/little-boy-unhappy-sad-tress-alone-611993264">Shutterstock</a></span></figcaption></figure><p>Child abuse and neglect is, unfortunately, a far more common occurrence in Australia than many people realise. </p>
<p>In Australia <a href="https://www.aihw.gov.au/reports/child-protection/child-protection-australia-2020-21/contents/about">in 2020–21</a> (the most recent figures available), there were more than half a million notifications to child protection services. Around 180,000 children and young people are receiving child protection support and 46,000 are in out-of-home care. These figures are all on the rise.</p>
<p>Child maltreatment can be hidden. Often children don’t know what they are experiencing is maltreatment, and they can find it hard to speak up. People who notice something isn’t right may not know how to get support. And those inflicting the harm may go to great lengths to cover it up.</p>
<p>Protecting children and young people is <a href="https://www.dss.gov.au/our-responsibilities/families-and-children/programs-services/protecting-australias-children">everyone’s business</a>, but there are some groups who can play a key role. Teachers, for example, are in a unique position to build trust with children and observe changes over time and are responsible for <a href="https://www.aihw.gov.au/reports/child-protection/child-protection-australia-2020-21/contents/notifications-investigations-and-substantiations/how-many-notifications-and-investigations-were-there">around one-quarter of all notifications</a>.</p>
<p>There is another workforce who encounter children and young people at risk of maltreatment. They have the advantage of being regularly asked to enter people’s houses, and are able to observe children at home: paramedics.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/bad-for-patients-bad-for-paramedics-ambulance-ramping-is-a-symptom-of-a-health-system-in-distress-169528">Bad for patients, bad for paramedics: ambulance ramping is a symptom of a health system in distress</a>
</strong>
</em>
</p>
<hr>
<h2>A unique view into the home</h2>
<p>Emotional abuse (when a child is made to feel worthless, isolated or frightened) is the <a href="https://kidshelpline.com.au/parents/issues/understanding-child-emotional-abuse">type of harm</a> child protection services <a href="https://www.aihw.gov.au/reports/child-protection/child-protection-australia-2020-21/contents/notifications-investigations-and-substantiations/what-types-of-abuse-were-substantiated">most commonly hear about</a> (around half the cases in Australia). This is followed by neglecting to provide essential care for children’s physical or emotional development (21%), physical abuse (14%) and sexual abuse (10%).</p>
<p>Child maltreatment is not usually the result of an unknown, “evil” person preying on vulnerable children. The harm is more likely to be <a href="https://www.dss.gov.au/our-responsibilities/families-and-children/programs-services/protecting-australias-children">inflicted by a family member</a>, or someone known to the child, and it’s also not always because they want to harm the child. Sometimes caregivers simply do not have adequate resources to properly care for their children. They may have poor access to health care or medications, or be in the grips of <a href="https://theconversation.com/are-you-living-in-a-food-desert-these-maps-suggest-it-can-make-a-big-difference-to-your-health-196477">food insecurity</a>. </p>
<p><a href="https://www.crimestatistics.vic.gov.au/family-violence-data-portal/family-violence-data-dashboard/ambulance-victoria">In the past five years</a>, 764 children (aged 0–17) were flagged by a paramedic for suspected maltreatment in Victoria alone. It is likely this is only a tiny fraction of the true number of children experiencing maltreatment who are seen by paramedics. </p>
<p>Paramedics are in a unique position to witness early signs of abuse and neglect that may otherwise remain hidden. Despite this potential, they have very little education on child maltreatment, and they report <a href="https://link.springer.com/article/10.1007/s42448-021-00091-9">feeling unprepared and unsure</a> how to help. This is likely a major contributor to the low reporting rates. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/almost-9-in-10-young-australians-who-use-family-violence-experienced-child-abuse-new-research-190058">Almost 9 in 10 young Australians who use family violence experienced child abuse: new research</a>
</strong>
</em>
</p>
<hr>
<h2>How well do paramedics recognise and report child maltreatment?</h2>
<p>We <a href="https://link.springer.com/article/10.1007/s42448-022-00144-7">asked 217 Victorian paramedics</a> about their knowledge of child maltreatment. They mostly understood how to make a report to child protection services. However, when we gave them ten short written portrayals of child maltreatment paramedics commonly encounter and asked them what they would do, the results were different.</p>
<p>Paramedics are quite good at identifying visible signs of maltreatment, such as physical or sexual abuse or neglect, but struggle to identify less-visible forms, such as emotional abuse or exposure to family violence.</p>
<p>They are also less likely to make a report about cases involving emotional abuse, which is worrying considering emotional abuse accounts for half of all substantiated cases.</p>
<p>Paramedics want to make sure children and young people are safe, but feel unsure and don’t act unless the maltreatment is obvious. They are being reactive – rather than taking a proactive, risk-based approach to prevent maltreatment before it occurs.</p>
<p>Typical reasons health-care professionals don’t make a report when they suspect child maltreatment include <a href="https://link.springer.com/article/10.1007/s42448-021-00091-9">not feeling supported by their employer</a> to do so. There are a few simple things we can do to address this. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1327023388305534977"}"></div></p>
<h2>Change is needed</h2>
<p>Paramedics could fill a huge gap in our child protective services, undertaking an “early warning system” role to help prevent maltreatment before it occurs. This would fall within the existing scope of practice for all paramedics in Australia, who have a legal and ethical responsibility to ensure the safety of their patients. </p>
<p>To do this we first need legislative change. In Australia there is <a href="https://aifs.gov.au/resources/resource-sheets/mandatory-reporting-child-abuse-and-neglect">legislation in each state</a> making it a crime for certain people to fail to report suspected child maltreatment. Paramedics are not listed in the legislation, despite nurses, doctors and teachers being listed. </p>
<p>Adding paramedics to this group would ensure there is a sufficient legal impetus for them to make a report. <a href="https://aifs.gov.au/resources/resource-sheets/mandatory-reporting-child-abuse-and-neglect">Mandatory reporting</a> increases the visibility of maltreated children and does not appear to significantly discourage people from using a health service.</p>
<p>Next, we need to improve paramedic education so they have a full understanding of all forms of child maltreatment and interrupting cycles of violence. This must emphasise less visible forms of maltreatment and early warning signs. Ambulance services should ensure paramedics understand their obligations, have access to clear policies and procedures, and feel supported.</p>
<p>Perhaps most importantly, we need to train our paramedics to be proactive, rather than reactive. Our research shows paramedics are reluctant to make a report until they see clear signs maltreatment has occurred. Because maltreatment often escalates over time, the earlier warning signs are identified, and children and caregivers connected with supportive services, the safer children will be.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/to-end-gender-based-violence-in-one-generation-we-must-fix-how-the-system-responds-to-children-and-young-people-192839">To end gender-based violence in one generation, we must fix how the system responds to children and young people</a>
</strong>
</em>
</p>
<hr>
<h2>If you are under 18 and reading this</h2>
<p>You can always tell a paramedic if you don’t feel safe. Paramedics are caring and trustworthy adults and will be able to find the right people to help you.</p>
<p>You can also call the <a href="https://kidshelpline.com.au">Kids Help Line</a> if you want to talk to someone on 1800 55 1800.</p><img src="https://counter.theconversation.com/content/197900/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Sawyer is affiliated with the Australasian College of Paramedicine. </span></em></p><p class="fine-print"><em><span>Alex Cahill receives funding from a range of Australian, state, and territory governments, and non-government agencies including child welfare and out-of-home care providers.</span></em></p><p class="fine-print"><em><span>Daryl Higgins receives funding from the National Health and Medical Research Council, a range of Australian, state, and territory governments, and non-government agencies including child welfare and out-of-home care providers.</span></em></p><p class="fine-print"><em><span>Navindhra Naidoo is affiliated with Western Sydney University, Australasian Council of Paramedicine and Australasian Council of Paramedicine Deans.</span></em></p><p class="fine-print"><em><span>Stephen Bartlett is affiliated with Queensland University of Technology and Australasian College of Paramedicine </span></em></p>With more than half a million notifications of suspected child maltreatment each year in Australia, we need to explore the better use of our health-care workforces to prevent maltreatment.Simon Sawyer, Adjunct Senior Lecturer, Australian Catholic UniversityAlex Cahill, Research Officer, Australian Catholic UniversityDaryl Higgins, Professor & Director, Institute of Child Protection Studies, Australian Catholic UniversityNavindhra Naidoo, Program Director: Paramedicine, Western Sydney UniversityStephen Bartlett, Senior Lecturer, paramedic science, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1901442022-11-08T04:32:49Z2022-11-08T04:32:49ZIt’s after-hours and I need to see a doctor. What are my options?<figure><img src="https://images.theconversation.com/files/492919/original/file-20221102-26769-rn9s3s.jpg?ixlib=rb-1.1.0&rect=0%2C361%2C5506%2C3371&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/35bnMbid2rQ">Shane/Unsplash</a></span></figcaption></figure><p>There are times when medical care can’t wait until 9am or first thing Monday. Perhaps your COVID has worsened and you’re becoming short of breath. Or your baby has a fever that’s worrying you. Or your elderly parent’s pain can’t be relieved with over-the-counter medications.</p>
<p>When last asked in 2020, <a href="https://chf.org.au/ahpafterhoursprimarycare">two-thirds of Australians</a> had accessed after-hours health services in the previous five years. But how do you access health care on weekends and after 5pm in 2022? </p>
<p>Many GP Super Clinics continue to operate beyond business hours, accept walk-ins and provide access to onsite pharmacy services. You can find their locations <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/pacd-gpsuperclinics-locations">here</a>, though opening hours and costs vary between clinics.</p>
<p>Search engines such as <a href="https://www.hotdoc.com.au/find/doctor/australia">HotDoc</a> and <a href="https://www.healthdirect.gov.au/australian-health-services">Healthdirect</a> can help you find local health services such as GPs, COVID testing clinics, emergency departments, and allied health services. You can filter search results by “open now”, bulk-billing and accessibility requirements such as building access ramps. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/emergency-departments-are-clogged-and-patients-are-waiting-for-hours-or-giving-up-whats-going-on-184242">Emergency departments are clogged and patients are waiting for hours or giving up. What's going on?</a>
</strong>
</em>
</p>
<hr>
<p>The COVID pandemic accelerated investment in virtual care for non-life-threatening emergencies, which can be less stressful for patients and families than attending an emergency department. </p>
<p>Here are some options for in-person and virtual after-hours care.</p>
<h2>Nurse helplines</h2>
<p>If you’re not sure whether you need medical care, or if you need basic information or advice, a useful starting point is to call a <a href="https://www.healthdirect.gov.au/nurse-on-call">free nursing helpline</a> such as <a href="https://www.health.vic.gov.au/primary-care/nurse-on-call">Nurse-on-Call</a> in Victoria, <a href="https://www.qld.gov.au/health/contacts/advice/13health">13HEALTH</a> in Queensland, or <a href="https://www.healthdirect.gov.au/nurse-on-call">Healthdirect</a> in other states.</p>
<p>In some cases, nurses may offer a <a href="https://about.healthdirect.gov.au/after-hours-gp-helpline">call-back from a GP</a> using phone or video consultation. </p>
<figure class="align-center ">
<img alt="Doctor talks on phone" src="https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492920/original/file-20221102-26775-8kxbwh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In some cases, the nurse may offer a call back from a GP.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/doctor-talking-on-the-cellphone-5207089/">Pexels/Karolina Grabowska</a></span>
</figcaption>
</figure>
<h2>Getting a doctor to visit you at home</h2>
<p>The <a href="https://homedoctor.com.au">National Home Doctor service</a>, which can be booked using telephone (13 74 25) or its mobile app, provides bulk-billed doctor home visits. </p>
<p>Telehealth consultations can also be booked through this service, though they may incur a fee.</p>
<h2>Video consultation with a GP</h2>
<p>A range of companies offer GP telehealth consultation after hours, for a fee. It doesn’t have to be an emergency, and can be used for things like last-minute repeat prescriptions.</p>
<p>Search engines <a href="https://www.hotdoc.com.au/find/doctor/australia">HotDoc</a> and <a href="https://www.healthdirect.gov.au/australian-health-services">Healthdirect</a> can direct you to these services through the “accepts telehealth” or “telehealth capable” options.</p>
<h2>Virtual emergency departments</h2>
<p>Virtual emergency departments in <a href="https://www.vved.org.au">Victoria</a>, <a href="https://metronorth.health.qld.gov.au/hospitals-services/virtual-ed">Queensland</a> and <a href="https://www.wacountry.health.wa.gov.au/Our-services/Command-Centre">Western Australia</a> allow people in these states to virtually connect with emergency doctors and nurse practitioners for treatment and advice on non-life-threatening emergencies. </p>
<p>In Victoria, the establishment of the <a href="https://www.vved.org.au/">virtual ED program</a> has <a href="https://www.prnewswire.com/news-releases/northern-health-using-the-clinicians-digital-health-platform-to-expand-their-victorian-virtual-emergency-department-statewide-301557186.html">decreased wait times</a>, with an easy-to-use platform, triage and waiting room. After the consultation, instructions can be emailed, or e-scripts sent to your local pharmacy. This service is currently covered by Medicare with no out-of-pocket costs, though that may change in the future.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/video-and-phone-consultations-only-scratch-the-surface-of-what-telehealth-has-to-offer-146580">Video and phone consultations only scratch the surface of what telehealth has to offer</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://www.myemergencydr.com">My Emergency Doctor</a> is a private service with a hotline and web-based consultations with expert emergency doctors, for patients across Australia. Typically consultations cost A$250-$280, however people living in <a href="https://www.myemergencydr.com/patients/patients-within-primary-health-networks/">certain Primary Health Networks</a> can receive free after-hours telehealth consultations through this platform. </p>
<h2>Children’s health services</h2>
<p>In South Australia, free paediatric emergency services are available through the Women’s and Children’s Hospital’s <a href="https://www.wch.sa.gov.au/patients-visitors/emergencies/virtual-urgent-care">Child and Adolescent Virtual Urgent Care Service</a>, though similar services aren’t available across the country. </p>
<p>However, on-demand services such as <a href="https://www.kidsdoconcall.com.au">KidsDocOnCall</a> and <a href="https://www.cubcare.com.au">Cub Care</a> provide telehealth paediatric services after-hours to people in all states and territories, for a fee. </p>
<figure class="align-center ">
<img alt="Small baby's hand" src="https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492924/original/file-20221102-12-2rqzk2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Paediatric telehealth is available after-hours for a fee.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/N-VEeMnm7gE">Baby Abbas/Unsplash</a></span>
</figcaption>
</figure>
<h2>Pharmacies</h2>
<p>If you need to see a pharmacist or buy medicine after-hours, the <a href="https://www.findapharmacy.com.au">Pharmacy Guild of Australia</a> and <a href="https://nationalnurse.com.au/late-night-pharmacies">National Home Nurse</a> pharmacy finders might be helpful. </p>
<p>In Victoria, <a href="https://www.chemistwarehouse.com.au/supercare-24-hour-chemist">Supercare Pharmacies</a> are also open 24/7, with nurses available from 6pm to 10pm.</p>
<p>Under the Pharmaceutical Benefits Scheme Continued Dispensing Arrangements, approved pharmacists may supply <a href="https://www.pbs.gov.au/info/general/continued-dispensing">eligible medicines</a> to a person in time of immediate need, when the prescribing doctor can not be contacted, once in a 12-month period.</p>
<h2>Medical chests in remote areas</h2>
<p>The Royal Flying Doctor service runs a <a href="https://www.flyingdoctor.org.au/sant/what-we-do/medical-chest-sant/">Medical Chest program</a>, to provide emergency and non-emergency, pharmaceutical and non-pharmaceutical treatments for people in remote areas, such as antibiotics, pain relief and first-aid. </p>
<p>Medical chests are provided for communities which are located more than 80 kilometres from professional medical services and maintained by a designated local medical chest custodian. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/our-study-found-after-hours-gps-actually-do-reduce-visits-to-emergency-rooms-79108">Our study found after-hours GPs actually do reduce visits to emergency rooms</a>
</strong>
</em>
</p>
<hr>
<h2>Mental health support</h2>
<p>Some mental health supports are available after-hours. Free options include:</p>
<ul>
<li><a href="https://healthability.org.au/services/after-hours-mental-health-nursing-service/">HealthAbility</a></li>
<li><a href="https://www.beyondblue.org.au/get-support/talk-to-a-counsellor">Beyond Blue</a></li>
<li><a href="https://www.suicidecallbackservice.org.au">Suicide Call Back Service</a></li>
<li><a href="https://www.lifeline.org.au">Lifeline</a> (13 11 14)</li>
<li><a href="https://kidshelpline.com.au">Kids Helpline</a>.</li>
</ul>
<p>You can also access paid psychologist services via platforms such as <a href="https://virtualpsychologist.com.au">Virtual Psychologist</a> and <a href="https://www.mymirror.com.au">MyMirror</a>. </p>
<figure class="align-center ">
<img alt="Woman waits in hospital waiting room" src="https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492927/original/file-20221102-26784-d2poox.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hospital emergency departments can be hectic places.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-sitting-hospital-ward-hallway-waiting-1085218841">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Indigenous health and wellbeing</h2>
<p><a href="https://www.vahs.org.au/yarning-safenstrong/">Yarning SafeNStrong</a> is a free, confidential, culturally suitable counselling service for Aboriginal and Torres Strait Islander people. This service offers support with social and emotional wellbeing, financial wellbeing, medical support including COVID testing, drug and alcohol counselling and rehabilitation services. </p>
<p>Other Indigenous health services include <a href="https://www.13yarn.org.au/contact-us-13yarn">13YARN</a>, <a href="https://supportact.org.au/get-help/first-nations-support-2/">Support Act</a>, and <a href="https://www.dardimunwurro.com.au/brother-to-brother/">Brother to Brother</a>. </p>
<h2>For people with communication needs</h2>
<p>Access to after-hours care is often dependent on people’s ability to communicate over a phone. </p>
<p>The <a href="https://www.infrastructure.gov.au/media-communications-arts/phone/services-people-disability/accesshub/national-relay-service">National Relay Service</a> can assist hearing- or speech-impaired people with changing voice to text or English to AUSLAN. </p>
<p>Non-English speaking people can access interpreter assistance for telehealth via the <a href="https://www.tisnational.gov.au">National Translating and Interpreting Service</a>. This service is typically free of charge, covers 150 languages, and can be accessed after-hours. </p>
<h2>Life-threatening emergencies</h2>
<p>Of course, none of the options above should replace the Triple Zero (000) service for life-threatening emergencies <a href="https://www.betterhealth.vic.gov.au/health/servicesandsupport/calling-an-ambulance">such as</a> difficulty breathing, unconsciousness and severe bleeding. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/looking-online-for-info-on-your-childs-health-here-are-some-tips-97701">Looking online for info on your child's health? Here are some tips</a>
</strong>
</em>
</p>
<hr>
<p>This handy infographic shows some of your options for after-hours care. Click on the hand icon on top right to activate interactive elements. Then press the + button to learn more:</p>
<div style="width: 100%;"><div style="position: relative; padding-bottom: 56.25%; padding-top: 0; height: 0;">
<iframe title="" frameborder="0" width="100%" height="675" style="position: absolute; top: 0; left: 0; width: 100%; height: 100%;" src="https://view.genial.ly/633e428a5edcf7001226ef91" type="text/html" allowscriptaccess="always" allowfullscreen="true" scrolling="yes" allownetworking="all"></iframe>
</div> </div>
<hr>
<p><em>We would like to acknowledge the following people for their input to this article: Dr Loren Sher (Director of Victorian Virtual ED at the Northern Hospital), A/Prof Michael Ben-Meir (Director of Emergency Department, Austin Health), Ms Karen Bryant (Senior Aboriginal Liaison Officer, Northern Health) and Dr Kim Hansen (Director of Emergency, St Andrew’s War Memorial Hospital).</em></p><img src="https://counter.theconversation.com/content/190144/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Sometimes you just can’t wait to see a doctor. With the addition of more virtual services during COVID, these days you have more options.Mahima Kalla, Digital Health Transformation Research Fellow, The University of MelbourneFeby Savira, Alfred Deakin Postdoctoral Research Fellow, Deakin UniversityKara Burns, Digital Health Program Manager at the Centre for Digital Transformation of Health, The University of MelbourneSathana Dushyanthen, Academic Specialist & Lecturer in Cancer Sciences & Digital Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1695282021-10-11T05:19:10Z2021-10-11T05:19:10ZBad for patients, bad for paramedics: ambulance ramping is a symptom of a health system in distress<figure><img src="https://images.theconversation.com/files/425622/original/file-20211011-15-4frwah.jpg?ixlib=rb-1.1.0&rect=16%2C16%2C5582%2C3715&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://photos-cdn.aap.com.au/Image/20210908001573843506?path=/aap_dev11/device/imagearc/2021/09-08/e9/e8/c2/aapimage-7hg0y29vellzyo0u7pf_layout.jpg">(AAP Image/Bianca De Marchi)</a></span></figcaption></figure><p>Long lines of ambulances idling outside hospitals have shocked the public in recent news reports, especially in <a href="https://www.news.com.au/national/victoria/news/victorian-paramedics-under-huge-stress-with-highest-number-of-triplezero-calls-in-years/news-story/afa07e7e58b8869e38f239f49fa87106">states</a> with high COVID case numbers and increased hospital admissions. </p>
<p>Mick Stephenson, executive director of clinical operations at Ambulance Victoria <a href="https://www.abc.net.au/radio/melbourne/programs/mornings/ambulance-victoria-hospital-ramping/13562788">told ABC radio</a> he’d “never seen the health system under the pressure it is under at the moment” and he expected worse to come.</p>
<p>In fact, ambulance ramping is an issue even in <a href="https://indaily.com.au/news/2021/04/01/truly-demoralising-bombshell-report-reveals-children-elderly-at-mercy-of-ambulance-ramping/">states</a> with low or no COVID cases, pointing to <a href="https://www.abc.net.au/news/2021-10-04/qld-covid-hospital-ramping-delta-outbreak/100511028">health systems</a> under stress. It’s a problem that risks the health of patients and paramedics. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hospital-emergency-departments-are-under-intense-pressure-what-to-know-before-you-go-169098">Hospital emergency departments are under intense pressure. What to know before you go</a>
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</em>
</p>
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<h2>After bypass was banned</h2>
<p>Ambulance ramping appears to have increased since some Australian states <a href="https://www.abc.net.au/news/2016-10-04/ambulance-ramping-on-the-rise-in-wa-labor-says/7901844">banned hospital bypass</a>. Hospital bypass previously allowed overwhelmed hospital emergency departments (EDs) to request ambulances “bypass” them for another hospital. But this just shifted a patient’s treatment to another hospital. An ambulance that would have bypassed a hospital under the strategy is now potentially ramped there.</p>
<p>Still, ambulance ramping is not a new phenomenon. It’s a decades-old problem and an <a href="https://www.ifem.cc/wp-content/uploads/2020/07/R-01_ED-Crowding-and-Access-Block-Report-Final-June-30-2020.pdf">international</a> one, not limited to Western countries. </p>
<p>The Australasian College for Emergency Medicine (ACEM) explains ramping as when </p>
<blockquote>
<p>[…] ambulance officers and/or paramedics are unable to complete transfer of clinical care of their patient to the hospital ED within a clinically appropriate timeframe, specifically due to lack of an appropriate clinical space in the ED.</p>
</blockquote>
<p>Overseas, ramping is also referred to as “off-stretcher time delays”, “ambulance turnaround delays” or “ambulance offload delay”. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1442440409666383872"}"></div></p>
<h2>Bad for patients and paramedics</h2>
<p>Ambulance ramping delays access to appropriate management for the ramped patient. It has <a href="https://www.sciencedirect.com/science/article/abs/pii/S1574626710000054">long been known</a> to contribute to longer ED stays and stress on service provision. </p>
<p>Ramping leads to a lack of ambulance resources to respond to new cases and delayed response times. When multiple crews are ramped at a hospital like Melbourne’s <a href="https://www.abc.net.au/news/2021-09-29/victoria-ambulance-hospital-health-system-covid-strain/100499266">Northern Hospital</a> or sitting with patients in hospital corridors while they wait to be seen, other crews might need to travel much farther to respond to life-threatening emergencies. Paramedic morale can suffer and lead to disillusionment with the potential for paramedic “burnout”.</p>
<p>News reports have identified people suffering and <a href="https://www.abc.net.au/news/2021-07-02/inquest-into-mans-death-in-2019-examines-ambulance-delays/100263032">dying after long periods of ramping</a>, even in states not greatly affected by high COVID cases.</p>
<p>Ambulance ramping is what the public see and hear about via news reports. They might be less aware of bed shortages or access blocks in the aged care sector, which flows back to the hospital bed availability. This in turn flows back to the ED. </p>
<p>As with many aspects of health care, <a href="https://www.croakey.org/under-pressure-health-leaders-express-deep-concerns-as-australia-marks-bleak-covid-milestone/">COVID has highlighted</a> and worsened existing problems and pressures.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/health-workers-are-among-the-covid-vaccine-hesitant-heres-how-we-can-support-them-safely-168838">Health workers are among the COVID vaccine hesitant. Here's how we can support them safely</a>
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<h2>A complex problem</h2>
<p>Some <a href="https://www.news.com.au/national/victoria/news/victorian-paramedics-under-huge-stress-with-highest-number-of-triplezero-calls-in-years/news-story/afa07e7e58b8869e38f239f49fa87106">state</a> ambulance services have had extremely high demand which has stretched service delivery, especially when combined with ramping. </p>
<p>Ambulance Victoria has announced <a href="https://www.news.com.au/national/victoria/news/defence-personnel-deployed-to-drive-victorian-ambulances-amid-surge-in-demand/news-story/f07aa190ce1a6ee6a55a62492bf2db67">plans to use the military</a>, other non-government staff and student paramedics to drive ambulances to cope with the anticipated surge in demand. Given the number of graduate paramedics in Australia without current employment in state or territory ambulance services, such graduates would be a better option as they at least know how to be part of a “paramedic crew”.</p>
<p>Hospital ED blockages and delays are caused by a number of factors. Some patients could be adequately managed by a GP. An ageing population means patients with complex medical conditions, who take longer to treat in the ED. Patient treatment may be delayed while they wait for a procedure room to become vacant and a lack of hospital beds for ED patients who need to be admitted. The time needed to assess and treat COVID patients and to maintain a COVID-safe environment also leads to longer waits.</p>
<p>The impact of states with significant COVID cases re-opening once certain vaccination percentanges have been reached has yet to be seen in Australia. Based on overseas experiences, patients may face trying to access a health system that becomes completely <a href="https://www.aljazeera.com/news/2021/1/17/uk-hopes-to-ease-covid-19-restrictions-rollout-live-updates">overwhelmed</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1447147562331361280"}"></div></p>
<h2>What’s needed now</h2>
<p>Rather than a piecemeal state-by-state approach to community paramedicine, there is a need for national role definitions and educational standards. Instead of the current situation of emergency calls and ramping, a workforce of advanced or extended care paramedics could safely manage many patients in a community setting, rather than take them to hospital.</p>
<p>Some hospitals have tried to implement processes to improve ED, but a patient’s progress still might come down to a bed being available in the hospital. </p>
<p>The issue remains a state or territory and federal problem with beds needed beyond the ED to ease pressure there. The federal government funds a significant amount of aged care beds and the National Disability Insurance Scheme (NDIS) slow processing of hospital patients means they are often stuck in a hospital awaiting a place in an aged facility or a NDIS-funded facility. This continues to limit or block access to hospital beds.</p>
<p>Ambulance ramping is one symptom of a <a href="https://pubmed.ncbi.nlm.nih.gov/29982911/">multi-factorial health system failure</a>. Until there is sufficient federal funding for aged care beds, improved NDIS processes and funding to allow GPs and allied health workers to manage patients in the community, we will continue to see patients and paramedics put at risk.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/living-with-covid-looks-very-different-for-front-line-health-workers-who-are-already-exhausted-167213">'Living with COVID' looks very different for front-line health workers, who are already exhausted</a>
</strong>
</em>
</p>
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<img src="https://counter.theconversation.com/content/169528/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Malcolm Boyle is receiving funding from the Department of Infrastructure, Transport, Regional Development and Communications. Malcolm Boyle previously worked for Ambulance Victoria and interacts with Queensland Ambulance Service as part of his role at Griffith University.</span></em></p>Long lines of ambulances have hit the headlines in recent weeks. But ‘ramping’ isn’t a new problem for patients or paramedics. COVID means we must fix it now.Malcolm Boyle, Academic Lead in Paramedic Education and Program Director Paramedicine Programs, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1690982021-10-05T00:26:20Z2021-10-05T00:26:20ZHospital emergency departments are under intense pressure. What to know before you go<p>Emergency departments around Australia have experienced COVID in a variety of ways. </p>
<p>From the first quarter of 2020, most if not all have worked hard to plan for an influx of very unwell, highly infectious patients. In the less fortunate of jurisdictions, those apprehensions are being realised — though thankfully not yet to the magnitude seen in some overseas cities. </p>
<p><a href="https://www.healthdirect.gov.au/hospital-emergency-departments">Hospital emergency departments</a> (EDs) are under <a href="https://www.abc.net.au/7.30/hospitals-put-under-pressure-from-covid-outbreak-%E2%80%93/13529812">intense pressure</a> and there have been calls for the public to carefully weigh up need before presenting there. Don’t come if you don’t need to, they’ve been <a href="https://www.nhsgrampian.org/news/2021/april/public-urged-to-stop-avoidable-hospital-admissions-as-lockdown-eases/">told</a>. But equally, don’t wait if you need treatment, <a href="https://www.theguardian.com/australia-news/2021/sep/27/more-than-half-of-the-covid-cases-who-died-at-home-in-nsw-were-unknown-to-health-authorities">especially for COVID</a>. </p>
<h2>Less staff, more pressure</h2>
<p>For all hospitals, COVID planning has involved creating streams of patient flow, to ensure those infected can be treated in addition to and at the same time as those who are not — while preventing the former infecting the latter. This is labour-intensive work, often duplicating patient pathways but without a doubling of staff. </p>
<p>In fact, staff numbers in many EDs are down in Australia, for a variety of reasons. Many smaller rural departments rely on fly-in-fly-out locums, now locked out by lockdowns. At times, doctors and nurses have been <a href="https://www.abc.net.au/news/2021-08-23/vic-furloughed-healthcare-workers-brace-impact-covid-19/100397820">furloughed</a> because they have been infected at work or elsewhere, or because they have been close contacts. </p>
<p>Understaffed EDs push on, with the greater burden being <a href="https://www.publish.csiro.au/ah/AH21014">carried by fewer health workers</a>, resulting in their subsequent burnout. To that, add the task of working in <a href="https://www.abc.net.au/news/2020-08-03/nurses-do-not-want-public-to-complain-about-coronavirus-masks/12512436">full personal protective equipment</a>, often for many hours at a time. It is physically demanding, uncomfortable, unpleasant work, in an environment in which both high levels of vigilance to keep staff safe and cognitive skills to manage often complex and rapidly deteriorating patients are required.</p>
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Read more:
<a href="https://theconversation.com/health-workers-are-among-the-covid-vaccine-hesitant-heres-how-we-can-support-them-safely-168838">Health workers are among the COVID vaccine hesitant. Here's how we can support them safely</a>
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<h2>Not just COVID patients</h2>
<p>Much of the focus in the media on health care in a time of pandemic has understandably been on COVID hospitalisations and subsequent intensive care unit admissions. Less has been said about the impact of COVID on the treatment of other illnesses or injuries. </p>
<p>We are very fortunate in Australia there is still more of “the other” in our EDs than there is COVID. That might change in the run up to Christmas.</p>
<p>The ED is most obviously a place of treatment for acute injuries and illnesses. In addition to that, we treat people with chronic illnesses. The ED can act as a safety net for those who have no one else to turn to and reassure many without affliction. For patients in each of these categories, the experience of ED has changed significantly. </p>
<p>There are great concerns many of those who need immediate medical care are deferring seeking it. They may fear catching COVID or being a burden on a strained system. Many in the latter category are elderly patients and those with probably the most reasonable indications for using our services.</p>
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Read more:
<a href="https://theconversation.com/heres-what-happens-when-youre-hospitalised-with-covid-167544">Here's what happens when you’re hospitalised with COVID</a>
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<h2>First off, it’s your emergency</h2>
<p>So how should we, as a resource-constrained civil society, in the middle of a pandemic, use our EDs?</p>
<p>The first and overriding principle is that any medical emergency is YOUR emergency. If you think you are experiencing a medical emergency — one you cannot see yourself addressing with the resources available to you, at the time you are experiencing it — you should come to ED. It doesn’t matter if it seems trivial to others, it’s your emergency. And we are your emergency department.</p>
<p>If you don’t feel too unwell, and are uncertain where you should go for medical care, there are alternatives to the ED where excellent medical advice and treatment can be found. </p>
<p>Telehealth has been a godsend to both patients and our GP colleagues. There are now also numerous <a href="https://www.health.gov.au/contacts/healthdirect-hotline">health lines</a> to call. Pharmacists can provide excellent information about medication, as well as now providing COVID vaccinations.</p>
<p>The ED is not the best place to go to have a COVID test. If you are otherwise well, there are many testing locations where you will wait a far shorter time for a test and the results. </p>
<p>Similarly, many concerns about the very rare side effects of COVID vaccination can be addressed with a telehealth consultation and a blood test if required.</p>
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Read more:
<a href="https://theconversation.com/how-covid-affects-the-heart-according-to-a-cardiologist-165446">How COVID affects the heart, according to a cardiologist</a>
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<h2>Extra precautions, longer waits</h2>
<p>If you do come to the ED, try and be patient. There are extra measures in place to keep you safe. </p>
<p>You’ll need to wear a mask and check in with a QR code, use hand sanitiser and physically distance. There are increasingly strict rules about the numbers of visitors. </p>
<p>If that’s a problem, you’re probably going to be asked to leave. It’s nothing personal — we have a duty of responsibility to all our patients. </p>
<p>You might wait longer than expected despite the efforts of medical staff to see everyone as quickly as possible. </p>
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Read more:
<a href="https://theconversation.com/how-contagious-is-delta-how-long-are-you-infectious-is-it-more-deadly-a-quick-guide-to-the-latest-science-165538">How contagious is Delta? How long are you infectious? Is it more deadly? A quick guide to the latest science</a>
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<h2>EDs treat all comers</h2>
<p>Finally, if you’re worried about the consequences of catching COVID, get vaccinated. We treat all comers, with a variety of beliefs about their medical care — all as long as they agree to abide by the rules of “The House”: to be respectful and abide by hospital procedures. </p>
<p>But vaccination will reduce your chance of needing ED attention as a consequence of COVID — and protect you from catching it if you come to ED for another reason.</p>
<p>Working in the ED at the moment isn’t much fun for anyone. We’re all really tired and, for many, that’s even before the ED where we work has become COVID-dominant. We’re looking forward to moving out of this phase of the pandemic, safely. Then we can get back to treating the mishaps of more normal human lifestyles, led to the fullest.</p>
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Read more:
<a href="https://theconversation.com/how-well-do-covid-vaccines-work-in-the-real-world-162926">How well do COVID vaccines work in the real world?</a>
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<p class="fine-print"><em><span>David Caldicott does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If you feel like you’re having a medical emergency then you should still go to hospital. Expect longer waits and extra precautions.David Caldicott, Senior lecturer, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1660332021-09-08T20:12:17Z2021-09-08T20:12:17Z20 years on, 9/11 responders are still sick and dying<figure><img src="https://images.theconversation.com/files/419188/original/file-20210903-23797-akqghk.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2396%2C1595&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://photos.aap.com.au/search/world%20trade%20center%20attack">Shawn Baldwin/AP/AAP Image</a></span></figcaption></figure><p>Emergency workers and clean-up crew are among 9/11 responders still suffering significant health issues 20 years after the <a href="https://www.history.com/topics/21st-century/9-11-attacks">terrorist attacks</a>.</p>
<p>More than <a href="https://pubmed.ncbi.nlm.nih.gov/18500709/">91,000 workers and volunteers</a> <a href="https://www1.nyc.gov/site/911health/enrollees/rescue-recovery-workers.page">were exposed</a> to a range of hazards during the rescue, recovery and clean-up operations.</p>
<p>By March 2021, some 80,785 of these responders had enrolled in the <a href="https://www.cdc.gov/wtc/">World Trade Center Health Program</a>, which was set up after the attacks to monitor their health and treat them.</p>
<p>Now our <a href="https://www.cambridge.org/core/journals/prehospital-and-disaster-medicine/article/abs/health-trends-among-911-responders-from-20112021-a-review-of-world-trade-center-health-program-statistics/09B87521287B943402782DAADB47E0B9">published research</a>, which is based on examining these health records, shows the range of physical and mental health issues responders still face.</p>
<h2>Breathing problems, cancer, mental illness</h2>
<p>We found 45% of responders in the health program have aerodigestive illness (conditions that affect the airways and upper digestive tract). A total of 16% have cancer and another 16% have mental health illness. Just under 40% of responders with health issues are aged 45-64; 83% are male.</p>
<p>Our analysis shows 3,439 of responders in the health program are now dead — far more than the <a href="https://parade.com/1248604/jessicasager/9-11-facts/">412 first responders who died on the day</a> of the attacks.</p>
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<p>Respiratory and upper digestive tract disorders are the number one cause of death (34%), ahead of cancer (30%) and mental health issues (15%). </p>
<p>Deaths attributed to these three factors, as well as musculoskeletal and acute traumatic injuries, have increased six-fold since the start of 2016. </p>
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Read more:
<a href="https://theconversation.com/how-the-pain-of-9-11-still-stays-with-a-generation-64725">How the pain of 9/11 still stays with a generation</a>
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<h2>An ongoing battle</h2>
<p>The number of responders enrolling in the health program with emerging health issues rises each year. More than 16,000 responders have enrolled in the past five years. </p>
<p>Cancer is up 185% over the past five years, with leukaemia emerging as particularly common, overtaking colon and bladder cancer in the rankings.</p>
<p>This equates to an increase of 175% in leukaemia cases over a five-year period, which is not surprising. There is a <a href="https://pubmed.ncbi.nlm.nih.gov/32771228/">proven link</a> between benzene exposure and acute myeloid leukaemia. Benzene is found in jet fuel, one of the toxic exposures at the World Trade Center. And acute myeloid leukaemia is one of the main types of leukaemia reported not only by responders, but by <a href="https://www.wtc-illness.com/cancers/leukemia-blood-cancer">residents of lower Manhattan</a>, who also have higher-than-normal rates. </p>
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<p>Prostate cancer is also common, increasing 181% since 2016. Although this fits with the age profile of many of the health program’s participants, some responders are developing an <a href="https://pubmed.ncbi.nlm.nih.gov/31221798/">aggressive, fast-growing form</a> of prostate cancer. </p>
<p>Inhaling the toxic dust at the World Trade Center site may trigger a cascading series of cellular events, increasing the number of inflammatory T-cells (a type of immune cell) in some of the responders. This increased inflammation <a href="https://pubmed.ncbi.nlm.nih.gov/26816843/">may eventually lead to prostate cancer</a>.</p>
<p>There may also be a <a href="https://pubmed.ncbi.nlm.nih.gov/31490535/">significant link between</a> greater exposure at the World Trade Center and a higher risk of long-term cardiovascular disease (disease affecting the heart and blood vessels). Firefighters who responded to the World Trade Center on the morning of the attacks were 44% more likely to develop cardiovascular disease than those who arrived the next day.</p>
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Read more:
<a href="https://theconversation.com/air-pollution-causes-cancer-so-lets-do-something-about-it-19380">Air pollution causes cancer, so let's do something about it </a>
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<h2>The mental health effects</h2>
<p>About <a href="https://pubmed.ncbi.nlm.nih.gov/31625489/">15-20%</a> of responders are estimated to be living with <a href="https://www.beyondblue.org.au/the-facts/anxiety/types-of-anxiety/ptsd">post-traumatic stress disorder</a> (PTSD) symptoms — roughly <a href="https://www.nimh.nih.gov/health/statistics/post-traumatic-stress-disorder-ptsd">four times</a> the rate of the general population. </p>
<p>Despite 20 years having passed, PTSD <a href="https://pubmed.ncbi.nlm.nih.gov/28805168/">is a growing problem</a> for responders. Almost half of all responders <a href="https://pubmed.ncbi.nlm.nih.gov/31776767/">report</a> they need ongoing mental health care for a range of mental health issues including PTSD, anxiety, depression and <a href="https://www.medicalnewstoday.com/articles/325578">survivor guilt</a>.</p>
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Read more:
<a href="https://theconversation.com/9-11-anniversary-a-watershed-for-psychological-response-to-disasters-2975">9/11 anniversary: a watershed for psychological response to disasters</a>
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<p>Researchers <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364857/">have also found</a> brain scans of some responders indicate the onset of early-stage dementia. This is consistent with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364857/">previous work</a> noting cognitive impairment among responders occurs at about twice the rate of people 10-20 years older.</p>
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<h2>COVID-19 and other emerging threats</h2>
<p>Responders’ underlying health conditions, such as cancer and respiratory ailments, have also left them <a href="https://www.usatoday.com/in-depth/news/nation/2021/05/05/covid-risk-911-september-2001-ground-zero-responders-causes-concern/4961779001/">vulnerable to COVID-19</a>. By the end of August 2020, <a href="https://www.newsweek.com/how-many-people-died-911-thousands-perishing-september-11-related-illnesses-1531058">some 1,172 responders</a> had confirmed COVID-19.</p>
<p>Even among responders who have not been infected, the pandemic <a href="https://www.thecity.nyc/2020/9/10/21431746/how-many-9-11-survivors-have-died-of-covid-19">has exacerbated</a> one of the key conditions caused by search and rescue, and recovery after terrorist attacks — PTSD.</p>
<p><a href="https://www.nbcnews.com/news/us-news/covid-19-has-killed-dozens-9-11-first-responders-n1239885">More than 100 responders have died</a> due to complications from the virus, which has also exacerbated other responders’ PTSD symptoms.</p>
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<p>The number of responders with cancers associated with asbestos exposure at the World Trade Center is expected to rise in coming years. This is because mesothelioma (a type of cancer caused by asbestos) usually takes <a href="https://www.canceraustralia.gov.au/cancer-types/mesothelioma-cancer/awareness#:%7E:text=It%20usually%20takes%20a%20very,and%20roofing%2C%20and%20in%20insulation.">20-50 years to develop</a>. </p>
<p>As of 2016, at least 352 responders had been diagnosed with the lung condition <a href="https://www.mayoclinic.org/diseases-conditions/asbestosis/symptoms-causes/syc-20354637">asbestosis</a>, and at least 444 had been diagnosed with another lung condition, <a href="https://www.mayoclinic.org/diseases-conditions/pulmonary-fibrosis/symptoms-causes/syc-20353690">pulmonary fibrosis</a>. Exposure to asbestos and other fibres in the toxic dust <a href="https://www.asbestos.com/world-trade-center/">may have contributed</a>.</p>
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Read more:
<a href="https://theconversation.com/health-harms-of-asbestos-wont-be-known-for-decades-14845">Health harms of asbestos won't be known for decades </a>
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<h2>Lessons learned</h2>
<p>Our research involved analysing data from existing databases. So we cannot make direct links between exposure at the World Trade Center site, length of time there, and the risk of illness. </p>
<p>Differences in age, sex, ethnicity, smoking status and other factors between responders and non-responders should also be considered. </p>
<p>Increased rates of some cancers in some responders may also be associated with <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764101">heightened surveillance</a> rather than an increase in disease.</p>
<p>Nevertheless, we are now beginning to understand the long-term effects of responding to the 9/11 terrorist attacks. Exposure is still having both a physical and mental health impact and it’s likely responders are still developing illnesses related to their exposures.</p>
<p>Ongoing monitoring of responders’ health remains a priority, especially considering the looming threat of new asbestos-related cancers.</p><img src="https://counter.theconversation.com/content/166033/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More 9/11 responders died from physical and mental health issues after the terrorist attacks than on the day itself. And survivors are still suffering 20 years later.Erin Smith, Associate Professor in Disaster and Emergency Response, School of Medical and Health Sciences, Edith Cowan UniversityBrigid Larkin, PhD candidate, Edith Cowan UniversityLisa Holmes, Lecturer, Paramedical Science, School of Medical and Health Sciences, Edith Cowan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1658752021-08-20T12:23:23Z2021-08-20T12:23:23ZHospitals often outsource important services to companies that prioritize profit over patients<figure><img src="https://images.theconversation.com/files/416848/original/file-20210818-15-48rvp1.jpg?ixlib=rb-1.1.0&rect=89%2C743%2C8464%2C5040&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many hospitals outsource services to specialized companies. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/paramedics-taking-patient-on-stretcher-from-royalty-free-image/1128171354?adppopup=true"> JazzIRT/E+ via Getty Images</a></span></figcaption></figure><p>Hospitals have long embraced the practice of outsourcing some services to specialized companies. Much of this outsourcing is for nonclinical tasks such as laundry, information technology and cybersecurity, and outsourcing those types of services can boost efficiency and quality. </p>
<p>However, over the past few years there has been <a href="https://cepr.net/report/private-equity-buyouts-in-healthcare-who-wins-who-loses/">a fast-growing trend</a> of hospitals outsourcing clinically relevant services – like anesthesiology and emergency medicine – to companies separate from the hospital. When that happens, hospitals relinquish some of the control they have over quality of care.</p>
<p>One of us is a researcher <a href="https://scholar.google.com/citations?user=ld1HFfUAAAAJ&hl=en&oi=ao">who studies service quality within health care systems</a> and the other is a <a href="https://scholar.google.com/citations?hl=en&user=MTBx4DoAAAAJ">practicing physician, researcher and adviser to medical centers</a> who has had direct experience with outsourcing. Together with collaborators, we analyzed published research to better understand the benefits and risks of outsourcing in health care. </p>
<p>Our research focused on four clinically relevant services – emergency care, radiology, laboratory services and environmental services – and we <a href="https://doi.org/10.1016/j.mayocp.2021.07.003">found tangible harm to patients and hospitals</a> when those were outsourced. </p>
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<a href="https://images.theconversation.com/files/416850/original/file-20210818-17-wp75wp.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A sign in front of a hospital giving directions for the emergency entrance." src="https://images.theconversation.com/files/416850/original/file-20210818-17-wp75wp.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/416850/original/file-20210818-17-wp75wp.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/416850/original/file-20210818-17-wp75wp.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/416850/original/file-20210818-17-wp75wp.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/416850/original/file-20210818-17-wp75wp.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/416850/original/file-20210818-17-wp75wp.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/416850/original/file-20210818-17-wp75wp.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Emergency rooms are often staffed by people who do not work directly for the hospital.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:MarkhamStouffvilleHospital3.JPG#/media/File:MarkhamStouffvilleHospital3.JPG">Raysohno/WikimediaCommons</a></span>
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<h2>Emergency care</h2>
<p>When you walk into an emergency room in the U.S., the physician who helps you might not work for the hospital you are in. <a href="https://www.forbes.com/sites/elliekincaid/2018/05/15/envision-healthcare-infiltrated-americas-ers-now-its-facing-a-backlash/?sh=3c941a62284f">Two-thirds</a> of U.S. emergency departments use some sort of outsourcing, and more than half of practicing emergency physicians work not for a hospital but for separate companies called contract management groups.</p>
<p>Some of these management groups are <a href="https://www.washingtonpost.com/health/2021/01/04/er-doctors-covid-jobs/">owned by private equity firms</a>. The private equity health care model is to purchase private medical practices and consolidate them into a bigger firm that provides outsourced services, quickly increase the firm’s value, and then sell the firm for a handsome profit.</p>
<p>Contract management groups claim to streamline the <a href="https://www.modernhealthcare.com/article/20151107/MAGAZINE/311079981/outsourcing-medical-staffing-hospitals-turn-to-managed-service-providers-to-handle-all-temporary-staffing-chores">recruiting and credentialing</a> of emergency department staff to relieve hospitals of these tasks and, hopefully, lower costs. But the elephant in the room for emergency medicine and other medical specialties is that a profit-maximizing goal can <a href="https://doi.org/10.1016/j.jemermed.2016.01.006">conflict with prioritizing the well-being</a> of patients and medical staff. </p>
<p>In emergency care, for example, these contracting groups often have <a href="https://doi.org/10.1016/j.jemermed.2016.01.006">aggressive patient-per-hour quotas</a> and provide incentives for medical staff to order <a href="https://doi.org/10.1001/jama.2019.1077">more procedures and tests</a> – even if they’re not warranted. In one study, more than one-third of emergency physicians employed by these groups said they had concerns about <a href="https://doi.org/10.1016/j.jemermed.2012.12.019">losing their job if they raised questions</a> about overtesting, quality of care, or patient treatment – roughly double the rate for doctors employed by hospitals.</p>
<p>Contract management groups have also contributed to surprise billing and excessive collections. For example, in the first six months of 2019, TeamHealth, one of the largest such groups in the U.S. that contracts out emergency room physicians, <a href="https://www.propublica.org/article/this-doctors-group-is-owned-by-a-private-equity-firm-and-repeatedly-sued-the-poor-until-we-called-them">filed more unpaid-bill lawsuits against patients</a> in Memphis, Tennessee, than three local hospitals did combined. It was only <a href="https://www.propublica.org/article/this-doctors-group-is-owned-by-a-private-equity-firm-and-repeatedly-sued-the-poor-until-we-called-them">negative publicity that made the company reverse course</a> and stop suing patients.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/416851/original/file-20210818-15-duajip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An X-ray image showing a fractured elbow." src="https://images.theconversation.com/files/416851/original/file-20210818-15-duajip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/416851/original/file-20210818-15-duajip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=441&fit=crop&dpr=1 600w, https://images.theconversation.com/files/416851/original/file-20210818-15-duajip.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=441&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/416851/original/file-20210818-15-duajip.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=441&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/416851/original/file-20210818-15-duajip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=555&fit=crop&dpr=1 754w, https://images.theconversation.com/files/416851/original/file-20210818-15-duajip.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=555&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/416851/original/file-20210818-15-duajip.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=555&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The interpretation of medical imaging is often outsourced to off–site companies.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:OlecranonFracMark.png">James Heilman, MD/WikimediaCommons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Radiology</h2>
<p>When you get an MRI or an X-ray, having a radiologist interpret the results is often the most costly and time-consuming part of the process. The potential to <a href="https://doi.org/10.1089/tmj.2016.0149">speed up</a> interpretation of results and cut costs has led many hospitals to contract with separate, off-site radiology services.</p>
<p>The practice is widespread: <a href="https://doi.org/10.1016/j.jacr.2019.05.053">About 50% of radiologists</a> say that they have interpreted imaging results away from where the images were taken and a quarter say that off-site interpretation is the majority of their work.</p>
<p>For smaller and rural health care systems that lack the resources to staff in-house radiologists, outsourcing may be essential. But for larger health care systems, outsourcing can sometimes lead to negative clinical and business consequences that outweigh the benefits. </p>
<p>For instance, off-site radiologists often <a href="https://doi.org/10.1007/s00330-019-6014-5">lack access</a> to patients’ prior imaging records or medical history. If these radiologists can’t see how a person’s condition has changed over time, it is <a href="https://doi.org/10.1007/s13244-016-0485-6">harder to make an accurate diagnosis</a>. This can lead to unnecessary and costly further testing. Moreover, off-site radiologists can have a harder time communicating with the physician who ordered the test, <a href="https://doi.org/10.1007/s00330-019-6014-5">potentially reducing the quality and continuity of care</a>. </p>
<p>Finally, there have been <a href="https://www.self.com/story/outsourcing-radiology-dangers">numerous reports</a> of for-profit radiology companies using radiology technicians who are not physicians for certain services. Radiology technicians are <a href="https://woman.thenest.com/orthopedic-technician-national-board-certification-13443.html">less expensive to hire than radiologists but also less well trained</a>. A licensed radiologist or physician is required by law to review and sign every report. But in a notorious example, one radiologist who owned a for-profit practice serving 15 U.S. hospitals signed off on more than 71,000 radiology reports during an eight-month period. The company was sued by the U.S. government, with investigators finding that licensed radiologists <a href="https://www.govinfo.gov/content/pkg/USCOURTS-ca11-11-16146/pdf/USCOURTS-ca11-11-16146-0.pdf">reviewed fewer than 6,000 – about 8% – of those reports</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/416852/original/file-20210818-17-gwz0gk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Small glass vials sitting in a blue vial holder." src="https://images.theconversation.com/files/416852/original/file-20210818-17-gwz0gk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/416852/original/file-20210818-17-gwz0gk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/416852/original/file-20210818-17-gwz0gk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/416852/original/file-20210818-17-gwz0gk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/416852/original/file-20210818-17-gwz0gk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/416852/original/file-20210818-17-gwz0gk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/416852/original/file-20210818-17-gwz0gk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">When hospitals outsource laboratory testing, they can face increased costs and lower-quality testing.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/gemmerich/7246889436">Greg Emmerich/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Laboratory services</h2>
<p>Another commonly outsourced service is bloodwork and other laboratory testing. Quest Diagnostics alone provides some level of lab service to <a href="https://newsroom.questdiagnostics.com/index.php?s=30664">about half of all U.S. hospitals</a>. </p>
<p>While the <a href="https://pubmed.ncbi.nlm.nih.gov/25318276/">potential financial savings</a> of using an off-site lab can be alluring to many hospitals, they often face <a href="https://doi.org/10.1177/2374289518765435">unplanned and sizable cost increases</a> caused by higher test prices, excessive testing and costly management fees. In one study, two academic medical centers that stopped outsourcing laboratory testing and brought it back in-house reported saving <a href="https://doi.org/10.1177/2374289518765435">$1 million to $4 million</a> in the first year. There is also evidence that outsourcing can result in <a href="https://doi.org/10.1177/2374289518765435">slower test turnaround times and nonreproducible test results</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/416854/original/file-20210818-19-168e61a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man in personal protective equipment mopping a floor in a hospital ward." src="https://images.theconversation.com/files/416854/original/file-20210818-19-168e61a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/416854/original/file-20210818-19-168e61a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=415&fit=crop&dpr=1 600w, https://images.theconversation.com/files/416854/original/file-20210818-19-168e61a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=415&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/416854/original/file-20210818-19-168e61a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=415&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/416854/original/file-20210818-19-168e61a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=521&fit=crop&dpr=1 754w, https://images.theconversation.com/files/416854/original/file-20210818-19-168e61a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=521&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/416854/original/file-20210818-19-168e61a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=521&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Outsourcing the environmental service staff that cleans health care facilities has been associated with higher rates of dangerous infections.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakBritain/bb20aa261af94708a5dba7e260e3f8c6/photo?Query=hospital%20cleaning%20staff%20covid&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=16&currentItemNo=2">Neil Hall/Pool via AP</a></span>
</figcaption>
</figure>
<h2>Environmental services</h2>
<p>Environmental services, previously known as “hospital housekeeping,” are a long underappreciated but key part of infection control in health care – even more so in the COVID-19 era. More than <a href="https://doi.org/10.7326/m20-2237">one-third of U.S. hospitals outsource environmental services</a>, but these outside firms often <a href="https://doi.org/10.1177%2F0730888414535352">don’t give workers adequate time to clean patients’ rooms, and they tend to pay lower wages</a> than in-house employers do. </p>
<p>In a study of about 300 California hospitals, those that outsourced environmental services reported nearly <a href="https://doi.org/10.1177/0019793916654482">twice the rate of <em>Clostridioides difficile</em> infections</a>, highly contagious bacterial infections that spread easily in hospitals. Difficult-to-treat staph infections known as MRSA are also <a href="https://doi.org/10.1016/j.socscimed.2016.12.015">more common in hospitals that outsourced</a> their environmental services. </p>
<h2>Outsource intelligently</h2>
<p>Health care is a unique service that must balance quality of care and people’s very lives with economic realities and profit motives. However, when profit becomes a singularly dominant goal, the best interests of patients, hospital staff and the hospital itself are jeopardized. Profit maximization does not align well with improving the safety and overall quality of patient care. </p>
<p>Many hospitals also are for-profit companies, but unlike contract management groups, hospitals are more visible and financially accountable to the public. Outsourcing has a beneficial role to play in health care when used for the right reasons and with the right partners and guidelines. But when health care systems outsource clinically important services to external companies, there is a real risk that it can lead to patient harm, unhappy staff and higher costs. We believe that outsourcing should be used only when it is the best option for all stakeholders, starting with the patients and staff.</p>
<p>[<em>Get our best science, health and technology stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-best">Sign up for The Conversation’s science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/165875/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Barach, MD, MPH, Maj. (ret.) has received research funding from including: NIH, AHRQ, HRSA, DOD, American Heart Association; Cardiomyopathy Foundation; European Union FP-7/Erasmus Plus; Norwegian Research Council; UK National Institute for Health Research, Department of Health; and Health Quality Improvement Partnership.</span></em></p><p class="fine-print"><em><span>Leonard L. Berry does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Outsourcing is common in many hospitals. But when health care systems outsource certain clinical tasks to separate companies, costs can go up, quality of care can fall and patients can be harmed.Leonard L. Berry, University Distinguished Professor of Marketing, Mays Business School; Senior Fellow, Institute for Healthcare Improvement, Texas A&M UniversityPaul Barach, Lecturer, Senior Advisor to the Dean College of Population Health, Thomas Jefferson UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1384602020-06-03T14:55:01Z2020-06-03T14:55:01ZCOVID-19 shows the world needs physicians who can look beyond medical charts<figure><img src="https://images.theconversation.com/files/339528/original/file-20200603-130951-1b0y43e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>As modern medicine has advanced, so too has our understanding of what affects health. Over recent decades this has generated a number of new fields in medicine. One of the most important that has been born out of the latest generation is social medicine. It studies how social and economic factors help determine our health, specifically inequalities within societies that negatively influence health outcomes.</p>
<p>Similar <a href="https://pubmed.ncbi.nlm.nih.gov/19933684/">to primary health care</a>, social medicine prioritises health equity and promotes a broad view of health, multi-sectoral action and the participation of communities. Both significantly contribute to progress in improving <a href="https://pubmed.ncbi.nlm.nih.gov/19933684/">health equity</a>. </p>
<p>COVID-19 has placed a spotlight on the field of social medicine. It has done so by showing up inherent injustices in society. An example is the fact that African-American and Native American communities in the US are experiencing <a href="https://www.theguardian.com/world/2020/may/20/black-americans-death-rate-covid-19-coronavirus">disproportionate</a> COVID-19 deaths. The result is that more people are beginning to argue that social medicine should take centre state in the medical community. But the argument towards a more progressive approach to healthcare is also being <a href="https://www.wsj.com/articles/med-school-needs-an-overhaul-11586818394">met with criticism</a> by those who still cling to the traditional model of medicine.</p>
<p>The argument has come to head over approaches to medical education.</p>
<p>The main argument against a ‘social medicine’ orientation in medical education is that it comes at the expense of “practical preparation” in areas like pandemic response and disaster preparedness. In a recent article a professor of medicine, Stanley Goldfarb, went as far as <a href="https://www.wsj.com/articles/med-school-needs-an-overhaul-11586818394">to argue</a> that social medicine should be removed from “the traditional American model of medical training.”</p>
<p>We are firmly in the camp of those who believe that social medicine is an integral part of the formation of health care professionals. We strongly believe that our trainees and graduates need to be content experts and “practitioners”. But that they also need to understand the social determinants of health and diseases.</p>
<p>Both are necessary for an integral understanding of any major health challenges – including pandemics.</p>
<p>Our view is that it’s not a question of social medicine at the expense of emergency medicine. This is a false dichotomy. Increasingly research has shown that a <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1916269">multi-sectoral approach</a> is needed to deliver effective healthcare. Clinicians should understand how factors such as poverty, food insecurity and racism have an impact on the population health. This is particularly true for the most vulnerable.</p>
<p>Consider this example: it’s not an uncommon in many developing countries to see a malnourished child get admitted to a hospital with serious complications. They receive appropriate care – including food – recover significantly and are discharged in a very good state. But they are then readmitted with the same condition. </p>
<p>The “treatment” of this child is not only the hospital-based administration of the food and medicine. It goes far beyond to food security, safe water provision, environmental health and other determinants of health and disease.</p>
<h2>Both lenses are needed</h2>
<p>Doctors should be trained in emergency and critical care. They should also be trained in social medicine. Missing out on either renders responses inadequate.</p>
<p>One danger of a one-track approach to medical education is that it creates technically capable physicians who are dangerously unaware of the numerous factors that determine health on the individual, community and global level. </p>
<p>This makes them ill-prepared for the reality of clinical experience. </p>
<p>The reality is that an application of both social justice and a bio-social lens, which focuses on how social factors influence health, are needed to understand how different groups are uniquely affected by an event such as the current pandemic, how they access existing health services, and how this, in turn, can affect a nation’s pandemic preparedness and response. </p>
<p>For example, in the US the coronavirus is disproportionately affecting African Americans. In US hotspot Louisiana, more than 70% of COVID-related deaths have been among black Americans, despite making up only 33% of the population, according to the <a href="http://ldh.la.gov/Coronavirus/">Louisiana Department of Health</a>. </p>
<p>Health professionals need to understand why. One reason could be the <a href="https://www.nytimes.com/2020/01/13/upshot/race-and-medicine-the-harm-that-comes-from-mistrust.html">well-documented</a> mistrust of the US health sector, which has, in the past, compromised public health responses. This has been also documented in other parts of the world, such as during outbreaks of <a href="https://www.nytimes.com/2016/01/18/us/in-rural-alabama-a-longtime-mistrust-of-medicine-fuels-a-tuberculosis-outbreak.html">tuberculosis</a>, <a href="https://link.springer.com/article/10.1007/s10461-012-0323-x">preventing the spread of HIV in Africa</a>, and efforts to contain <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6762146/">Ebola outbreaks.</a></p>
<h2>Why social justice matters</h2>
<p>The experience of COVID-19 has been a case study in why medical students need exposure to more, not less, social justice issues. </p>
<p>There is a reason why medical schools globally are adopting these principles of social medicine, and why students <a href="https://www.wsj.com/articles/take-two-aspirin-and-call-me-by-my-pronouns-11568325291">encounter patients before they graduate</a>. </p>
<p>It comes back to the problem that has plagued the success of multiple health policies over time; how can you design and implement health systems, or treat patients, without understanding the historical, social, geographic and political circumstances of those you are serving? </p>
<p>An effective pandemic response can’t be separated from the how or the why of its arrival, the factors contributing to its transmission, or its devastating after effects. </p>
<p>Concentrating only on fundamental classroom training puts a metaphorical plaster on the wound, and simply awaits the next graze on the knee. Understanding how and why these diseases come to fruition, avoids taking these learnings into the future, and protects millions of lives.</p>
<h2>Putting patients at risk</h2>
<p>From our experience as health practitioners and health educators, medical education that is not patient centred and pinned around social medicine puts patients at risk. </p>
<p>Of course the world <a href="https://www.wsj.com/articles/med-school-needs-an-overhaul-11586818394">needs physicians</a> “who are better prepared to help battle deadly pandemic diseases like COVID-19”. But students also need enough bio-social tools and social justice training to prevent, respond, and disaggregate the burden of pandemics in a way that’s inclusive of everyone. And consequently benefit entire societies.</p>
<p>Not doing this increases the risk for all – even those who have the privilege of accessing care.</p>
<p>Only by training a new generation of physicians who can look beyond medical charts and see the bigger picture can we be prepared for the next pandemic – and any other health challenge we will face in the future.</p><img src="https://counter.theconversation.com/content/138460/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Removing social medicine from the education of medical students would be to their detriment - as well as their future patients.Abebe Bekele, Dean of the School of Medicine, University of Global Health EquityAgnes Binagwaho, Vice Chancellor, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1165042019-05-08T22:34:43Z2019-05-08T22:34:43ZHow to stop kids from cutting themselves – advice from an ER doctor<figure><img src="https://images.theconversation.com/files/273499/original/file-20190509-183103-1uobcww.jpg?ixlib=rb-1.1.0&rect=5%2C115%2C3841%2C2451&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many teenagers who self-harm do so to cope with overwhelming thoughts and emotions. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>I recently worked a shift in the emergency room at a Toronto-area hospital and was asked to see a 12-year-old boy who had cut himself for the first time, on his wrist. </p>
<p>Cutting with razors, knives or other sharp objects is a common method of inflicting <a href="https://www.suicideinfo.ca/resource/self-harm-and-suicide">“self-harm”</a> — deliberate attempts to hurt oneself, without conscious suicidal intent. Other methods include burning or hitting oneself. </p>
<p>Hospitalizations from incidents of self-harm are increasing in Canada — <a href="https://www.cihi.ca/web/resource/en/info_child_harm_en.pdf">especially among pre-teen and teenage girls</a> — and <a href="https://www.reuters.com/article/us-self-harm/one-in-12-teenagers-self-harm-study-finds-idUSTRE7AG02520111117">globally</a>. </p>
<p>Over five years from 2009-10 to 2013-14, the rate of <a href="https://www.cihi.ca/web/resource/en/info_child_harm_en.pdf">intentional self-harm-related hospitalizations in girls increased by more than 110 per cent</a> — from 78 to 164 per 100,000 female youth. The rate for boys increased by more than 35 per cent — from 23 to 32 per 100,000 male youth. And this does not include all the cases that do not make it into the hospitals. </p>
<p>Like many, this boy did not know exactly why he did what he did; so I talked it through with him while I repaired his laceration. He left smiling and satisfied. His mom sent me an email today thanking me for taking care of her son.</p>
<h2>Why young people self-harm</h2>
<p>I recall another incident last year, with another 12-year-old boy who had cut himself. This was his third emergency room visit for cutting; the story was that “he began cutting only after having met a female friend who cuts.” </p>
<p>I asked him why he cuts? He looked up briefly and said it’s because “everyone hates me.” I asked him why if others hate him, they aren’t doing the cutting. He looked puzzled. </p>
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<p>I then asked him if it is possible that he is struggling with difficult feelings or thoughts that he can’t stop, and if he is using the pain of cutting to interrupt them. He looked up and held my gaze for the first time and nodded his head. </p>
<p>I asked him what else he does to stop these thoughts and feelings. Does he play video games? He quickly denied it. His mom pointed out that he plays hockey and has no time to waste. So I asked him again what else he does to stop his thoughts. His mom looked surprised when he finally said he punched walls. </p>
<p>I asked him if the pain helps him stop his thoughts and feelings. He said yes. I then asked him what else? He said he banged his head against walls. </p>
<p>Like <a href="http://www.arwtraining.com/wp-content/uploads/2015/02/03-Self-Harm-Perspectives-from-Personal-Experience-First-Hand-Experience-Testimonies.pdf">many others who self-harm</a>, this boy is cutting himself in an attempt to cope with events in his life, and the overwhelming emotions and thoughts that arise. </p>
<h2>‘Take Five:’ A mindfulness strategy</h2>
<p>I asked the first boy if I could share with him <a href="https://www.mentalhealthcommission.ca/English/media/4157">a mindfulness-based and painless technique called “Take Five”</a> that may help him deal with difficult thoughts. He looked at me earnestly and agreed. </p>
<p>I instructed him as follows: </p>
<ol>
<li>Hold up one spread hand and hold out the index finger in the other.<br></li>
<li>Slowly trace the outline of the spread hand with the index finger of the opposite hand in the following way. </li>
<li>Wait for the next (preferably involuntary) breath. </li>
<li>Trace up the digit with each inspiration.<br></li>
<li>Trace down the digit with each expiration. </li>
<li>Repeat until the entire spread hand is traced.</li>
</ol>
<p>I explained to him that by intentionally paying attention to the sensation of his breath and the tracing of his hand, he can redirect his attention away from his difficult thoughts and feelings without the the pain and trouble of his current methods. </p>
<p>I encouraged him to practise this new technique at every chance he gets. I suggested that his ability to direct his attention will improve with these regular practices — just like hockey drills improve his play.</p>
<h2>Mental health challenges are common</h2>
<p>According to <a href="https://cmha.ca/about-cmha/fast-facts-about-mental-illness">the Canadian Mental Health Association</a>, around 50 per cent of the population will have experienced mental illness by the age of 40.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/mental-illness-on-campus-really-is-a-thing-94571">Mental illness on campus really is 'a thing'</a>
</strong>
</em>
</p>
<hr>
<p>The 2016 report of <a href="http://oucha.ca/pdf/2016_NCHA-II_WEB_SPRING_2016_ONTARIO_CANADA_REFERENCE_GROUP_EXECUTIVE_SUMMARY.pdf">an American College Health Association survey in Ontario</a> revealed that 65 per cent of students “reported experiencing overwhelming anxiety in the previous year” and 13 per cent had seriously considered suicide.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/273498/original/file-20190509-183112-1ntd4gj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/273498/original/file-20190509-183112-1ntd4gj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/273498/original/file-20190509-183112-1ntd4gj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/273498/original/file-20190509-183112-1ntd4gj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/273498/original/file-20190509-183112-1ntd4gj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/273498/original/file-20190509-183112-1ntd4gj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/273498/original/file-20190509-183112-1ntd4gj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A technique like Take Five can offer an alternative way of redirecting attention away from difficult thoughts and emotions.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Encouraging <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383812/#!po=0.505051">preliminary evidence</a> suggests that therapists can foster <a href="http://www.mindfulnessinstitute.ca/mbsr">mindfulness</a>, in a relatively brief period of time and that mindfulness can affect a variety of processes thought to contribute to suicidal behaviour.</p>
<h2>Opportunities for greater understanding</h2>
<p>Before he left, I asked this boy if anyone else in his family suffered difficulty with thoughts and feelings. He said “my twin.” I asked, “who else?” He pointed to his mom. </p>
<p>I asked, “what about when your dad loses his temper and yells at you about hockey?” He thought and began smiling and nodding. So I suggested that he might find an appropriate moment to share his new knowledge and Take Five with his father.</p>
<p>He held my gaze continuously. In my peripheral vision, I noticed he had continued to practise Take Five by tracing his hand.</p>
<p>I suggested to him that many people struggle with these challenges and that he is not alone. I explained that by developing his ability to choose the object of his moment to moment attention, <a href="https://self-compassion.org/wp-content/uploads/publications/Nonsuicidal_selfinjury.pdf">he can develop self-compassion</a> and open many exciting possibilities.</p>
<p>I also pointed out to him that even the Olympic silver medallist may cry for being only the second best; that the “worst” player exhibits great courage for simply being part of the game; and that everyone has the right to be happy.</p>
<p>I directed him to a <a href="https://palousemindfulness.com/">free online mindfulness training program</a> and encouraged his family to check it out.</p>
<p>He then reached out and shook my hand firmly for helping him.</p>
<p><em>If you, or someone you know, is struggling with self-harm or suicidal thoughts, free crisis support is available at Canada’s <a href="https://www.crisistextline.ca">Crisis Text Line</a> and international <a href="http://www.suicide.org/international-suicide-hotlines.html">suicide prevention hotlines</a>.</em></p><img src="https://counter.theconversation.com/content/116504/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carlos Yu does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A doctor explains how he introduces mindfulness to self-harming youth in the emergency room.Carlos Yu, Assistant Professor, Department of Community and Family Practice, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/978822018-06-13T14:27:15Z2018-06-13T14:27:15ZA head injury could cost a footballer more than the World Cup<p>Liverpool goalkeeper, Loris Karius, made crucial errors during the recent Champions League final, including throwing the ball to Real Madrid striker, Karim Benzema. Five days after the match, Karius was <a href="https://www.bbc.co.uk/sport/football/44367148">diagnosed with concussion</a>. </p>
<p>Head injuries can have more serious consequences than losing an important match or <a href="https://www.bbc.co.uk/sport/football/43057859">ending a career</a>, however. In Europe, it is the <a href="https://www.center-tbi.eu/">leading cause of death in young adults</a>, and football players could be a particularly vulnerable group.</p>
<p>About 1% of people who suffer a blow to the head have life-threatening injuries (mainly bleeding in the brain) and need <a href="https://www.nice.org.uk/guidance/cg176/ifp/chapter/Head-injuries">advanced medical treatment</a>, sometimes including brain surgery. About 30% of people develop concussion – a catch-all term that describes impaired brain function due to head injury – with a range of symptoms, such as nausea, vomiting and dizziness, as well as impaired thinking that <a href="https://patient.info/health/post-concussion-syndrome">can last months</a>. But most people who suffer a blow to the head have no lasting ill effects. The problem is that all three groups can initially appear the same. </p>
<p>When a patient is admitted to an emergency department (A&E) with a head injury, a structured assessment and brain scans are used to identify patients who may have life-threatening injuries. However, despite a ton of research in this area, we still can’t reliably predict who will develop concussion. </p>
<p>If a patient injures their head again, while concussed, it can lead to a catastrophic worsening of their symptoms. So the standard advice in the UK is that all patients with head injuries should avoid contact sports for two to four weeks following injury, and they should seek further medical attention if their symptoms persist.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Jamie Roberts played for 15 minutes with a fractured skull.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=27655256">Blackcat/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Assessing a player, pitch side, in the middle of a competitive football match, is a very different challenge, though. Without the benefit of CT scans, the medic must first determine whether the player has a potentially life-threatening injury that needs hospital treatment. Then they must determine whether the player has a concussion and cannot play on. </p>
<p>The symptoms of concussion may not be immediately apparent, making it difficult to diagnose. This difficulty was demonstrated in the case of Jamie Roberts, the Welsh international rugby player, who played on for 15 minutes in 2008 with a fractured skull, after passing a pitch-side medical assessment.</p>
<p>Most footballers who suffer a blow to the head will have no underlying brain injury. A balance must be found that protects player welfare and allows players to safely play on when possible. </p>
<h2>Lessons from rugby union</h2>
<p>This is an area where football could learn from rugby. In August 2015, rugby union introduced a head injury assessment that outlines criteria for the immediate assessment and removal of players with a head injury, pitch side, and for the identification of delayed concussion symptoms. </p>
<p>Identifying head injury in rugby union is perhaps easier, as it’s a full contact sport and <a href="http://www.espn.co.uk/football/blog/fifa/243/post/3091640/video-assistant-referees-football-can-learn-from-rugby-cricket-tennis-nfl">recently introduced pitch-side video assisted referees</a>. The UK Football Association, to its credit, has released recent guidance recommending that head-injured players who have periods of loss of consciousness should be removed from play. FIFA might also want to consider strengthening its position on head injuries in football. Extending existing guidelines to include the assessment of delayed concussion symptoms would be helpful. </p>
<p>Hopefully, greater awareness in football will equip coaches and the medical support team to recognise when a player has been affected by a head injury and empower them to remove the athlete from play.</p><img src="https://counter.theconversation.com/content/97882/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carl Marincowitz is funded by a National Institute for Health Research Doctoral Fellowship.
This article presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
</span></em></p><p class="fine-print"><em><span>Andrew Garrett received funding from the João Havelange Research Scholarship (FIFA) in 2015. Investigating the health and safety of female footballers, as they adapt to playing in hot conditions. </span></em></p>Football could take a leaf from rugby union’s book on how to treat head-injured players, pitch side.Carl Marincowitz, NIHR Doctoral Research Fellow, University of HullAndrew Garrett, Lecturer in Exercise and Environmental Physiology, University of HullLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/922642018-03-19T00:32:51Z2018-03-19T00:32:51ZBeyond Triple Zero: towards a digital, proactive emergency response<p>Imagine you’re camping in the Australian outback. Your friend falls and breaks a leg, and you call Triple Zero (000) – but you’re panicking, and can’t remember which roads you took to the rocky outcrop where the accident took place. </p>
<p>Getting help in this sort of situation may soon be simpler, with Apple <a href="https://www.apple.com/uk/newsroom/2018/01/apple-previews-ios-11-3/">recently announcing</a> that the iOS 11.3 update (available in coming months) will support Advanced Mobile Location technology (AML). With AML, when an emergency call is made from a mobile phone, the location of the caller is automatically sent to the emergency communication operator. </p>
<p>But one vital step is missing for this to work in Australia. AML also has to be supported by the operator that manages the emergency communication service in that country. At the moment, this happens only in <a href="http://eena.org/download.asp?item_id=209">United Kingdom, Estonia, Lithuania, Austria, Iceland, Belgium, Ireland, Finland and New Zealand</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/snakebites-are-rarer-than-you-think-but-if-you-collapse-cpr-can-save-your-life-81614">Snakebites are rarer than you think, but if you collapse, CPR can save your life</a>
</strong>
</em>
</p>
<hr>
<p>In June 2017, the <a href="http://www.minister.communications.gov.au/mitch_fifield/news/tenders_to_be_sought_for_next-generation_triple_zero_emergency_call_service#.WpYP76jFLD5">Australian government announced</a> that a request for tender will be issued to deliver a new Triple Zero (000) service (Telstra has been the service provider since 1961).</p>
<p>This new service will need to support location-based data, with AML indicated as the preferred solution. Further, the government indicated that the new service will need to be flexible enough to support alternative technologies in the future. </p>
<p>The timing of the tender process is currently not clear. Still, Apple’s announcement means that the majority of mobile phones around the world will have AML by default – news <a href="http://www.eena.org/news/apple-anounces-aml#.WpXjH6jFLD6">welcomed with enthusiasm</a> by emergency communication professionals.</p>
<p>Close to 100% of Android phone users already have a similar setup, with AML capability automatically incorporated from July 2016 (from their <a href="https://blog.google/topics/google-europe/helping-emergency-services-find-you/">Gingerbread version</a> onwards). Android’s AML is called <a href="https://crisisresponse.google/emergencylocationservice/how-it-works/">Emergency Location Service</a>, or ELS.</p>
<h2>Emergencies in Australia</h2>
<p>Research by the <a href="https://www.acma.gov.au/theACMA/Library/researchacma/Research-reports/triple-zero-by-the-numbers">Australian Communications and Media Authority</a> shows that in Australia in 2017, around 70% of emergency calls came from mobile phones, with 14% of Australians making at least one call to Triple Zero (000) between January and June 2017.</p>
<p>To dispatch the appropriate emergency services (Police, Fire or Ambulance), the emergency operator has to know the caller’s location with an appropriate level of accuracy. </p>
<p>This can be problematic, especially in a situation of extreme distress, and when the caller is unfamiliar with their surroundings – for example, in a remote area or where a street number is not immediately visible.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/seven-ways-to-protect-your-pets-in-an-emergency-83484">Seven ways to protect your pets in an emergency</a>
</strong>
</em>
</p>
<hr>
<p>To tackle this issue, in 2015 the Push Mobile Location Identification (<a href="https://www.itnews.com.au/news/govt-wants-better-location-tracking-for-000-mobile-calls-435176">Push MoLI</a>) was introduced in Australia. This system identifies the caller’s location based on the proximity to telecommunications cellular towers and automatically sends it to the operator.</p>
<p>However, the Push MoLI only provides an area within which the caller is located. The accuracy of location largely depends on the proximity to, and the number of, nearby cell towers. In remote regions, such area can have a radius of <a href="https://www.itnews.com.au/news/why-only-60-percent-of-triple-zero-calls-will-be-tracked-466177">up to 100 kilometres</a>.</p>
<p>To address such issues, in 2014 Australia’s Triple Zero Awareness Group launched <a href="http://emergencyapp.triplezero.gov.au/">Emergency+</a>. Once downloaded, the app uses a mobile phone’s internal GPS to calculate latitude and longitude and show them on the screen. When prompted, the emergency caller can read their coordinates to the operator. Emergency+ has already exceeded 1 million downloads.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"967966416145080320"}"></div></p>
<p>Examples of Emergency+‘s effectiveness are reported in the <a href="https://www.theaustralian.com.au/business/technology/opinion/emergency-app-that-could-save-your-life-one-day/news-story/4203adf4bcddb8d7082bd89d813ae446">media</a>.</p>
<p>Nonetheless, <a href="http://necwg-anz.org/wp-content/uploads/2017/02/NECWG-ANZ-Mobile-Location-in-Emergency-Situations-White-Paper-2017_Final.pdf">some limitations</a> have been highlighted. As of June 2017, <a href="https://www.arnnet.com.au/article/631029/mobile-takes-hold-aussie-internet-explorers/">15.45 million Australian adults</a> owned a smartphone, which indicates that, at best, not more than 6.5% of them have the app. </p>
<p>Also, the process of reading one’s latitude and longitude introduces chances of human error, either by the caller or the operator. Further, some users may be unfamiliar with spelling their coordinates from a mobile app (e.g. the elderly). AML is intended to address these issues. </p>
<h2>The future of emergency communication</h2>
<p>The future of emergency communication is expected to be digital-friendly, flexible and diversified. </p>
<p>We can already see public acknowledgement of the <a href="https://www.dhs.gov/news/2011/05/04/written-statement-craig-fugate-administrator-federal-emergency-management-agency">growing importance of digital technologies</a> for emergency communications. In the UK, the Merseyside Police has recently launched an initiative for citizens to report non-urgent crimes through social media.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"959140552875835392"}"></div></p>
<p>However, it has been <a href="https://theconversation.com/the-role-of-social-media-as-cyclones-batter-australia-37835">pointed out</a> that social media should not be considered a replacement for more traditional (and sometimes reliable) forms of communication. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-role-of-social-media-as-cyclones-batter-australia-37835">The role of social media as cyclones batter Australia</a>
</strong>
</em>
</p>
<hr>
<p>The National Emergency Communication Working Group - Australia and New Zealand (<a href="http://necwg-anz.org/">NECWG-A/NZ</a>) consists of Australia and New Zealand representatives from emergency service organisations, public safety organisations, emergency call persons (the initial triage points for emergency callers, currently Telstra in Australia and Spark in New Zealand) and carrier representatives. </p>
<p>In 2014, NECWG-A/NZ produced the <a href="http://necwg-anz.org/?page_id=88">Next Generation Triple Zero Strategy (NG000)</a>. This document describes a vision for a Next Generation Emergency Call Service enabling:</p>
<blockquote>
<p>(…) any person requiring emergency assistance to use any device anywhere anytime to connect to emergency services. </p>
</blockquote>
<p>The vision consists of a multichannel approach, with inter-operable systems (allowing the different emergency agencies to be connected upon a single request) and that enables digital technologies. </p>
<p>Being proactive rather than reactive is another focus for future Triple Zero (000) and emergency communications. This idea was described in a <a href="http://necwg-anz.org/wp-content/uploads/2017/11/The-Emergency-Communication-Centre-of-the-Future-report-FINAL.pdf">recent report</a> from NECWG-A/NZ working with the <a href="http://www.chairdigitaleconomy.com.au/">Chair in Digital Economy</a> at QUT and Pricewaterhouse Coopers. </p>
<p>The emergency communication centre envisaged in this report uses data coming in from different sources (calls, videos, SMS, social media, sensors, etc.) and converts them into information used to prepare for, and possibly prevent, future emergencies. It has a constant presence of staff members from different emergency service and public safety organisations, with profiles ranging from data analysts to robotics experts and more.</p>
<p>NECWG-A/NZ is currently working on a <a href="http://necwg-anz.org/wp-content/uploads/2017/11/ECCF_Executive-Summary_A3.pdf">roadmap</a> to guide future development across three key aspects of emergency management: response, preparedness, and prevention.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/208235/original/file-20180228-36700-16q1re3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/208235/original/file-20180228-36700-16q1re3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=273&fit=crop&dpr=1 600w, https://images.theconversation.com/files/208235/original/file-20180228-36700-16q1re3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=273&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/208235/original/file-20180228-36700-16q1re3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=273&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/208235/original/file-20180228-36700-16q1re3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=343&fit=crop&dpr=1 754w, https://images.theconversation.com/files/208235/original/file-20180228-36700-16q1re3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=343&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/208235/original/file-20180228-36700-16q1re3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=343&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Building a proactive emergency communication centre.</span>
<span class="attribution"><span class="source">Authors</span></span>
</figcaption>
</figure>
<p>The Triple Zero (000) emergency service has saved the lives of many Australians. With the advent of digital technologies, it is now ready for its “Next Generation”. AML is the next step to accomplish. Beyond, lie numerous possibilities for a proactive emergency communication centre.</p>
<hr>
<p><em>The author would like to recognise a significant contribution to this article from Chris Beatson, Director, PoliceLink Command, NSW Police Force.</em></p><img src="https://counter.theconversation.com/content/92264/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The research cited in this article was completed during Ivano Bongiovanni's appointment as a Postdoc Researcher with the Chair in Digital Economy, Queensland University of Technology. Ivano Bongiovanni received funding from NECWG-A/NZ, QUT, PwC Australia, Queensland Government, and Brisbane Marketing. </span></em></p>Whether for police, ambulance or fire fighters, the future of emergency communication is expected to be digital-friendly, flexible and diversified.Ivano Bongiovanni, Postdoctoral Research Fellow - Adam Smith Business School, University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/846622017-10-04T22:09:54Z2017-10-04T22:09:54ZHow to improve the skills of tomorrow’s doctors<figure><img src="https://images.theconversation.com/files/188714/original/file-20171004-6713-1v44l96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new model of 'competency based' medical education is gaining popularity globally, in which trainees are assessed on skill rather than mere time invested.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Imagine you’re inside an ambulance racing to the emergency room with the lights and sirens blaring. You and your nine-year-old daughter were in a car accident; she is unconscious and bleeding. The paramedic has initiated an IV, placed cardiac monitors and an oxygen mask on her. </p>
<p>Minutes later, you arrive at the hospital. You need the best doctors available to take care of your child. You are at the mercy of their skills and expertise.</p>
<p>This scenario happens multiple times every day in my role as an emergency room physician. Patients and their family members place their trust in our team to care for them in a way that is competent, compassionate and patient-centred. As a clinical faculty supervisor, I also guide physician trainees to take on this leadership role. As a leader in medical education at Queen’s University’s medical school, I help create, refine and optimize physician training for the doctors of tomorrow. </p>
<p>This is why we have recently launched something called <a href="http://www.queensu.ca/gazette/stories/better-training-better-care">competency-based medical education (CBME)</a> at Queen’s. With this new model, trainees progress to the next stage of their education only once they have achieved required competency in clinical tasks — and not before. In the old system, they progressed when they had completed a set number of hours in a rotation, with no flexibility to slow down, or speed up, their path to independent practice. </p>
<p>The Royal College of Physicians and Surgeons of Canada recommended adopting competency-based medical education (CBME) several years ago. Many medical schools and teaching hospitals across Canada are slowly shifting their curriculum, specialty by specialty. In launching CBME all at once, Queen’s University’s medical school is <a href="https://beta.theglobeandmail.com/news/national/queens-university-to-revamp-medical-training-to-focus-on-skills/article28253206/?ref=http://www.theglobeandmail.com&">the first in North America</a> to fully adopt this innovative new approach to medical education across all of its residency education programs.</p>
<h2>Training that uses time as a resource</h2>
<p>The traditional model of apprenticeship-style, time-based medical training, introduced in the last century, has served us well for many years. Yet we are now at a tipping point for physician training in Canada. Health care is far more complicated today and a number of opposing forces are challenging the status quo. </p>
<p>How do we reconcile the need to decrease trainee hours — to optimize physician wellness and improve patient safety — with developments in new technology, diagnostic tests, therapeutic drugs and procedures, end-of-life care options and overall medical progress? </p>
<p>One might wonder — is CBME really necessary? Such a large-scale transformation of medical training has huge implications for universities, hospitals, accreditation bodies and government funding structures. It’s normal, perhaps necessary, to be skeptical.</p>
<p>But the term “resident” doctor comes from decades ago when 100- to 120-hour work weeks were common. You lived in the hospital for prolonged periods of time while you cared for patients and developed your skills as a physician. You had little direct supervision, practised many skills for the first time on real patients and learned from your mistakes at the patient’s expense. </p>
<p>For years, everyone has recognised this “traditional” way of training is more than outdated — it is unacceptable — and only a transformative approach will take us to where we need to go moving forward. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=473&fit=crop&dpr=1 600w, https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=473&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=473&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=595&fit=crop&dpr=1 754w, https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=595&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=595&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">With CMBE, trainees can progress through their education faster, but only if they achieve the competencies to function effectively in their speciality.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>If we continue in a time-based system, where time spent on numerous clinical rotations is the standard to become competent as a doctor, it will take even longer than the current average of 13 to 15 years at university to graduate as a specialist physician. This cannot be. There must be a better approach to training that uses time as a resource.</p>
<h2>Promotion based on competence</h2>
<p>Competency based education (CBE) is not a new concept. It has been part of adult learning methods for many decades. Only recently has it become <a href="http://macyfoundation.org/docs/macy_pubs/JMF_CBTVHPE_Summary_web_JMF.pdf">integrated into medicine</a>. </p>
<p>At its root, competency based medical education (CBME) is very simple. It reduces the emphasis of learning in clinical rotations based on “units of time” and instead <a href="https://www.researchgate.net/publication/45387545_Competency-based_medical_education_in_postgraduate_medical_education">shifts the basis of trainee promotion to the demonstration of competence</a>. </p>
<p>A trainee is directly supervised and is promoted only once skills (competencies) can be performed independently. In a CBME system, there is not a fixed time frame. The time to promotion may be longer for slower development, or may be quicker if a trainee demonstrates early mastery.</p>
<p>In the drive to transform how doctors are trained, CBME is an idea worth sharing with everyone. Depending on who you are as a stakeholder, CBME means different things. For a resident trainee, CBME offers a more flexible curriculum, greater individualized learning plans, more frequent assessment and better overall preparedness for practice — through the attainment of “entrustable professional activities (EPAs).” </p>
<p>For the patient, it is more focused on patient-centred care, allows direct feedback on residency assessment and provides greater physician accountability. Faculty in a CBME system provide enhanced learner driven instruction, focus assessments on real-time observable competencies and use well-defined learning outcomes. For society, CBME tightens the gap between medical education, health care delivery and societal health needs.</p>
<h2>Canada can lead medical education globally</h2>
<p>Canada has a world-class reputation in medical education and is well-positioned to be at the cutting edge of the transition to CBME. Our country has been a leader for decades, since launching <a href="http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf">the seven essential “CanMeds” roles of a physician</a> (communicator, collaborator, health advocate, leader, medical expert, professional, scholar). Many countries have implemented pioneering work from Canada.</p>
<p>More recently in 2010, the College of Family Physicians of Canada (CFPC) launched a transformational competency framework — <a href="http://www.cfpc.ca/Triple_C/">The Triple C</a> — to optimize how family physicians are trained across the country. </p>
<p>And the Royal College of Physicians and Surgeons of Canada announced in 2015 the creation of a new <a href="http://www.royalcollege.ca/rcsite/cbd/competence-by-design-cbd-e">Competency by Design (CBD)</a> framework that will transform residency education across more than 60 specialties at all 17 universities with medical schools in Canada. </p>
<h2>Strong institutional leadership needed</h2>
<p>So what are the next steps to make training better for our future doctors? To be successful, the following changes to our medical training models must occur:</p>
<ol>
<li><p>All sides of the patient care interaction need to become engaged with CBME. This includes universities, hospital and government leadership, as well as students, residents, faculty, allied health care providers and patients and their families. </p></li>
<li><p>Strong institutional leadership is needed — to implement change in a strategic, collaborative and meaningful manner.</p></li>
<li><p>Barriers within government funding models must be broken down to become more fluid in all stages of medical training — medical school, residency training and continuing career development.</p></li>
</ol>
<p>Ultimately, every patient, parent and family member must have confidence that all doctors involved in their care are competent, compassionate and have the prerequisite expertise required. </p>
<p>Arriving in the emergency room, the operating room, the intensive-care unit, a hospital ward environment or clinic can be a frightening situation. As a parent myself, I know I need the next generation of physicians to be competent to care for my family too.</p><img src="https://counter.theconversation.com/content/84662/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J Damon Dagnone does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A radical new model of “competency based” medical education emphasizes trainee skill over time invested. Queen’s University is the first in Canada to fully embrace this shift.J Damon Dagnone, Associate Professor of Emergency Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/831282017-09-24T23:12:50Z2017-09-24T23:12:50ZSeven ways to soothe your child’s pain in the hospital<figure><img src="https://images.theconversation.com/files/187103/original/file-20170921-21005-1l35ph9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are real consequences to ignoring children’s pain in hospital. These include increased sensitivity to pain, abnormal social behaviours when older and higher levels of anxiety before a future procedure.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Imagine this: You are having a lovely day at the park, when your sweet boy, only seven years old, falls from the monkey bars and screams loudly. His wrist is swelling quickly and looks deformed. You rush to the local hospital, where they tell you he will need x-rays and an IV. And his bones will need to be reset in the emergency department. </p>
<p>He is still crying, scared and in pain. What can you do, as a parent, to make this experience less stressful and painful for your child?</p>
<p>As a pediatrician who specializes in emergency care, I have had the privilege of caring for children with unexpected injuries and illness for over 15 years. During this time, I have seen and reflected on the tremendous pain that children sometimes experience, due in part to their injuries but also in part to the medical tests and procedures we must do. </p>
<p>For years, I did everything I could, as a doctor, to offer the best pain relief. When I realized that there were many unanswered questions about pain treatment, I took advantage of my position as a professor in the Faculty of Medicine and Dentistry at the University of Alberta to research the issue. Over the last decade, I have worked with various teams to research <a href="https://www.ncbi.nlm.nih.gov/pubmed/28077923">the best treatments for both presenting pain</a> (such as headaches, fracture-related pain and abdominal pain) and <a href="https://www.ncbi.nlm.nih.gov/pubmed/26720064">procedural pain</a> (such as blood tests, urine catheter insertions and IV insertions). </p>
<p>Based on current research, there are several straightforward things that parents can do — to help minimize their child’s pain and distress during a hospital visit.</p>
<h2>1. Give pain medicine early</h2>
<p>Often parents believe treating their child’s pain before visiting the doctor will make it harder to diagnose the problem. This is not the case! It is a myth that doctors need “all the pain” to be present in order to figure out what is going on. Truthfully, it is very difficult to examine a child when they are writhing in agony, and much easier when they are comfortable. Remember, no over-the-counter pain reliever is capable of masking serious ailments. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pain in infancy can have long term effects, such as increased sensitivity to pain and anxiety before procedures.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>So, treat your child with over-the-counter pain relievers (e.g. Tylenol or Advil) <em>before</em> you go the hospital (if they are able to swallow and are not vomiting). Use proper weight-based doses; your health professional can help you with this. If you arrive at the hospital and were unable to give your child medication before coming, ask for pain relievers EARLY! In many emergency departments, the triage nurse can treat your child’s pain even before a doctor sees them.</p>
<h2>2. Advocate for your child</h2>
<p>Health professionals now have <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=11533354">decades of research</a> that demonstrate the benefits of proper pain treatment. Properly treating pain actually <a href="https://www.ncbi.nlm.nih.gov/pubmed/15967972">improves success rates</a> and can prevent the need for repeat attempts at the same procedure. Further, there are real consequences to ignoring children’s pain. Children who experience moderate levels of pain during infancy may have <a href="https://www.ncbi.nlm.nih.gov/pubmed/11533354">long-term physical, psychological, and behavioural changes</a>, including increased sensitivity to pain, abnormal social behaviours when older and higher levels of anxiety before a future procedure. </p>
<p>Surprisingly, health professional sometimes forget to prioritize pain treatment. It is not a malicious thing. They are often busy, under-resourced, unaware of the evidence that exists and focused on “fixing the problem” — sometimes at the expense of adequate pain management. </p>
<p>As a parent, you can advocate for your child’s pain treatment and remind the team not to forget this key aspect of your child’s hospital visit.</p>
<h2>3. Use physical comfort measures</h2>
<p>There are many things we can do to make a child more physically comfortable. If they have an injured limb, splinting it can relieve a great deal of the pain. Using ice on a limb or joint injury reduces swelling and pain as well. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Holding a child can also help a child reduce anxiety and soothe pain.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>If you have a baby, swaddling them in blankets and rocking them can soothe them when they are in pain. Even simply cuddling your child can go a long way in comforting them during painful tests or while waiting for results.</p>
<h2>4. Use distraction</h2>
<p>Distraction helps children feel less distress and pain. There are low-tech options, such as bubble-blowing, playing i-Spy games, reading books, talking and listening to music. These can be offered by you or the health care team at little cost. For some children, especially as they get older, digital technology is a preferred option. Choices include tablets, smart phones, video games, and more recently, robots and virtual reality. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A child uses a Virtual Reality headset in a clinic.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>If you have time to plan, bring one of these options with you to your hospital visit. If you didn’t have time to plan, ask your health care team what they can offer. Many children’s hospitals even have “child life specialists,” whose very job it is to make your child’s hospital stay less stressful.</p>
<h2>5. Ask for numbing cream</h2>
<p>IVs and blood-work hurt. A lot. In fact, children tell us that getting an IV is the worst and most painful part of their hospital stay. There is <a href="http://dx.doi.org/10.1002/14651858.CD004236.pub2">indisputable research</a> that tells us that numbing creams (e.g. EMLA, Maxilene), when applied 30 to 60 minutes before a blood test or IV, reduce much or all of the pain of the procedure. </p>
<p>These products are available at most, if not all, hospitals and emergency departments, but you need to ask for them early, so that they do not cause your child’s tests or treatments to be delayed. Ideally, the health care team will offer them to you. If they don’t, ask about them!</p>
<h2>6. Remember that sugar eases pain</h2>
<p>Concentrated sugar drops, dripped onto a baby’s tongue two minutes before and during a medical test (such as a urine catheter insertion or a blood test) <a href="http://dx.doi.org/10.1002/14651858.CD001069.pub5">reduce pain for babies under 12 months of age</a>. It only takes two millilitres of this seemingly magical liquid to make a medical procedure easier for a baby! There are virtually no side effects to it, and it is safe even for premature newborns. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Parents have many options to help reduce their child’s pain in hospital.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>When combined with a pacifier, the sugar drops seem to work even better for many babies. Breastfeeding is well known to help ease pain and distress, as well, and should be chosen over sugar and pacifiers, if available for a baby.</p>
<h2>7. Ask for a pain management plan for home</h2>
<p>Emergency department visits and hospital stays are often just a “blip” in the timeline of your child’s journey back to health. In other words, most of your child’s pain will be dealt with by you, without the benefit of nurses and doctors. When it is time to leave the hospital, ask your health care team what to do <em>at home</em>. Ask what medications to use, and what non-medication things you should do. Ask them what to do if the first-choice medicines don’t work. And don’t forget to get advice on return to activity.</p>
<p>Children’s pain matters, and should not be ignored. There is absolutely no reason that a child should be in pain while the doctor is trying to figure out what is going on. As parents, we should feel empowered to ask for the best pain treatment possible for our children.</p><img src="https://counter.theconversation.com/content/83128/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samina Ali receives unrestricted research funding from the Canadian Institutes of Health Research, Alberta Innovates, and the Women & Children's Health Research Institute.</span></em></p>From broken limbs to blood tests, hospital visits can cause unnecessary pain for children. An emergency care pediatrician offers seven easy strategies for parents to lessen this pain.Samina Ali, Professor of Paediatrics and Emergency Medicine, University of AlbertaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/798132017-07-09T23:51:30Z2017-07-09T23:51:30ZLessons for first responders on the front lines of terrorism<figure><img src="https://images.theconversation.com/files/176110/original/file-20170628-3154-7e5e7g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">After two terror attacks the prior week, police patrolled the Westminster Bridge on election day 2017 in London.</span> <span class="attribution"><span class="source">AP Photo/Markus Schreiber</span></span></figcaption></figure><p>Acts of terrorism are <a href="http://www.cnn.com/2016/11/16/world/global-terrorism-report/index.html">on the rise globally</a>. Over the past several weeks alone, the world has seen stabbings, shootings and bombings in Flint, Tehran, <a href="https://theconversation.com/us/topics/london-bridge-attack-39289">London</a>, Kabul and Bogota.</p>
<p>We’ve spent the past several years researching how communities can prepare to provide urgent medical care to the large numbers of victims these events produce. </p>
<p>Given the persistent risk of terrorist attacks and large-scale accidents, it’s more critical than ever to learn from past incidents. That will ensure that first responders can work together effectively during the chaotic but critical minutes and hours after an incident. </p>
<h1>Better coordination</h1>
<p>Televised images of attack or disaster scenes often show patients being treated and transported by paramedics. Hours later, hospital press conferences often recount the heroic efforts of emergency physicians, trauma surgeons and nurses to minimize loss of life and limb. </p>
<p>But equally important are the actions of nonmedical first responders. Police, firefighters and even bystanders compress wounds, apply tourniquets or drive casualties to hospitals.</p>
<p>In the <a href="http://jamanetwork.com/journals/jama/article-abstract/1684255">Boston marathon bombing</a>, for instance, 264 victims transported to local hospitals survived, despite many serious injuries. This was credited not only to excellent triage, transport and care by medically trained paramedics, EMS and hospital staff, but also to <a href="http://journals.lww.com/annalsofsurgery/Abstract/2014/12000/The_Initial_Response_to_the_Boston_Marathon.4.aspx">immediate lifesaving actions</a> by police and bystanders. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/176109/original/file-20170628-31297-1pafc77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176109/original/file-20170628-31297-1pafc77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=389&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176109/original/file-20170628-31297-1pafc77.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=389&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176109/original/file-20170628-31297-1pafc77.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=389&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176109/original/file-20170628-31297-1pafc77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=488&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176109/original/file-20170628-31297-1pafc77.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=488&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176109/original/file-20170628-31297-1pafc77.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=488&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Responders help those injured after a bomb went off near the finish line of the Boston Marathon.</span>
<span class="attribution"><span class="source">AP Photo/Charles Krupa</span></span>
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<p>However, things do not always go so well. In the often chaotic post-incident scene, it can be difficult to coordinate the efforts of multiple response agencies and bystanders. Even as EMS personnel triage and transfer victims, law enforcement needs to maintain security, preserve evidence and locate potential perpetrators. That makes it challenging to manage access to and traffic around the scene. </p>
<p>For instance, <a href="http://www.cbsnews.com/news/orlando-nightclub-shooting-report-reveals-new-details-inside-pulse/">an Orlando Police Department report on the Pulse nightclub attack</a> cited the need for improved communication and coordination between the police and fire departments responding to the incident. While such problems do not always affect how many lives are saved, they can slow down the overall response. </p>
<p>Even when well-coordinated, those not trained in post-disaster casualty triage can unintentionally cause problems. They might transfer patients to hospitals that lack the resources needed to treat them, or transfer them in vehicles that lack critical life-support equipment, such as IVs or oxygen.</p>
<p>What’s more, unforeseen events such as poor weather or volume-related cell tower outages can create additional challenges. </p>
<h1>Preparing for the next attack</h1>
<p>Our recent research looked at three mass casualty incidents in the U.S. between 2013 and 2015, examining both the health care system and community responses.</p>
<p>We identified several best practices that can help medical and nonmedical first responders handle these incidents more effectively. </p>
<p>First, we must provide co-training for medical and nonmedical first responders. Police and firefighters are already starting to be trained in basic lifesaving skills in non-mass casualty incident contexts. In some communities, such as Atlanta and Irvine, California, police patrols carry <a href="http://www.sca-aware.org/sca-news/law-enforcement-agencies-putting-aed-devices-in-patrol-cars">automated electronic defibrillator devices</a> as well as <a href="http://www.emsworld.com/news/12318404/police-departments-carrying-narcan-to-save-both-the-public-and-police">Narcan</a> to reverse opioid overdose. Other police departments, such as in Denver, provide staff training in <a href="https://www.policeone.com/police-trainers/articles/6150110-Saving-lives-in-the-tactical-space-Training-to-use-tourniquets/">tourniquet application</a>. These efforts should be continued. </p>
<p>Moreover, both medical and nonmedical responders should be trained in scene safety, bystander management, field triage and medical techniques such as effective application of tourniquets. Even many medical professionals lack sufficient training in these skills. </p>
<p>Second, we need to ensure open communication lines. A dedicated radio frequency can facilitate communication among the various responder disciplines, as well as guard against problems caused by cell tower outages. Also, responders can be trained to rely, when necessary, on text messaging, which worked when voice communication did not during the events we studied.</p>
<p>Third, interdisciplinary disaster drills are critical. Communities should conduct regular citywide disaster drills that include EMS, fire and police departments, as well as area hospitals and health care systems. Responders need to test their training and protocols under conditions that simulate some of the complexity and stress of real events. This could include adding components without notice, to <a href="https://www.phe.gov/Preparedness/planning/hpp/surge/Pages/default.aspx">simulate the sudden onset of terrorist events</a>. </p>
<p>Such drills will help each group understand how its actions contribute to an integrated multidisciplinary response. They can also promote more effective collaboration during response to an incident. </p>
<p>Finally, we need to build relationships in advance that can be leveraged during emergencies. Our research indicates that one of the most important ingredients of an effective multidisciplinary medical response is strong relationships and trust among key players. Regular exercises and drills can help, but they need to be supported by leaders and organizational cultures. </p>
<p>For example, in recent years, with support from the federal government, many communities across the U.S. have created health care coalitions that provide formal mechanisms – including regular multi-stakeholder meetings and agreements to share critical resources – for coordinating the preparedness and response efforts of first responders, health care providers and private sector partners. </p>
<p>Moreover, given the frequent role of bystanders, professional responders should reach out to community emergency response teams and other organizations. That can help raise citizen awareness of basic lifesaving techniques. </p>
<h1>Public support</h1>
<p>Effective medical response to terrorism and disasters requires sustained investment. That can be difficult to muster in an era marked by increasing skepticism about public investment and distrust in public institutions. </p>
<p>However, experience suggests that we need collaboration among medical and nonmedical response organizations – and civilians. Through supporting public investments in mass casualty incident preparedness and response, both policymakers and civilians should have the confidence that, even when attacks cannot be prevented, their communities are resilient enough to respond to and recover from them.</p><img src="https://counter.theconversation.com/content/79813/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mahshid Abir is an Affiliated Adjunct staff member at the RAND Corporation and received funding from the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response (HHS/ASPR) for the research discussed in this article. </span></em></p><p class="fine-print"><em><span>Christopher Nelson is Professor of Policy Analysis at the Pardee RAND Graduate School and Senior Political Scientist at RAND. He received funding from the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response (HHS/ASPR) for the research discussed in this article.</span></em></p>Given the persistent risk of terrorist attacks and large-scale accidents, it’s more critical than ever for EMTs, police, firefighters and others to learn from the past.Mahshid Abir, Assistant Professor, Department of Emergency Medicine, Director of the Acute Care Research Unit, Affiliated Adjunct and Natural Scientist, RAND Corporation, University of MichiganChristopher Nelson, Professor of Policy Analysis, Pardee RAND Graduate SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/685782016-12-07T02:08:36Z2016-12-07T02:08:36ZWhy it’s wrong to blame Obamacare for health care ills<figure><img src="https://images.theconversation.com/files/148743/original/image-20161205-8039-1rpcf0a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Screen shot of ACA enrollment website.</span> <span class="attribution"><span class="source">Pablo Martinez Monsivais/AP</span></span></figcaption></figure><p>The Affordable Care Act (ACA), often called Obamacare, has come under sharp criticism. Now, with the nomination of Rep. Tom Price (R-Ga.) for secretary of health and human services, there are concerns about whether it will be repealed or changed. Price, a physician, has been a long-time critic of the law and has devised proposals of his own to replace it.</p>
<p>While Price may have alternative proposals that may be easier to pass in Congress, it is important to understand that the challenges associated with health care reforms are more than just a political battle. The ACA has been blamed for rising deductibles for people who do not receive subsidies and narrow networks. Critics want to blame the law for every flaw in our health care system. This is an inaccurate way to view the law, which has provided coverage for nearly 20 million people. </p>
<p>Most recently, critics of the law have cited an <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1609533#t=article">increase in visits to emergency rooms</a> over the last three years as an example of a failure of the law. Insuring people and providing them care in a doctor’s office was supposed to cut down on visits, and therefore costs, or so the thinking went. Critics cite the increase as proof that the law has failed. </p>
<p>We are not political scientists and have no comments on the policy changes that are almost certain in the near future. However, as researchers studying health care delivery and emergency department (ED) care, we think it is important to draw attention to some of the findings that may need a holistic approach to solving health care issues. </p>
<p>As our nation grapples with how best to provide health care, it is also important to keep in mind that our health care system has problems beyond Obamacare. A shortage of primary care doctors and <a href="http://content.healthaffairs.org/content/28/4/w657.abstract">nurses</a> is just one of the serious issues that need attention. </p>
<p>Based on our experiences, we also believe it is important for policymakers to know the facts and not rely on emotions and preconceived notions about ACA, and we will explain why. </p>
<h2>The supply-and-demand side of health care systems</h2>
<p>The Washington Post recently reported the <a href="https://www.washingtonpost.com/news/wonk/wp/2016/10/19/more-evidence-expanding-medicaid-increases-emergency-room-visits/">surge in ED volumes across several states</a>. The article also noted that the supporters of the ACA are disappointed that the spike, which was first reported two years ago, is not temporary. </p>
<p>While the spike may be real, there could be other factors driving the increases in ED volumes for an extended period (we refer to this as the demand side of the health care equation). Our concern is that conclusions derived from just looking at the increased usage of ED may not be thorough unless we understand the supply and quality side of the health care equation.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/148741/original/image-20161205-8003-1wwr9g5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/148741/original/image-20161205-8003-1wwr9g5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=444&fit=crop&dpr=1 600w, https://images.theconversation.com/files/148741/original/image-20161205-8003-1wwr9g5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=444&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/148741/original/image-20161205-8003-1wwr9g5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=444&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/148741/original/image-20161205-8003-1wwr9g5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=557&fit=crop&dpr=1 754w, https://images.theconversation.com/files/148741/original/image-20161205-8003-1wwr9g5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=557&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/148741/original/image-20161205-8003-1wwr9g5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=557&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Emergency room sign in Santa Clarita, California.</span>
<span class="attribution"><span class="source">Jason Redmond/AP</span></span>
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</figure>
<p>Our overall message is simple: Policy changes on the ACA based on volume spikes (demand side) may not solve the root cause of the health care access problem in the United States. The solution to health care problems, on the contrary, involves high-quality access through other forms of health delivery systems and improving the supply side of health care. </p>
<p>We will better explain the results from recent studies that found increased ED visits after ACA. </p>
<h2>Basic science: Correlation is not causation</h2>
<p>For instance, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27569108">Dresden and colleagues’ </a>study in the Annals of Emergency Medicine find that the average monthly ED visit in state of Illinois increased by 5.7 percent after ACA implementation. The same study finds that the total number of uninsured visits decreased, but this number is relatively small compared to the increases in ED use by Medicaid and private insured beneficiaries. </p>
<p><a href="http://news.mit.edu/2013/study-having-medicaid-increases-emergency-room-visits">Another study</a>, based on Oregon’s Medicaid expansion program, found that ED visits increased by 40 percent in the first 15 months of the program. While the surges in volumes are well-documented, increases in ED volumes are not a measure of ED operations quality or the efficiency of health care delivered. </p>
<p>In fact, the most common <a href="http://www.ahrq.gov/research/findings/final-reports/ptflow/section3.html">operations and quality metrics</a> to measure ED efficiencies used by Centers for Medicare and Medicaid (CMS) across hospitals are: </p>
<ul>
<li>Median time from ED arrival to ED discharge</li>
<li>Admit decision times to ED departure times </li>
<li>ED-patient left without being seen</li>
<li>Patient satisfaction</li>
<li>Door to diagnostic evaluation time</li>
<li>ED mortality rates </li>
</ul>
<p>As the above two studies conclude, it is quite possible that with the advent of the ACA, patients who did not have medical coverage in the past may have visited the ED due to the lack of access to primary care. As a result, one plausible theory is that though the ED volumes may have increased post-ACA, the severity of patient’s illness visiting ED may have decreased. As a result, some of these metrics may have improved post-ACA. </p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/27569108">second study</a> suggested this, in showing that the number of hospitalizations did not change, despite increases in ED volumes. </p>
<p>On the other hand, it is also quite possible that the patients who never sought medical care pre-ACA are seeking care through EDs, which could adversely impact the above metrics. It is also equally possible that the newly insured ACA patients may see ED as a step-up in quality from urgent care clinics and hence are crowding the system. </p>
<h2>A deeper issue: Shortage of primary care doctors</h2>
<p>Finally, it is also important to account for any changes to the delivery of care in the ED itself that are not currently considered in these publications. </p>
<p>For instance, a <a href="http://catalyst.nejm.org/how-the-freestanding-emergency-department-boom-can-help-patients/">recent study in the New England Journal of Medicine</a> suggests a 76 percent increase in free-standing emergency departments (FSEDs) between 2008-2015 that did not exist earlier. So, an increase in patient ED visits could also be due to the increase in access of new EDs that did not exist in the past. </p>
<p>Essentially, merely looking at demand side (just the ED volumes) and concluding that the ACA has increased health care costs may not be valid. It is important to get into these micro details before evaluating the benefits. </p>
<p>Evaluating the benefits from ACA requires us to also look at the supply side (i.e., resources available for patients) as well as the quality of the care provided. One of the founding principles of ACA is that this surge in demand is handled through preventive care access in the form of family medicine or primary care appointments, and other wellness appointments. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/148742/original/image-20161205-8034-axroyj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/148742/original/image-20161205-8034-axroyj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/148742/original/image-20161205-8034-axroyj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/148742/original/image-20161205-8034-axroyj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/148742/original/image-20161205-8034-axroyj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/148742/original/image-20161205-8034-axroyj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/148742/original/image-20161205-8034-axroyj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Doctors in Louisiana, where budget shortages are causing a shortage of doctors.</span>
<span class="attribution"><span class="source">Gerald Herbert/AP</span></span>
</figcaption>
</figure>
<p>When looking at the supply side of the health care delivery equation, we find that there is minimal change to this part of the equation, which may be the root cause of the problem. A study by the Association of American Medical Colleges finds <a href="https://www.aamc.org/newsroom/newsreleases/458074/2016_workforce_projections_04052016.html">severe physician shortages </a>in the near future. The report suggests that “demand for physicians continues to grow faster than supply, leading to a projected shortfall between 46,100 and 90,400 physicians by 2025.” </p>
<p>For years, a similar shortage of nurses has been reported, according to a study by <a href="http://content.healthaffairs.org/content/28/4/w657.abstract">Buerhaus and colleagues</a> from Vanderbilt University. </p>
<p>As the new administration decides what to do to tweak or repeal the ACA, it needs to keep in mind that a growing insured population without adequate health care delivery options will exacerbate ED crowding. It also will reduce ED efficiency, quality of care and the overall quality of life of the patient. We believe that fixing the supply side of the delivery equation by creating more opportunities to provide care would be a meaningful approach to fixing this health care crisis instead of denying insurance. </p>
<p>Clearly ED volumes (demand side) continue to rise despite or because of the ACA so that EDs remain an important safety net. The challenge is improving the supply side regarding unscheduled or unplanned care in a way that improves both access and quality.</p><img src="https://counter.theconversation.com/content/68578/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Affordable Care Act gets blamed for many health care ills, but here’s one condition that it should not be blamed for.Aravind Chandrasekaran, Associate Professor (Operations & Healthcare), The Ohio State UniversityDaniel Martin, Professor of Emergency Medicine and Internal Medicine, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/651422016-09-09T21:18:14Z2016-09-09T21:18:14ZDisaster communications: Lessons from 9/11<p>“The hotel is being evacuated. Please return to your rooms and prepare to exit.” That was the first communication one of us, Dr. Terndrup, recalls receiving at a medical research meeting in the Brooklyn Marriott hotel that September morning. </p>
<p>Out on the street was pandemonium, Terndrup remembers. Just two miles from what would come to be called “Ground Zero,” people were running away from Manhattan. <a href="https://dx.doi.org/10.1016/S0300-9572(02)00442-2">Members of our team</a> – all medical professionals – split up to find ways to help. With a medic I had never met before, and whose name I didn’t ever learn, I walked across the Brooklyn Bridge, toward the World Trade Center site. Most people were heading the other way, of course.</p>
<p>The medic and I didn’t know quite what to do, though, because we didn’t know what was going on. We could see the smoke and ash covering much of the city skyline, as we headed in to help. Even the <a href="https://www.youtube.com/watch?v=rsIWPPw-JzU">nonstop TV coverage</a> didn’t give us many details we could use. Once we got to Manhattan, we got some useful information from police and other medics. But despite being in the heart of a major city with television cameras everywhere and thousands of emergency workers responding, it was challenging to get accurate, timely information. </p>
<p>What we and the other <a href="http://dx.doi.org/10.1186/cc1053">responders learned that day</a>, under the pressure of a disaster of incredible scale, scope and urgency – not to mention the international media spotlight – went on to spark major changes in U.S. emergency response communication.</p>
<h2>Setting up to respond</h2>
<p>Once over the bridge and into lower Manhattan, the medic and I found our way to an office building off Vesey and Church streets, where we joined several dozen doctors, nurses, paramedics, police, firefighters and others hoping to help. We set up a makeshift clinic, including securing four elevators to stay on the ground floor to serve as “treatment rooms.” Then we waited.</p>
<p>When someone said there was a group of exhausted firefighters in a nearby bank, a few people went over to help rinse out their smoke- and dust-filled eyes (the most common problem) and help them use nebulizers (acquired from a nearby pharmacy) to combat the effects of smoke inhalation.</p>
<p>Communications were primitive at best. Cellular service was completely gone. In the first few minutes after the planes hit the towers, New York City’s 9-1-1 call centers received 3,000 calls – throughout that day, <a href="http://psc.apcointl.org/2011/09/06/911-10-years-later/">more than 55,000 came in</a>.</p>
<p>Thousands of law enforcement officers and firefighters were <a href="http://psc.apcointl.org/2011/08/10/10-years-later-n-y-responders-communicate-better/">trying to connect by phone, radio</a> and <a href="https://www.schneier.com/blog/archives/2009/11/leaked_911_text.html">two-way pager</a>. Devices and networks, not to mention personnel, were overloaded. <a href="http://www.cbsnews.com/news/communication-breakdown-on-9-11/">Police radios were generally working</a>, but the best information was often by word of mouth. </p>
<p>At our office-building clinic, the volunteers resorted to face-to-face communication, sending people to meet up with a group of responders gathering on the nearby Pace University campus and bring back what information they could. The main message rapidly went from bad to worse. It could be summed up as, “There’s nobody coming out of that alive.”</p>
<h2>Planning to communicate</h2>
<p>While obviously both of us hope nothing like that ever happens again, as emergency responders it’s our job to plan for the unthinkably disastrous. No matter what, responders need to be able to deliver messages to the public, talk to hospitals, and connect with each other.</p>
<p>Since 1999, New York City’s Office of Emergency Management, charged with coordinating all aspects of the response, had occupied <a href="http://empirezone.blogs.nytimes.com/2007/05/15/giuliani-911-and-the-emergency-command-center-continued/">permanent headquarters in Seven World Trade Center</a>, on Greenwich Street, just north of the landmark twin towers. A vital communications link was the <a href="http://www.emsworld.com/article/10324490/new-york-citys-public-safety-communications-three-years-after">radio repeater system</a> based on the ground floor of One World Trade Center, the north tower. The loss of those facilities – and key personnel working there – significantly hampered the response.</p>
<p>Today, it’s considered a bad idea to put an emergency operations center near places likely to be direct targets or at risk for collateral damage. When building a new emergency-response headquarters, New York City put it across the East River in <a href="http://www.interiorsandsources.com/article-details/articleid/5333/title/new-york-city-office-of-emergency-management-new-york-ny-.aspx">downtown Brooklyn</a>, far from all potential targets and landmarks in lower Manhattan.</p>
<h2>Making the connections</h2>
<p>But that distance can be a weakness if communications are reduced, as we were, to sending messengers on foot to have face-to-face conversations to relay information.</p>
<p>Even if radios and phones are working, they’re much less useful if responders can’t talk to each other. In 2001, the Fire Department of New York, the New York Police Department and the Port Authority Police <a href="http://psc.apcointl.org/2010/09/09/911-five-years-later-the-way-we-were/">all used different radio systems</a> with different capabilities on different frequencies. Unable to connect with each other, neither the agencies nor the rescuers themselves could efficiently coordinate to help victims. This disconnection may also have prevented <a href="http://psc.apcointl.org/2011/08/10/10-years-later-n-y-responders-communicate-better/">the evacuation of responders</a> before the buildings fell.</p>
<p>If leaders are to be farther away and yet still act rapidly in an unfolding situation, they need more than one way to communicate with each other and with people directly on the scene. When one system gets cut off or stops working properly, there must be other options.</p>
<h2>Constructing resilience</h2>
<p>In our work with Ohio’s FEMA Urban Search and Rescue Team, <a href="http://www.publicsafety.ohio.gov/ohtf1/">Task Force 1</a>, we have multiple communication methods. Mainly we use a <a href="https://ecfsapi.fcc.gov/file/60001707365.pdf">national wireless network</a> – which itself is designed to be <a href="https://www.verizon.com/about/emergency-information/prepared-weather-storm">resilient in emergencies</a>, with redundant network connections and switching equipment and round-the-clock system monitoring. The company can also bring in portable cellular towers when regular cell towers are disabled, or to improve coverage in an area where existing service is overloaded.</p>
<p>We have wireless service for the bus that serves as our mobile operations center, and for cell phones and tablets issued to our task force leaders. The bus also has a Wi-Fi system that can connect additional devices.</p>
<p>If the cellular network is severely compromised by the disaster, we can use satellites. <a href="http://www.cobham.com/communications-and-connectivity/satcom/land-mobile-satcom-systems/land-based-satcom-applications/explorer-msat-g3/explorer-msat-g3-data-sheet/">MSAT devices</a> carry our voice traffic, and our data travels via portable <a href="http://www.bgansatellite.com/">BGAN terminals</a>, which connect to laptop computers. </p>
<p>Our base of operations (BoO) at a disaster is equipped with a <a href="http://www.gatr.com/products/1-8-antenna-system">1.8-meter VSAT satellite dish</a> that can provide data and internet access for all the responders in the area. As further backup, we have portable radios and a repeater system.</p>
<h2>What we communicate about</h2>
<p>Another communications lesson from 9/11 comes from something that, tragically, didn’t happen. That day, <a href="https://www.newsday.com/911-anniversary/9-11-01-treating-the-victims-1.790094">New York hospitals called in all available staff</a>, to be ready to receive large numbers of patients. They worried, as did we, in our makeshift clinic just north of the twin towers, that thousands of people would need lifesaving care all at the same time.</p>
<p>Yet there was <a href="http://www.rand.org/content/dam/rand/pubs/technical_reports/2006/RAND_TR317.pdf">no way to know which hospitals were full</a>, which ones had operating rooms available or anything else about where to send patients, had they arrived in large numbers. Some hospitals likely would have been beyond overwhelmed, while others nearby might have had plenty of space and available doctors and nurses standing ready.</p>
<p>The lesson has spread across the country. Columbus, Ohio, where we work now, uses a system called “<a href="http://www.centralohiotraumasystem.org/rtas">Real Time Activity Status</a>,” which connects all the hospitals in our own Franklin County and three neighboring counties. It notifies ambulance dispatchers when their emergency rooms are too busy and need to divert patients to other hospitals. A similar system saved many lives <a href="http://www.newyorker.com/news/news-desk/why-bostons-hospitals-were-ready">after the 2013 Boston Marathon bombing</a>.</p>
<p>By ensuring that – no matter what happens – we can communicate with each other, the emergency response community <a href="http://www.jems.com/articles/supplements/special-topics/courage-under-fire/ems-untold.html">keeps the memory of 9/11 alive</a> in our own way every single day.</p><img src="https://counter.theconversation.com/content/65142/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Terndrup receives funding from the National Institute of Health. </span></em></p><p class="fine-print"><em><span>Nicholas Kman is affiliated with Ohio Task Force 1, FEMA Urban Search and Rescue. </span></em></p>What we and other responders learned that day would go on to spark major changes in U.S. emergency response efforts.Thomas Terndrup, Professor of Emergency Medicine, The Ohio State UniversityNicholas Kman, Associate Professor of Emergency Medicine, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/567302016-04-11T03:44:23Z2016-04-11T03:44:23ZWhy emergency care in Africa needs to become a specialised course<figure><img src="https://images.theconversation.com/files/117862/original/image-20160407-16260-i7rb9z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An ambulance arrives to evacuate casualties from a fire at the Nakumatt supermarket in Kenya.</span> <span class="attribution"><span class="source">Reuters/Antony Njuguna</span></span></figcaption></figure><p>The young patient was wheeled into our emergency centre by the ambulance service. He had sustained what appeared to be a severe head and pelvis injury and possibly also a spinal one. </p>
<p>Our emergency care team leapt into action. They took over his breathing, placing a tube through his mouth into his lungs. We splinted his pelvis and rapidly replaced the blood he had lost. In no time we were heading to the CT scanner with a fully stabilised patient.</p>
<p>Earlier that evening I sutured a three-year-old’s face after an unwelcome encounter at home that resulted in a broken window and an unsightly cut. She may recall the accident that led to the injury but not her hospital experience nor any traces of the wound. I gave her a light sedation and used a combination of fine sutures and skin glue to close the wound.</p>
<p>Before that, I treated a would-be mother who suffered a miscarriage. I also slowed down a young man’s heart that was beating too fast and treated another person’s acute asthma attack.</p>
<p>Each patient could safely go home after the emergency centre treatment. Each had a follow-up arrangement at their usual primary care doctor. My trauma patient couldn’t go home – at least not today. But he did get the best chance at a good outcome thanks to the presence of the specialised emergency care team in the emergency centre.</p>
<h2>Inadequate training on offer</h2>
<p>This scenario can be replicated by very few African emergency centres. But it did form part of my daily routine when I trained and worked as a specialist in emergency medicine at an English hospital. There, this level of emergency care is considered standard.</p>
<p>In contrast, emergency centres in South Africa – including privately operated ones – are mainly staffed by general practitioners and early career medical officers, who are largely non-specialists. Elsewhere in Africa, emergency centres may be staffed by clinical officers, who are not quite doctors but able to provide more advanced care than a nurse.</p>
<p>Undergraduate courses in most of Africa, and certainly in South Africa where I work, largely skimp on emergency care training. And the two- to three-day courses – usually a prerequisite to work in an emergency centre – mainly cover aspects of resuscitation. The result is that emergency centres are staffed with clinicians who either do not practice emergency medicine full-time or are only trained to deal with a small section of specialised emergency care. </p>
<p>There are currently five universities in South Africa that offer specialist training in emergency medicine. The first was established in 2003. But the trickle of specialists produced annually has not yet tangibly filtered down into the health-care system. There are only nine similar offerings on the rest of the continent.</p>
<p>In contrast, emergency medicine as a speciality has existed in developed countries such as Canada, the US, United Kingdom, Australia and New Zealand, and in parts of Western Europe for between 20 and 45 years. </p>
<h2>Africa needs emergency care specialists</h2>
<p>African countries make up more than half of the <a href="https://www.cia.gov/library/publications/the-world-factbook/rankorder/2066rank.html">top 20 countries</a> that have the highest annual death rates. </p>
<p>The two biggest contributing factors are: a lack of attention to prevention at the one end, and emergency care at the other.</p>
<p>Injury related deaths are <a href="http://www.who.int/healthinfo/global_burden_disease/projections/en/">projected to overtake</a> HIV-related deaths by 2030. Noncommunicable causes of death such as acute strokes and heart attacks have steadily increased over the past decade, overtaking the slowing tide of infectious causes of death such as HIV, tuberculosis and malaria.</p>
<p>An emergency care epidemic from injuries and noncommunicable diseases has been quietly filling the room just as HIV and tuberculosis were being ushered out. With proper emergency care only haphazardly practiced, health practitioners are ill prepared to cope with the stresses this will place on an already resource-limited and overburdened health-care system.</p>
<p>From what is known internationally about the ideal standard of emergency care, Africans appear to be getting a raw deal. This is the same whether you are attending a dilapidated public “casualty” department or a tidy private emergency centre. </p>
<p><a href="http://mybroadband.co.za/news/business/157603-why-discovery-is-so-expensive.html">Private medical aid providers admit</a> to this service failure. They point to inappropriate decisions taken by inexperienced doctors working in private emergency centres as one of the key reasons for rising private health-care costs in South Africa. This effect is likely to be similar, if not worse, in public emergency centres staffed by doctors with a similar scope. </p>
<p>Emergency medicine as a speciality involves providing specialist-level care for all acute illnesses or injuries for any age group, whether in or outside the hospital. It means having neurologist, cardiologist, surgical and a whole host of other specialist skills sets available in the emergency centre, with the safety and convenience of not having to wait longer than needed. The knock-on effect is reduced mortality, morbidity and cost. </p>
<p>By providing specialist input early in the patient journey, diagnoses are made sooner, appropriate treatment is started earlier and admissions are made appropriately. This leads to timely care, less complications and earlier discharge – often from the emergency centre. </p>
<p>As shown by multiple <a href="http://www.jogh.org/documents/issue201602/jogh-06-020304.pdf">studies</a> it is really that simple: by investing in the front end of acute care, savings (in more ways than one) are made downstream for both patients and health-care systems. </p>
<p>It is paramount to incorporate proven local solutions into African emergency care because Western solutions don’t face the same resource restrictions. </p>
<p>African countries could, for example, take a leaf out of <a href="http://www.sciencedirect.com/science/article/pii/S2211419X12000067">HIV’s success story</a>. As with antiretroviral treatment, emergency care is a front-end solution that has an effect on nearly every part of the health-care system. And stakeholders from every part of the health-care system need to be involved to set up and maintain the service. </p>
<p>But to achieve any of this, health-care leaders in the public and private sector need to be mobilised as advocates.</p><img src="https://counter.theconversation.com/content/56730/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stevan Bruijns receives funding from the National Research Foundation as a rated researcher. He is the editor-in-chief for the African Journal of Emergency Medicine, an open-access journal affiliated with the African Federation for Emergency Medicine, a not-for-profit organisation supporting emergency care across Africa</span></em></p>Few African emergency centres are able to provide comprehensive emergency care because they are staffed by general practitioners.Stevan Bruijns, Senior lecturer in the Division of Emergency Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.