Ethics of CPR

I understand why Obama has encouraged primary care physicians to talk with their patients about end of life care. It's not about forcing patients into rash decisions, or figuring out how much a life is worth, it's about truly addressing a patient's desires for end-of-life care.

I lost my grandmother about a month ago. While we were sad at her funeral, it was as much a relief as anything- one family member joked, "if she were a dog, we would have put her down months ago." She was in pain, in a nursing home, in diapers, and had little clue what was going on around her. It wasn't really her laying in that nursing home bed the last time I visited her in June. We all knew she would never make it out of the nursing home. Fortunately, it didn't last that long.

Shortly thereafter I sat in on a CE class regarding CPR initiatives. And I have to say that I didn't pay much attention in class. I spent most of my time wondering if it's right to be resuscitating many of the people we resuscitate.

While my medical director correctly pointed out that it's not my job to judge who gets resuscitated and who doesn't (which wasn't entirely my implication, but he's right, nonetheless), having been through a recent loss that was actually more comforting than any other loss I've ever experienced, I'm not convinced that paramedics should be resuscitating everyone. I don't know the best way to make this happen, other than to encourage people to think about it early.

I'm a bit hypocritical though. While I've talked with my husband and mom about it, I don't have anything in writing saying what my final wishes are. At 27 years old, I know that if there is no chance of me surviving an event without a majority return of function, I'd like to be allowed to die with dignity. But without it written down, would my family respect my wishes? Would they feel greedy NOT giving me every opportunity to survive? Would they feel guilty for making decisions on my behalf, and assume that I want everything done to keep me alive, regardless of what I have told them?

I hope not. But it happens. And that's why we have double-sequential cardioversion, an ungodly number of drugs, and are now back to working arrests for hours. Unfortunately, a majority of these arrests will occur in nursing homes, or in private homes of patients who, if they had been asked right before they died, would probably rather have been left peacefully- not have ribs violently cracked with CPR, not have a breathing tube shoved down their throat, and not costing their loved ones grief, shattered hope, and lots of money. Or, worse, they're resuscitated but with a brain injury, and now live as vegetables in a nursing home, never to be functional again.

Staff Welfare in EMS

In my previous post, I included a link to a youtube video of a lecture given by Dr. Brian Maguire. Dr. Maguire is a professor in the EMS department at the University of Maryland, Baltimore county, and recently received a Fulbright scholarship to study safety in EMS in Australia.

In the series of videos that comprises this half hour lecture, Dr. Maguire discusses the importance of creating a healthy workforce. The word healthy in this context is a holistic type of healthy- not just eating right and hitting the gym three times a week. While a healthy body is certainly a part of being a healthy person, having a healthy mind and spirit are equally as important. This is a relatively easy concept for the individual, but translating this concept to an entire workforce is more difficult.

Certainly it makes sense that a healthy and happy employee will be a good, positive employee. But how does an EMS organization help to generate and maintain happy and healthy employees? Encourage employee physical health, provide resources to employees to help with stress management, encourage a generally healthy lifestyle. Get together with local gyms and nutritionists and find discounts for employees, figure out of benefits providers (e.g. health insurance) will provide discounts for weight loss, smoking cessation programs, or other health improvements. And let the employees know about it.

But one healthy employee does not a healthy workforce make. Nor does an entire body of healthy employees make a healthy workforce-- while the workforce is made up of individual people, the group as a whole has its own dynamics. Workforces as a whole have many of their own ailments preventing good health. Supervisors who aren't helping their employees do their jobs to the best of their ability, but supervisors who are chewing out their employees for small oversights that have little or no effect on patient outcomes. Poor leadership and poor management, a lack of recognition of good work- whether it's a part of their day to day job or not. EMS, in my experience, has generally failed in this regard.

In my experience, paramedics don't come to work intending to screw up, or intending to be forgetful, or intending to make their supervisors' lives busier or more complicated, or rife with paperwork. They come to work to do a good job- to take care of people, show compassion, and do good medicine. In the process mistakes are made. Good supervisors look to these mistakes as learning experiences, not time to verbally berate field employees. The best supervisors find ways to make the learning experiences so memorable that those particular mistakes won't happen again.

So, how then does an organization create a healthy workforce? Make sure the world is in balance. While EMS organizations say that they often put patients first, at what cost does that come to the organization? The goal of an EMS organization is to provide excellent patient care. But sometimes, field level employees need to come in at least in second.

Blog Revitalization

OK, so I haven't posted in a really, really long time. I haven't had anything to write about.

But now I do.

Being in grad school for EMS has given me stuff to write about- my opinions on EMS in general. So, because I'd like to get some practice writing articles, I will occasionally (when I'm bored, I guess), write some articles. I'll start with a link to a lecture by one of my professors, Dr. Brian Maguire, entitled "Developing a Culture of Staff Welfare in the Emergency Services." I'll write about it next post.

http://www.youtube.com/watch?v=WCtqZrF9OJw

This is the first part of the lecture- there are three parts- you'll find links on the right of the page under "related videos"- the ones that say part 2 and part 3.