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Stop the Bleed: Training Bystanders to Be Prepared in a Crisis

Posted on Tue, Jan 17, 2017
Stop the Bleed: Training Bystanders to Be Prepared in a Crisis

By Stephen Flaherty, MD

A person who is bleeding can die from blood loss in less than five minutes.

As a trauma surgeon, it’s important for me to be involved in all aspects of care of injured patients. This starts with injury prevention and severity mitigation, and extends through pre-hospital care, acute care and rehabilitation.

I recently became an instructor for “Stop the Bleed," a federal campaign to train non-clinical bystanders how to take simple steps in mass casualty situations to save lives. The program was created in response to recent mass shootings and empowers bystanders to act as immediate responders by providing public access to bleeding control tools already used by first responders and the military. Often times victims die from bleeding that could potentially be stopped before EMS providers are able to reach the victim.

I got involved with the initiative because several of my colleagues were members of the working group that developed the program. We had worked together in the military developing a combat casualty care doctrine and the Department of Defense Joint Trauma System. Stop the Bleed is an example of military-civilian integration directly applied to the active shooter situation.

Training involves a two-hour class: a lecture that provides an overview of the concepts being taught and a hands-on session for practical experience in applying a tourniquet and packing a wound. There is no exam.

I’ve personally trained more than 70 people. Through my initiative, the El Paso Border Regional Advisory Council (RAC) has championed the course. Under its guidance, more than 400 people were trained in 2016, including El Paso ISD safety officers, Sun Bowl event staff, police officers and teachers. This year, I’m working to bring this course to Middlebury College in Vermont, where my son Colin is a freshman.

It’s unbelievably rewarding to empower citizens to be able to react calmly and competently in terrorist attacks, active shooter situations, like Pulse Night Club shootings in Orlando, and even motor vehicle accidents. We teach people how to differentiate life-threatening arterial bleeding from venous or capillary bleeding and then we help them practice placing a tourniquet or pack a large wound. We also talk to people about the difference between a compressible site, (arm or leg), a junctional site (neck, axilla, groin) and the non-compressible sites of the chest or abdomen. It buys time for victims until first responders can get to the scene – and those are valuable minutes.

I believe we can make great strides in reducing morbidity and mortality due to injury by improving care prior to arrival at the hospital. The goal is zero preventable deaths.

Stephen Flaherty, MD, FACS, is the trauma medical director at Del Sol Medical Center in El Paso, Texas, and a regional medical director in the surgical services division of EmCare. He earned his bachelor’s degree and medical degree from Tufts University, Boston. He completed a fellowship in trauma/critical care at Boston University Medical Center and a residency in general surgery at Eisenhower Army Medical Center, Fort Gordon, Ga. He achieved the rank of colonel in the United States Army and was deployed on several military combat rotations before retiring in 2010.
 

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Documentation Tip: Urosepsis

Posted on Mon, Jan 16, 2017
Documentation Tip: Urosepsis

Our recurring series of documentation tips for clinicians.

By Timothy Brundage, MD

UROSEPSIS: There is NO CODE in ICD-10. Documenting the term “urosepsis” is ambiguous and nonspecific for coding purposes.

Please consider: “Sepsis secondary to UTI.”

  • NO SOI (not sick) - Urosepsis
  • LOW SOI (sick) - UTI
  • HIGH SOI (very sick) - Sepsis due to UTI

This tip will help reflect severity of illness (SOI) and have your patient appear as sick on paper as they are in the bed.

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

Dr. Timothy Brundage

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The Evidence Behind Healthy Living

Posted on Wed, Jan 11, 2017
The Evidence Behind Healthy Living

By Alberto Hazan, M.D.
 
One out of every five American deaths is directly linked to obesity.
 
As physicians, we try to educate our patients to lead healthier lives by encouraging them to “diet and exercise.” And yet, diets have been shown to be ineffective for permanent weight reduction, and our current recommended exercise regimen (i.e., 30 minutes of physical activity three to four times a week) is grossly inefficient.
 
If we want to make an impact and decrease the morbidity and mortality associated with obesity, we need to encourage our patients to make better decisions about the choices they make. Lifestyle modifications have been shown to decrease the prevalence of diabetes, heart disease, strokes, hypertension, and even many types of cancers. But which measures are the most important to focus on? After all, we only have a few minutes with our patients and there are multitudes of preventive medicine measures we can go over, each with varying levels of evidence behind them.
 
Without question, the most crucial step a person can take to improve the quality of their life is to quit smoking. Other measures include limiting alcohol intake to a single glass of red wine (no more than three or four times a week), getting adequate sleep, and reducing stress.
 
In addition to these steps, recent articles in the literature suggest that the following may be critical approaches to treating obesity and preventing disease.
 

1. Cultivate your microbiome. Changes in the gut flora alone can lead to obesity. The seminal case occurred in 2011. A patient with Clostridium difficile colitis that was resistant to antibiotics received a stool transplant from an obese family member and was cured of her diarrhea. Subsequently to the transplant, however, the patient unexpectedly gained significant weight and became obese. Many possible explanations were offered for the weight gain, but the case suggests that the microbiome could have a strong influence on obesity.


This makes sense. There are an estimated one hundred trillion live microbes colonizing our skin, respiratory, and gastrointestinal tract — 10 times the number of cells that comprise the human body. These microbes are thought to have an essential role for vitamin production and perhaps, most importantly, for “crowding out” harmful species that can cause severe local and systemic toxicity, such as Clostridium difficile. There is an emerging body of evidence that the disruption of this symbiotic relationship may lead to impaired immunity, cancer, endocrine disorders and neuropsychiatric disorders like bipolar and schizophrenia.


2. Nourish your body. There are a plethora of diet styles; they can be boiled down to low carbohydrate, low fat or the Mediterranean diet. While a diet low in carbohydrates will allow patients to lose weight quickly, there is no evidence to suggest that this has any long-term advantage when it comes to disease prevention. By eliminating carbohydrates from your diet completely, you might eliminate “resistant carbohydrates.” This subclass of carbohydrates is found in legumes and are “resistant” to digestion by gastrointestinal enzymes. Instead, they are broken down by colonic bacteria to small chain fatty acids that feed the lining of the colon and decrease the risk of colon cancer. 

The best evidence regarding patient centered outcomes, such as decreased myocardial infarction, seems to be the Mediterranean diet. This diet seems to eliminate the nutrient poor foods containing the “bad stuff” like unsaturated fats and sugar, while adding food that is high in nutrients and omega 3 fatty acids. Joel Fuhrman, M.D., author of “The End of Dieting,” focuses on the micronutrients and uses the term “nutrient density” to describe the foods that are ideal for consumption in a typical healthy diet.

Equating obesity to a simple calories in/calories out equation is reductionist, since this disease is often multifactorial. For instance, poor sleep can have profound effects on hormones, such as leptin, that regulate appetite, thus increasing caloric intake out of proportion with increased physical activity at night.

Changes in diet reliably alter gut flora. People whose diets have higher meat consumption will harbor more bile-resistant organisms, such as Bacteroides. Higher plant consumption is associated with bacteria that metabolize plant polysaccharides such as Firmicutes species.

3. Lead an active and social life. Dan Buettner, an educator and explorer, has devoted a large part of his life studying “blue zones,” areas around the world that have the highest quality of life, the longest life expectancy, and the least prevalence of illness. His research has found that none of the centenarians living in these “blue zones” engage in the typical exercise regimen promulgated by physicians (i.e., 30 minutes of cardiopulmonary exercise three to four times a day). Instead, these robust, energetic and highly functioning elderly populations consistently engage in moderate amounts of physical activities in their daily lives. In addition, they were all engaged in spiritual activities and had deep social connections with their friends and family members. And none of them followed a regimented diet. Instead, they ate a diet rich in fresh fruits and vegetables, whole grains and fish. 
 
We need to encourage our patients to nourish themselves and, as outlandish as it sounds, the microbes they harbor. We need to emphasize the importance of leading an active life. And we need to inspire them to build strong relationships with their family, friends and peers. As physicians we need to be leaders in promoting a movement toward a healthy culture. We are currently in a public health crisis. We need to advocate for changes in our cultural habits. Millions of lives depend on it.

Dr. Alberto Hazan

Dr. Alberto Hazan is an emergency physician and the director of the Desert Springs Hospital Medical Center Emergency Department in Las Vegas. He is the author of the medical thriller Dr. Vigilante and the preteen urban fantasy series The League of Freaks.
 

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