< Previous20 QUIZ 1. Which of the following is a possible differential diagnosis for this patient? a.) Acute myocardial infarction b.) Narcotic use c.) Trauma d.) A or B 2. Which vessels are occluded by pulmonary emboli? a.) Bronchioles b.) Pulmonary veins c.) Pulmonary arteries d.) Deep veins in the lower extremities 3. Where must a thrombus pass before lodging in the pulmonary vasculature? a.) The right side of the heart b.) The left side of the heart c.) The coronary arteries d.) The coronary veins 4. When temperature is assessed the patient is found to be febrile, which of the following could be the culprit ? a.) Pneumonia b.) Pulmonary embolus c.) Acute myocardial infarction d.) All of the above 5. How many lobes are the lungs composed of ? a.) Two b.) Three c.) Four d.) Five 6. If this patient was tachycardic, which street drugs might be responsible ? a.) Amphetamines b.) Psilocybin c.) Heroin d.) A and B 7. What can be said about the cough of a pneumonia patient? a.) It is productive b.) It is unproductive c.) It may be productive or dry d.) Pneumonia patients don’t cough 8. If this patient was pregnant, why would there be a greater risk of pulmonary embolism ? a.) This increased risk only occurs with placenta previa b.) Impeded venous blood return c.) Increased clotting factor d.) Both B and C are correct 9. Why does a pulmonary embolism cause shortness of breath? a.) It doesn’t usually cause SOB b.) Because of the state of anxiety c.) Because of circulatory obstruction d.) Because of respiratory obstruction 11. 12-lead ECG showed a sinus rhythm at eighty beats per minute, with right axis deviation and T wave inversion in leads V1 – V4, II, III and aVF . A palpated pulse matched what was seen on the monitor, but the patient’s heart rate eventually increases until it is over 100 bpm. 10. What is considered normal/narrow QRS width/duration? a.) 120 ms b.) <120 ms c.) >120 ms d.) Both A and B 11. What is considered a normal QT interval for this patient ? a.) Greater than ½ the R-R interval b.) QTc between 460 and 470 ms c.) QTc < 450 ms d.) QTc > 480 ms 12. What can right axis deviation indicate? a.) Right ventricular strain b.) Anterior fascicular block c.) Left bundle branch block d.) Left ventricular enlargement 13. What can peaked P waves mean? a.) Right atrial enlargement b.) Left atrial enlargement c.) Hypokalemia d.) A and/or C EUROPEAN HOLIDAY BY RON OSWALD A twenty-two year old female complains of new onset of chest pain and shortness of breath, after arriving home from an overseas vacation. On arrival of EMS, patient presents as anxious, with tachypnea and a non-productive cough. She reports no pertinent medical history, no allergies and is not taking any medications. She felt fine until about twenty minutes prior to calling “911.” She has not suffered any recent trauma. There is a family history of protein S deficiency. The nearest hospital is about twenty minutes away. Her vital signs are respirations of approximately 30/min, heart rate 76, blood pressure of 110/54, oximetry of 95% on room air, her temperature is unknown, and blood glucose is 5.0 mmol/L.21 QUIZ 14. Which of the following is a normal PR interval? a.) < 120 ms b.) > 120 ms c.) > 0.20 ms d.) < 0.20 ms 15. What do notched P waves mean? a.) Right atrial enlargement b.) Left atrial enlargement c.) Hypokalemia d.) A and/or C 16. What can T wave inversion indicate ? a.) Ischemia b.) Reciprocal changes c.) Ventricular strain pattern d.) All of the above are possible 17. When is d-dimer not useful in the diagnosis of pulmonary embolism? a.) When the patient is on blood thinners b.) Post-operative patients c.) During menstruation d.) It is always useful 18. Which type of pneumonia might cause empyema? a.) Viral b.) Bacterial c.) Chemical d.) All of the above 19. How does a thrombus affect pulmonary artery pressures ? a.) It decreases pressure b.) It increases pressure c.) It causes alternans d.) It has no effect 20. What is the Well’s criteria? a.) History and clinical signs to help diagnose pneumonia b.) History and clinical signs to help diagnose pulmonary embolism c.) History and clinical signs to help diagnose myocardial infarction d.) History and clinical signs to help diagnose hyperventilation syndrome 21. Which is an appropriate pre-hospital treatment for pneumonia? a.) Ipratropium bromide b.) Antibiotics c.) Fluid bolus d.) All of the above 22. Which of the following is part of the pre-hospital treatment plan for myocardial infarction? a.) ASA b.) Fluid bolus c.) Defibrillation d.) All of the above 23. What is the appropriate pre-hospital treatment plan for pulmonary embolism? a.) Nitroglycerine SL b.) Fluid bolus c.) Heparin d.) Oxygen 24. What is the appropriate pre-hospital treatment plan for this patient? a.) ASA b.) Oxygen c.) Nitroglycerin d.) All of the above 25. What is most likely happening to this patient ? a.) Myocardial infarction b.) Pulmonary embolism c.) Drug reaction d.) Pneumonia ABOUT THE AUTHOR Ron Oswald works as an Advanced Care Paramedic for Alberta Health Services in Milk River, Alberta, and the Prairie EMS division of Medavie.22 PRE-HOSPITAL EMERGENCY MEDICAL CARE - A GATEWAY TO HEALTH CARE SYSTEM? BY GEORGE AMOLO AND FLORIAN FIKUART INTRODUCTION Historically, global health policy emphasized multiple, vertically oriented programs that concentrated on maternal health and the control of communicable childhood diseases (1).This resulted in major public health agencies focusing their support on selective programs that address priority diseases and activities (2).Unfortunately, vertical programs do not encourage the development of strong and efficient health care delivery systems. The weakness of this approach is most apparent during crises, such as medical emergencies or incidents involving large numbers of casualties PREHOSPITAL EMERGENCY MEDICAL CARE The purpose of prehospital emergency medical care is to stabilize patients who have life- threatening or limb-threatening injury or illness out of hospital. In contrast to preventive medicine or primary care, emergency medical care focuses on the provision of immediate or urgent medical interventions. It includes two major components: medical decision-making, and the actions necessary to prevent needles death or disability because of time-critical health problems, irrespective of the patient’s age, gender, location or condition. PREHOSPITAL EMERGENCY MEDICAL CARE AND HEALTH SYSTEM PERFORMANCE The three fundamentals functions of a health system are to improve the health of the population, respond to people’s expectations, and provide financial protection against the costs of ill-health 9. Prehospital Emergency medical care can contribute positively to these functions. There are no empirical data on the number of lives or disability-adjusted life-years (DAILYs) saved through emergency medical care. Nevertheles, it is clear that many of the conditions that contribute to the burden of disease in Kenya can be mitigated through prompt treatment.10 Enhancing a health system’s responsiveness to people’s expectations lead to improved utilization of services and better outcomes.10 Access to medical care for urgent or life- threatening conditions is a key expectation in many communities. In Kenya mostly in rural areas and in urban centre people use their primary health care centre more often for medical emergencies than for preventive services, such as family planning or prenatal care11.in most instances they use traditional home remedies for minor ailments but turned to primary care medical facilities for acute complaints or when a child seemed seriously ill. The role of prehospital emergency medical care in providing financial protection against the costs of ill health is complex. The onset of an acute illness or injury forces many families in Kenya to choose between risking financial ruin because of medical expenses or risking death or life long disability attribute to lack of medical care. Both outcomes can have a catastrophic long-term impact.12 Prompt access to care during an emergency is essential, irrespective of whether the system gives financial protection through prepayment options, government provision of health care, or other insurance schemes.12 CORE COMPONENTS OF PREHOSPITAL EMERGENCY MEDICAL CARE Prehospital emergency medical care has three components: care in the community; care during transportation, which is related to the question of access; and care on arrival at the receiving health facility. It is designed to overcome the factors most commonly implicated in preventable mortality, such as delays in seeking care, access to a health facility, and the provision of adequate care at the facility.13 PRE-HOSPITAL EMERGENCY MEDICAL CARE IN THE COMMUNITY The outcome of acute illness or injury is strongly influenced by early recognition of its severity and the need for medical intervention.14 Since most emergencies start at home, any system to promote the early recognition of emergency conditions should be based in the community. 15 In order to save the lives of pregnant women it is important to reduce delays in accessing health care16 and this can happened if we invest in prehospital emergency medical care the provision of well- equipped ambulances for emergencies and employing Registered Paramedics. Many of of the benefits of prehospital emergency medical care could be realized by training more paramedics. County governments should allocate funds and buy modern ambulances stationed at strategically positioned ambulance stations. Other benefits of prehospital emergency medical care are that it can reduce time wastage at the accident and emergency department in the hospital. Professional prehospital emergency care helps to identify patients with acute need for treatment, identifying serious complications and can refer road accident victims who are seriously injured to higher levels of care immediately. Similarly, prompt referral of severely ill children to advanced health services can reduce child mortality. Many of the benefits to provide quality emergency medical care and patient safety will be realized by supporting professional prehospital providers and allocating funds to support prehospital emergency medical care. Efforts of a sufficient working EMS system could be a further step to the implication 23 of a universal health coverage strategy in Kenya. Further more it may be possible to reduce mortality rates noticeable. PREHOSPITAL EMERGENCY MEDICAL CARE AND TRANSPORTATION An absence of emergency medical transport is a common barrier to care.17 This may arise because of several factors including the lack of well-equipped modern ambulance, untrained staff not competent in prehospital emergency medicine, the absence of inadequacy of roads, and the ability to pay for ambulance services.17 The consequences of a lack of transport can be grave. In Kenya many acutely ill or injured patients die either on the way to hospital or at the hospital while waiting to be admitted in the accident and emergency department or in the reception area of an outpatient hospital.18 There is empirical evidence that providing emergency transport saves lives. Developing a well- structured emergency medical services response, better communication system between pre- hospital emergency care and receiving hospitals.19 The prevailing models of emergency medical transport used in Kenya are quite costly and would be impractical for communities who can’t afford. Poor condition of roads, lack of ambulance availability may dictate the utilization of a wider range of options. For example we have witnessed critically ill patients in Kenya being taken to a hospital using wheelbarrows as mode of emergency transportation of the weakest links in the system. Conditions of many seriously ill or injured patients arriving at the clinics or hospitals end up not recognized. Instead of receiving immediate emergency care patients sometimes keep waiting for long periods of time before being given proper treatment. This results in avoidable deaths and disability. Late patient referral to tertiary care lead to many preventable deaths, poor triage of incoming patients and inadequate provision of emergency care jeopardize the lives of arriving patients at many hospitals over Kenya. Majority of County hospitals in Kenya do not have an adequate triage system. Inappropriate or delayed triage of cases, poor clinical assessments, and potentially harmful delays are only some of the negative factors during the treatment process. PREHOSPITAL EMERGENCY MEDICAL CARE AND REFERRAL FACILITIES The readily availability of treatment in the prehospital care is the first component of emergency medical care.17 In addition to supplementing the knowledge and skills of professional providers at prehospital care the Kenyan government through parliament and senate should consider passing a emergency medical care bill that will recognize prehospital emergency care as key function allied to the health care system in Kenya. By ensuring registered paramedics take charge in community paramedicine practice the healthcare accessibility for citizens especially in rural areas could be increased.20 At the other end of the spectrum, attention should be given to education received by paramedics. 21, 22 There is a marked disparity between what is taught in medical schools and what is expected of medics in Kenya. Most medical students in Kenya acquire their training and skills on in patient wards of large hospitals in urban areas, where emphasis is placed on making the right diagnosis then on the principles of triage and emergency management. However, this model does not prepare medics in Kenya to work in prehospital care set up. For county hospitals in Kenya, the most pressing requirement is to sort sick patients and make appropriate triage and treatment decisions. In order to do this well, doctors and nurses need to be trained to recognize the severity of illness and to categorize conditions in relation to the likelihood of a threat to life, treatment priority, and the strategies most likely to maximize outcome, rather than on the basis of precise diagnoses. The training of healthcare providers in this manner requires a critical mass of physicians, nurses and paramedics who understand the principles of emergency care and are prepared to exert pressure for their inclusion in curricula of their respective disciplines. 23 The measures described are not particularly expensive if well-structured and can benefit large numbers of patients. However; cost is still likely to represent a formidable barrier to implementing emergency medical care systems in Kenya. Depending on the extent of Counties health care infrastructure, the implementation of an effective emergency medical care system will require little or more than incremental reforms, or it may demand a major overhaul of the health care system.24 CONCLUSION Health care in Kenya has not traditionally focused on prehospital emergency medical care. A sufficient prehospital care for acute illnesses and injuries is essential for good outcomes. Although health promotion and disease and injury prevention should be core values of any health system, many acute health problems will continue to occur. The incorporation of prehospital emergency medical care into health care systems could have a significant impact on the well-being of Kenyans and decrease the long-term human and economic costs of illness and injury. The priority should be placed on developing minimum guidelines for emergency medical care over the 47 counties in Kenya. The efficiency of such care could be assessed by implementing pilot programs in some counties. This would help to determine the degree to which prehospital emergency medical care systems save lives and at what cost. Prehospital emergency medical care remains to be the gateway to the healthcare system all over the world. Universal health care coverage is not possible without a proper prehospital emergency medical care system. REFERENCES 1 Garg S, Bhatnagar N, Singh MM, Borle A, Raina SK, Kumar R, Galwankar S. Strengthening public healthcare systems in India; Learning lessons in COVID-19 pandemic. J Family Med Prim Care. 2020 Dec 31;9(12):5853-5857. doi: 10.4103/ jfmpc. jfmpc_1187_20. PMID: 33681007; PMCID: PMC7928139. 2 Matifary CR, Wachira B, Nyanja N, Kathomi C. Reasons for patients with non- urgent conditions attending the emergency department in Kenya: A qualitative study. Afr J Emerg Med. 2021 Mar;11(1):113-117. doi: 10.1016/j.afjem.2020.09.004. Epub 2020 Sep 30. PMID: 33680731; PMCID: PMC7910189. 3 Wachira BW, Mwai M. A baseline review of the ability of hospitals in Kenya to provide emergency and critical care services for COVID-19 patients. Afr J Emerg Med. 2021 Jun;11(2):213-217. doi: 10.1016/j. afjem.2021.01.001. Epub 2021 Jan 18. PMID: 33495726; PMCID: PMC7816953. 4 Mantena S, Rogo K, Burke TF. Re-24 Examining the Race to Send Ventilators to Low-Resource Settings. Respir Care. 2020 Sep;65(9):1378-1381. doi: 10.4187/ respcare.08185. PMID: 32879035. 5 Moresky RT, Razzak J, Reynolds T, Wallis LA, Wachira BW, Nyirenda M, Carlo WA, Lin J, Patel S, Bhoi S, Risko N, Wendle LA, Calvello Hynes EJ; National Institute of Health Fogarty International Center convened the Collaborative on Enhancing Emergency Care Research in LMICs (CLEER). Advancing research on emergency care systems in low-income and middle- income countries: ensuring high-quality care delivery systems. BMJ Glob Health. 2019 Jul 29;4(Suppl 6):e001265. doi: 10.1136/ bmjgh-2018-001265. PMID: 31406599; PMCID: PMC6666806. 6 Patel H, Suarez S, Shaull L, Edwards J, Altawil Z, Owuor J, Rogo D, Schwartz K, Richard L, Burke TF. Patient Characteristics from an Emergency Care Center in Rural Western Kenya. J Emerg Med. 2019 Jan;56(1):80-86. doi: 10.1016/j. jemermed.2018.10.019. Epub 2018 Dec 4. PMID: 30527618. 7 Botchey IM Jr, Hung YW, Bachani AM, Paruk F, Mehmood A, Saidi H, Hyder AA. Epidemiology and outcomes of injuries in Kenya: A multisite surveillance study. Surgery. 2017 Dec;162(6S):S45-S53. doi: 10.1016/j.surg.2017.01.030. Epub 2017 Apr 3. PMID: 28385178. 8 Turner CD, Lockey DJ, Rehn M. Pre- hospital management of mass casualty civilian shootings: a systematic literature review. Crit Care. 2016 Nov 8;20(1):362. doi: 10.1186/s13054-016-1543-7. Erratum in: Crit Care. 2017 Apr 13;21(1):94. PMID: 27825363; PMCID: PMC5101656. 9 Lukas, Carol VanDeusen; Holmes, Sally K.; Cohen, Alan B.; Restuccia, Joseph; Cramer, Irene E.; Shwartz, Michael; Charns, Martin P. Transformational change in health care systems, Health Care Management Review: October 2007 - Volume 32 - Issue 4 - p 309-320 doi: 10.1097/01. HMR.0000296785.29718.5d 10 McIntosh, B., Hinds, P., & Giordano, L. (1997). The Role of EMS Systems in Public Health Emergencies. Prehospital and Disaster Medicine, 12(1), 30-35. doi:10.1017/ S1049023X00037183 11 Diamond-Smith N, Sudhinaraset M, Montagu D. Clinical and perceived quality of care for maternal, neonatal and antenatal care in Kenya and Namibia: the service provision assessment. Reprod Health. 2016 Aug 11;13(1):92. doi: 10.1186/s12978- 016-0208-y. PMID: 27515487; PMCID: PMC4981972. 12 Otieno, P.O., Wambiya, E.O.A., Mohamed, S.M. et al. Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya. BMC Public Health 20, 981 (2020). https://doi.org/10.1186/ s12889-020-09106-5 13 Balikuddembe, J.K., Ardalan, A., Khorasani-Zavareh, D. et al. Weaknesses and capacities affecting the Prehospital emergency care for victims of road traffic incidents in the greater Kampala metropolitan area: a cross-sectional study. BMC Emerg Med 17, 29 (2017). https://doi. org/10.1186/s12873-017-0137-2 14 Sager MA, Franke T, Inouye SK, et al. Functional Outcomes of Acute Medical Illness and Hospitalization in Older Persons. Arch Intern Med. 1996;156(6):645–652. doi:10.1001/ archinte.1996.00440060067008 15 Myers JG, Hunold KM, Ekernas K, et al Patient characteristics of the Accident and Emergency Department of Kenyatta National Hospital, Nairobi, Kenya: a cross-sectional, prospective analysis BMJ Open 2017;7:e014974. doi: 10.1136/ bmjopen-2016-014974 16 Diamond-Smith N, Sudhinaraset M, Montagu D. Clinical and perceived quality of care for maternal, neonatal and antenatal care in Kenya and Namibia: the service provision assessment. Reprod Health. 2016 Aug 11;13(1):92. doi: 10.1186/s12978- 016-0208-y. PMID: 27515487; PMCID: PMC4981972. 17 Kironji AG, Hodkinson P, de Ramirez SS, Anest T, Wallis L, Razzak J, Jenson A, Hansoti B. Identifying barriers for out of hospital emergency care in low and low- middle income countries: a systematic review. BMC Health Serv Res. 2018 Apr 19;18(1):291. doi: 10.1186/s12913-018-3091- 0. PMID: 29673360; PMCID: PMC5907770. 18 Gathecha GK, Ngaruiya C, Mwai W, Kendagor A, Owondo S, Nyanjau L, Kibogong D, Odero W, Kibachio J. Prevalence and predictors of injuries in Kenya: findings from the national STEPs survey. BMC Public Health. 2018 Nov 7;18(Suppl 3):1222. doi: 10.1186/s12889-018-6061-x. PMID: 30400906; PMCID: PMC6219001. 19 Kobusingye OC, Hyder AA, Bishai D, et al. Emergency Medical Services. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006. Chapter 68. Available from: https://www. ncbi.nlm.nih.gov/books/ NBK11744/ Co- published by Oxford University Press, New York. 20 O’Meara, P., Stirling, C., Ruest, M. et al. Community paramedicine model of care: an observational, ethnographic case study. BMC Health Serv Res 16, 39 (2015). https:// doi.org/10.1186/s12913-016-1282-0 21 Lincoln EW, Reed-Schrader E, Jarvis JL. EMS Quality Improvement Programs. [Updated 2020 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK536982/ 22 Michau, R., Roberts, S., Williams, B. et al. An investigation of theory-practice gap in undergraduate paramedic education. BMC Med Educ 9, 23 (2009). https://doi. org/10.1186/1472-6920-9-23 23 Mackway-Jones K, Carley SD, Morton RJ, Donnan S. The best evidence topic report: a modified CAT for summarising the available evidence in emergency medicine. J Accid Emerg Med. 1998 Jul;15(4):222-6. doi: 10.1136/emj.15.4.222. PMID: 9681304; PMCID: PMC1343127. 24 Kenya Emergency Medical Care Policy 2020-2030, Ministry of Health - Republic of Kenya ABOUT THE AUTHORS George Amolo is a Student Paramedicine BSc(Hons) Masinde Muliro University of Science and Technology, Registered and accredited AREMT-Global assessor, Registered and accredited AREMT- Advanced EMT, Co-founder Paramedic Association Of Kenya , Over 9yrs Practicing as an EMT, and Rally medic staff WRC. Dr. Florian Fikuart MD MBA is the founder and CEO of East Africe Ambulance Service. He is also a Consultant Anesthesis and ICU Physician with over 10 years of experience in EMS.26 PARAMEDICS PROVIDING PALLIATIVE CARE: UNDERSTANDING FAMILY AS THE FIRST RESPONDERS BY DR. SAMANTHA WINEMAKER AND DR. HSIEN SEOW Eighty percent of Canadians choose home as their preferred place of death. (1) However, only about 30% have their wish granted. (2) Regardless of where they die, people facing progressive life-limiting illnesses spend many of their declining months at home. The typical phenotype of a person being cared for at home has one or more advanced non-curable conditions, wants to avoid the ER or hospitalizations, and is being cared for by their informal care team, ‘their family.’ Over the years, the level of clinical complexity has increased, caregivers are more aged, and community supports have waned, all of which have contributed to the need for increased rapid response supports in the home environment. Evidence shows that paramedics providing palliative care in the home improve patient satisfaction and decrease ambulance transfer to the emergency room. (3) For paramedics to provide a palliative care approach in the home, they have necessarily required formal palliative care training. In addition to acquiring the skills to provide ‘comfort measures,’ paramedics will need to understand and appreciate the patient’s natural care team—the ‘family’. No doubt, there are many new concepts to this approach to care that require a re-wiring of usual paramedic practice patterns. The following constructs are essential to consider as paramedics are integrated into the fibres of a home-based palliative approach to care. 1. Families are the ‘first responders. Contrary to popular belief, the paramedics are not always ‘first responders.’ They are often ‘second responders’. Most people with progressive life-limiting illnesses do not live alone. The first responder on the scene is typically the person’s ‘family’ member or informal caregiver. Unfortunately, this informal layer of support is often unprepared and ill- equipped to respond to a perceived crisis. 2. Families lack an illness ‘roadmap’. They are seldom offered information about the ‘big picture’ of the illness, describing what to expect and how things will unfold. This is often, despite having had many teams involved in the patients’ care. Health care professionals are busy dealing with acute issues, treatment decisions, and test results. Rarely do they have time to explain to the patient and family what any of it means in the context of their illness trajectory. Often the ‘long-view’ of the illness is avoided because of the worry that the health care provider will make the patient and family give up hope. Without any discussion about the overarching illness roadmap, families operate in their caregiver/first responder role in the dark, with no formal interview, training, coaching or respite from the role. 3. Family caregivers often feel unprepared, self-doubting and anxious in their role. Without knowing what is happening and what to expect, all typical and expected changes in their loved one’s condition are perceived as ‘wrong’ and interpreted as a crisis. It would be like a pregnant person not knowing three trimesters exist and what labour and delivery will be like. Similarly, families do not have a ‘play-book,’ and their threshold for panic is lower without it. Fear and anxiety blur their clinical judgement, and the result is that families commonly misinterpret the meaning of what they are seeing. Too often, they feel that their loved one is suffering. 4. Family caregivers are part of the paramedicine ‘unit of care’. They often suffer as much, and sometimes more, than their loved ones. Their suffering influences their read on a situation and can fuel their sense of crisis. Families anticipate that their loved one will have pain and that it will crescendo until death. They are hyper- vigilant and constantly scanning for pain even when pain has never been part of the patients’ illness experience. Many of them promise their loved ones that they will protect them from pain. So doctors prepare caregivers to respond to pain by stocking pain medications in the home. They, too, worry about pain. Because ill- informed family members anticipate pain, pain medication is initiated and titrated frequently, and suddenly their loved one becomes restless and agitated from the side effects of opioids. Once again, the patient is perceived to be in pain. This perception triggers more pain medications to be given, and the vicious cycle ensues. 5. Families feel better when they ‘take action’. They feel less helpless when they perform a duty, which usually means giving their loved ones more medication, than when idly standing by and observing their loved ones’ pain. Paramedics can fall prey to the same pitfall in their mandate to ‘respond to a crisis’. The best assistance can come in the form of just ‘being’ instead of ‘doing’. Often what is needed is a calming presence. 6. Most important, every 911 call is an opportunity for the paramedic to educate the patient and family/caregiver. What precipitated the call? Is it likely to reoccur based on the natural history of this particular illness? How can it be prevented or identified earlier next time? How can the first responder’s action plan be fine- tuned for the future? Paramedics arriving on the scene of a person requiring a palliative approach to care would benefit from taking their time to assess the situation comprehensively. Know that this family and informal caregiver is doing their best with very little preparation for their role. Rarely has someone sit down with them to explain their role, the regular changes they will experience in their loved one’s condition, and how to differentiate what is expected versus what is not. Many calls to 911 are triggered by family panic, but often what is needed is a trained professional to arrive for reassurance. It is helpful to ask the family if their concern is due to a sudden or gradual change in their loved one’s condition. Has this ‘emergency’ ever happened before? If so, what was done? Sometimes the situation will require intervention, like medication. However, often what is required is the strength to resist changes to the treatment plan and instead listen. Hear from the family how worried they are, how scary it has been, how isolated they feel making medical decisions. Most families are operating with half the information they must have to perform in this role that has been bestowed upon them. The home is, after all, a unique setting requiring consideration of the family as not only our care partners; but, in many cases, the care recipient as well. They, 27 too, are experiencing an illness journey: their loved ones’ and their own. They are in the dual role of grieving and caring simultaneously. It is through this lens that they decide to call 911. Palliative care training is essential for paramedics to respond appropriately in the home of someone needing a palliative approach. However, this training must encompass much more than ‘pain and symptom’ management directed at the patient with the illness. It requires an ‘urgent holistic assessment’, which is very different from the standard paramedic response. The old axiom, ‘know your audience’, comes to mind. Know whom you are responding to. Paramedics must ask themselves who in the home is suffering? Have they been called because the patient is in crisis, or is the family/caregiver in distress? Accordingly, they should refrain from ‘taking immediate action’ on arrival. Instead, they should walk slowly into the home, pull up a chair, and sit to listen patiently while the ‘first responder’, gives a report. REFERENCES 1. Brazil K, Howell D, Bedard M, Krueger P, Heidebrecht C. Preferences for place of care and place of death among informal caregivers of the terminally ill. Palliat Med. 2005;19(6). 2. Tanuseputro P, Beach S, Chalifoux M, Wodchis WP, Hsu AT, Seow H, et al. Associations between physician home visits for the dying and place of death: A population-based retrospective cohort study. PLoS One. 2018;13(2):e0191322. 3. Rosa A, Dissanayake M, Carter D, Sibbald S. Community paramedicine to support palliative care. Progress in Palliative Care. 2021:1-5. ABOUT THE AUTHORS Dr. Samantha Winemaker, MD, is a palliative care physician in the community. She is an Associate Clinical Professor, McMaster University, and award-winning palliative care educator. (@SammyWinemaker). Dr. Hsien Seow, PhD, is the Canada Research Chair in Palliative Care and Health System Innovation and an Associate Professor, McMaster University. His research expertise is in palliative care, quality improvement, and health policy. (@HSeowPhD) They are the co-hosts of the podcast, The Waiting Room Revolution (waitingroomrevolution.com).28 EMS TAKES PART IN LARGEST COORDINATED PATIENT MOVE IN AHS HISTORY BY ERIN LAWRENCE & DALLAS PIERSON. For many of us, moving involves some boxes, bubble wrap, maybe some friends, and a truck. But when it comes to relocating an entire hospital, there are considerations most of us could never dream of. Well before sunrise on the morning of December 4th, 2021 in the northern Alberta city of Grande Prairie, Alberta Health Services (AHS) launched the largest coordinated patient move in the organization’s history, beginning the delicate task of relocating about a hundred patients from the old Queen Elizabeth II (QEII) Hospital and the new Grand Prairie Regional Hospital (GPRH). “I believe that this is the first time in Alberta, likely in Canada and possibly even in North America where the “lift and shift” approach was taken to move a hospital— and all the patients—in a single day. It was an amazing, well-coordinated, team-work based success,” says Darren Sandbeck, Senior Provincial Director and Chief Paramedic, at Alberta Health Services EMS. Planning for the relocation started well before that morning and contingencies were made to move nearly two hundred patients, if necessary. All would require transport by EMS—and it would all need to happen in a single day so that the entire operation of the hospital could be fully operational at the new site. “Paramedics are very accustomed to fast and large responses to incidents such as floods and fires, but the difference with this event was we had time on our side, as we had a number of months to plan for this move,” says Rob Barone, Associate Executive Director, AHS EMS North Zone. “Patient needs ranged from minimal medical attention to complex care requirements – including some patients on mechanical ventilators. We would need to move all patients safely, and as quickly as possible, seven kilometers to the new Grande Prairie Regional Hospital. We did a lot of planning for every eventuality – matching each patient’s needs with the appropriate level of EMS care team.” Logistics and planning included AHS, EMS, and all hospital departments including protective services, pharmacy staff and equipment, porters, contracting, procurement and supply management. “When you’re moving a hospital patient, there’s additional considerations, and that’s why EMS was so important to the move. We needed to ensure specific medications and specialized equipment were available and brought along, and that anyone who needed ongoing care would receive it, uninterrupted, while in the care of EMS,” explains Barone. “But there were plenty of other important things to consider, like having Personal Protective Equipment available for everyone involved, plus equipment decontamination, since we were pulling this off during a global pandemic.” The patient care teams and GPRH planners stayed in constant contact with both sites and with EMS to feed information back and forth to all teams involved in the move. “I am always impressed by the way multiple disciplines and departments come together to work through any significant event that impacts AHS,” shares Dallas Pierson, Special Operations Supervisor, AHS EMS North Zone. “We were constantly managing changing circumstances; keeping tabs on how many patients had been moved and how many more were still to come, and each of their conditions through the entire transport process. It was a real team effort between EMS and hospital staff and I couldn’t have been any prouder in terms of how everyone got it done—and done safely for our patients.” EMS needed to plan for a number of factors including estimating how long it would take to ready, load and drive each patient, particularly when each one might have different or more acute care needs. Timing also included donning and doffing of PPE for EMS paramedic crews, plus including the need for proper documentation of each patient and handing them off to nursing staff at the new hospital. 29 The plan also required extensive “what if” contingency planning. ”We started that planning by taking the full hospital capacity number of 187 patients and dividing it by an 18 hour time frame, just in case we needed that much time. We knew this could mean we might have to move 10 patients every hour—that sounds way better than a patient every six minutes!” Pierson explains. “That was the maximum capacity that we were ready for.” The night before the move, EMS staff from across the province began arriving in Grande Prairie, along with support staff and spare ambulances. In total, 87 EMS staff and paramedics volunteered for this herculean assignment, ready to make history. They were part of the 1,192 total AHS staff members involved in the move, along with 24 physicians and 95 volunteers. While an influx of patients on that Friday night could have altered logistics and planning for the move the following day, the numbers remained largely static, and by go-time 99 patients were awaiting transport. As the day progressed, the relocation teams took to calling the mission ‘Operation 99 – the great one day move,’ a nod to hockey great Wayne Gretzky’s number and nickname, ‘the great one’.” At 6 A.M. EMS transport teams arrived at the old QEII hospital to take the first patient, Kelsi Ching, and her newborn to GPRH by ambulance. Paramedics Crystal Cartwright and Kyla Mosenko did the honours. “The exceptional teamwork made the day go seamlessly from our perspective”, says Kyla Mosenko, an Advanced Care Paramedic with AHS EMS. Teams of porters, hospital staff, EMS support staff and leadership watched as Ching and her child arrived in the very first ambulance, then entered the hospital to the sound of bagpipes. “It took a full eleven hours to transport all the patients,” according to Phillip Tautchin, Deployment Manager, AHS Northern Communications Centre. “This was definitely a solid example Next >