FlightBridgeED
MAR
28

Red Blood Cell

Mixed venous oxygen saturations can help to establish the relationship between oxygen consumption and oxygen delivery.  Understanding the difference between the amount of oxygen being delivered and the amount of oxygen being consumed by the body can lead the clinician to early detection of a soon-to-be-deteriorating patient.  The mixed venous oxygen saturation is a key monitoring parameter for both the in-hospital and pre-hospital critical care provider.  Average mixed venous oxygen saturation in a healthy adult patient is approximately 70%.

When learning about mixed venous oxygen saturations, there are often two variables that are discussed – SvO2 and ScvO2; the difference being the addition of the letter “c” in the name.  The SvO2 is typically the oxygen saturation of mixed venous blood as it is found in the pulmonary artery.  Remember that this blood is a mixture of different sources of venous blood – the inferior and superior vena cava and the coronary sinus; whereas the ScvO2 is primarily just a sample of the vena cava blood.  Knowing this, we can clearly understand why the ScvO2 is slightly higher (3-5%) than the SvO2.  Mixing the vena caval blood with the coronary sinus (used blood from the myocardium) causes a further reduction in the saturation of oxygen on the hemoglobin.

If the body is consuming increased levels of oxygen, the amount of oxygen returning to the heart would be low.  This is typically seen in situations where the body’s cells are hyperactive and demanding more oxygen.  On the contrary, if the SvO2 comes back high, the body is typically being blocked from extracting oxygen from the blood into the tissues.  Situations like drug-induced paralysis or infiltrative microbial disease could be a cause of such.

Overall, the efficacy of circulation can be best measured by a mixed venous oxygen saturation.  The more central you obtain the sample, the more accurate the result.  Remember, the difference between oxygen consumption and oxygen demand, lies in the value of the mixed venous oxygen saturation.

 Peer Review #1:

While many of you may dismiss this blog under the premise that SvO2 (and certainly the more invasive ScvO2) are going the way of the Swan-Ganz catheter, replaced by newer metrics such as lactate and end-tidal CO2. However, even if your daily practice does not require interpretation of central oxygen saturation values, the concept of shock as a mismatch of supply and demand is always worth reviewing, and several new devices are about to hit the airwaves that will play off this theme.

In the world of resuscitation, the sole purpose of the human body is to deliver oxygenated blood to tissues. While oxygenation status is definitely a contributor, the most clinically relevant factor that limits this delivery is a decrease in tissue perfusion via limited blood volume, pump failure, and/or shunting away from the microcirculation. This explains why we generally get away with focusing on the oxygen content of blood returning to the heart, whether through measurement of blood samples taken from the vena cava or coronary sinus or via an oxygen saturation-measuring central venous catheter, rather than always comparing these values to measurements taken from the arterial side of the circulation.

The point is well made that a true systemic sample - either SvO2 or ScvO2 - is necessary to gain insight into the perfusion status of the entire body rather than a single limb (as with oxygenation measurements taken from a peripheral catheter) or specifically from the brain (as with a jugular venous sample). However, new devices are available for noninvasive tissue measurements, requiring careful site selection and understanding of the specific perfusion patterns for that tissue under pathophysiological conditions. Examples include near-infrared measurement of cerebral lactate-to-pyruvate ratios (again, reflecting the delicate balance between supply and demand), gastric pH, rectal mucosal perfusion (surprisingly, not as popular to study!), and skeletal muscle oxygen saturation (SmO2). It is clear that we will need to gain experience with some of these indirect and/or organ-specific devices before we can use them most effectively to care for our patients. In the meantime, keep the SvO2/ScvO2 lessons in mind and understand the basic paradigm of shock as a mismatch of supply and demand.

Dr. Dan Davis, MD

  9945 Hits
FEB
12

cateter swan ganz

Yes, this is a medical article; yes, it is relevant to the critical care transport provider and finally, yes, it is definitely worth reading.  Suffice it to say that you’ve already passed the most difficult piece of this article – the title.  With that said, let’s cut to the point.  The ports on a flow-directed pulmonary artery catheter (FDPAC) are to be used with extreme prejudice.  They are NOT innocuous; and careless utility can absolutely be the cause of patient death.  Not knowing is a crappy reason to put a patient at risk.  Learn with me, as we explore which ports we can use and those that we should avoid.

I’ll start with a short but impactful phrase that stuck with me from the first moment I heard it.  “RED and YELLOW will KILL a fellow”.  This phrase traditionally references the color patterns on specific types of snakes; helping to identify a poisonous snake from a non-poisonous snake.  If we were to compare the coral snake (venomous) with the king snake (harmless) by simply looking at them, they look very similar – a mixture of red, yellow and black stripes.  One might ask themselves – to touch or not to touch?!  I can assure you that my answer would be the latter regardless of the color, size, shape or type.  However, for the more curious folk, a closer look reveals a distinct difference.  On the coral snake (the venomous one), the red and yellow stripes are touching each other.  On the king snake (the non-venomous one) red and yellow never touch, but are separated by a black stripe – hence, the catchy phrase - “RED and YELLOW will KILL a fellow”.  If you see a snake and the red stripes and yellow stripes are touching each other – take the subtle hint, and steer clear.  We can apply this same simplicity to the various, color-coded ports on the flow-directed pulmonary artery catheter.

As you can gather, the two ports that should be avoided when working with a Swan-Ganz catheter are the red port, and the yellow port.  Regardless of the manufacturer, these two colors have been reserved for the two ports that should be avoided.  The red port is typically the balloon port.  The provider may notice that this port is typically shorter than the others and will also have a locking device built into it.  The locking device ensures that in the event the control syringe becomes separated from this port, no air will be pulled into the patient’s body.  When air is pushed through this port, it ends up at the distal portion of the catheter and fills a balloon.  The appropriate capacity for this balloon is 1.5 milliliters; and is only accessed with a control syringe (only allows the provider to draw up a max volume of air equaling 1.5 milliliters).  Using this port to infuse anything other than the aforementioned air is not appropriate and could cause significant harm to your patient – as in balloon rupture followed by a downstream shower of foreign emboli.

The second port to avoid is the yellow, also known as the distal port.  The termination of this port is at the very tip of the catheter; exactly where the pressure transducer is located.  During transport of a critically ill patient who has a Swan-Ganz catheter, the provider should be transducing pulmonary artery waveform, to assure that the catheter does not migrate.  For this reason, any infusion through this port can significantly alter the pressure being transduced – providing a false representation of the patient’s current hemodynamics.  It is important to understand that many Swan-Ganz catheters are colored yellow, creating further confusion when identifying this port.  At the very proximal portion of the port, the provider will notice that this port will be labeled as PA or distal – further making it clear that it should not be used for continuous or intravascular push medications.  The critical care provider may see other healthcare specialists which do infuse fluid through this port; these situations are usually related to procedure areas such as the cardiac catheterization laboratory, etc.  The provider may also notice that during the initial set-up and placement of a flow-directed pulmonary artery catheter, the distal or PA port, may be flushed with a heparin-infused saline solution.  Note, that this is typically only done while the catheter is OUTSIDE of the patient’s body.  To reiterate, during transport of critically ill patient who have this catheter, the distal port is NOT to be used for infusion purposes.

So, let’s recap – discriminatory use of the ports on a Swan-Ganz catheter is imperative.  For purposes of critical care transport, use of the red and yellow ports for any type of fluid infusion is never appropriate – and like the snake, steer clear.  Remember “RED and YELLOW will KILL a fellow”!!

Peer Review #1:

Excellent article! As Bruce brings up, one of the most important things a provider can do when transferring a patient with a FDPAC, is monitoring for migration. The ways I remember what to look for on the wave form is by thinking about Dub Step music. Right after the bass drops the song gets crazy! Well if you notice the PA waveform base drop you have migrated to the RV and....!!  Could get crazy! 

Right Heart Pressures
When Physicians are passing these lines the goal is to spend as little time in the RV as possible to avoid arrhythmias. So watch out for that base drop!! The quickest way to terminate a invasive line induced arrhythmia is to withdraw the line. However make sure you have deflated the balloon first.
Tyler Christifulli, FP-C
 
Peer Review #2:

As the indications for Swan-Ganz catheterization decrease, familiarity with their safe use becomes problematic.  Rather than applying the old adage “See one, do one, teach one…” or relying upon frequent use to maintain competency, we have to develop unique strategies to avoid complications when one of these patients is encountered.  The author of this blog applies the concept of “disconjugate imagery”, in which a completely unrelated but memorable image is introduced.  Rather than being more difficult to recall under stress, you will find that the mental image of a coral snake will pop into your brain the next time you see a Swan-Ganz catheter.  Just remember that, like our blog author, both red and yellow may “kill a fellow”.

Dr. Dan Davis, MD

Peer Review #3:

The Swan-Ganz catheter has slowly lost its use in many patients. The evidence suggests no improvement in 30-day discharge when used in sepsis or other hemodynamically unstable patients. Although the use is still widely acceptable in the thoracic surgery or cardiac ICU setting, these catheters are removed as soon as possible due to the infection risk associated.  With than being said, the critical care paramedic or nurse may encounter these catheters or see questions on exams related to their use and applicability. Using teaching tips such as mental imagery will allow the provider quick recall abilities.  I truly believe we remember pictures much easier and can relate images to things we like or dislike.

The saying “Red Touch Yellow” Kill a Fellow was coined for purposes of Coral vs. King snake identification. Dr. Swan happened upon this literature as he and Dr. Ganz were developing this catheter. As they attempted to color code these ports he identified and related this saying to the color-coding system now used with the Swan-Ganz catheter. The balloon port “Red” and distal port “Yellow” are not by accident. We should always remember the potentially lethal consequence associated with the improper use of these two ports.  Remember, the coral snake is the deadliest snake in the US, although docile, the coral snake will get you if your not paying attention.  Remember this the next time you grab the ports off the Swan-Ganz catheter! “Red and Yellow” Will Kill a Fellow!

Eric Bauer, MBA, FP-C, CCP-C, C-NPT

  11950 Hits
JAN
14

Damped

Since the inception of hemodynamic monitoring, square wave testing, also known as dynamic response testing, continues to intermittently confuse both new and experienced critical care providers.  Square wave testing can have a direct impact on the validity and accuracy of the hemodynamic values which are obtained from the invasive monitoring device.  It is imperative that critical care clinicians be competent in understanding not only the purpose of square wave testing, but how to interpret its results.

The primary utilization of the square wave test is with arterial lines – those invasive monitoring cannulations which reside within the lumen of a systemic artery – and can be transduced to reveal a beat by beat graphic of luminal arterial tension.  In order to properly and accurately interpret the values being transduced, it is recommended to perform a square wave test.  This test is nothing more than fast flushing (with high pressure) the non-compliant tubing with saline (or heparinized saline) – in terms of tangible work, that’s about it.  What comes next is the ability to interpret what is displayed on the monitor!

There are two factors to consider when evaluating the square wave test (or the dynamic response test).  The first is called the natural resonant frequency, and the second is referred to as the damping coefficient.  When the invasive monitoring system is flushed, it exposes the transducer to a pressure signal (a very high-pressure signal), which in turn causes the transducer to vibrate.  How quickly the system vibrates is, essentially, the natural resonant frequency.  This phenomenon is rapidly followed by the damping coefficient, which is the speed at which those vibrations stop and return to normal transduction.  The vibrations caused by the fast flush should be quickly quelled and the system should return to pressure transduction.

In broad terms, there are three responses that are typically seen with a square wave test; adequately-damped, over-damped, and under-damped.  An adequately-damped waveform is when there are only two oscillations that follow the fast-flush wave.  The two oscillations should be no more than one-third the height of the previous oscillation.  The subsequent transducing should demonstrate a clear arterial waveform with a discernable dicrotic notch.  This result requires no further intervention or evaluation, and the hemodynamic values displayed on the monitoring device, can be interpreted with legitimacy and accuracy.

Image from Deltex Medical Limited, 2015

An over-damped waveform is when there is only one oscillation (or little to no vibrations / ringing) following the square wave test.  A waveform that is damped will appear small in amplitude and flattened.  The dicrotic notch will be hard to visualize and appreciate.  Additionally, the systolic pressure will be poorly reflected, causing it to be reported lower than it actually is.  Conversely, the diastolic blood pressure will be over-estimated, and will be reported higher than it actually is.  There are a number of causes of an over-damped waveform.  Tiny air bubbles in the tubing, a clot at the tip of the catheter, tubing that is “too” stiff or kinked and / or a catheter that is positioned against the wall of the blood vessel.  Remember that air is easily compressible, and will almost always cause an over-damped waveform.  An over-damped waveform is a relatively common occurrence and can be fairly easy to correct.

Image from Deltex Medical Limited, 2015

Last, an under-damped waveform is where there is “ringing” or multiple oscillations / vibrations that follow the square wave test.  A waveform that is under-damped will appear saltatory in nature causing variations in the systolic and diastolic blood pressure values.  Typically, the systolic blood pressure will be reported higher than it actually is, and the diastolic blood pressure will be reported lower than it truly is.  The dicrotic notch will be visible and likely exaggerated in size in an under-damped waveform.  The causes of this type of waveform are limited and therefore, it is not as common to see in clinical practice.  Things like excessive tubing length, the use of multiple stopcocks, and patient conditions, such as tachycardia, or a high cardiac output, can all cause under-damping.  In the event that the patient condition is causing a under-damped waveform, it is acceptable to treat the underlying condition to ensure a more adequate and accurate waveform interpretation.

Image from Deltex Medical Limited, 2015

In order to ensure that invasive monitoring be used as a reliable resource, critical care providers should be challenged to master the skill of performing a square wave test and competently interpreting the ensuing waveform – whether it is adequately-damped, under-damped or over-damped.  The best practitioners know that information such as this is only as good as the technical quality will allow – therefore making it an additional priority when caring for a patient undergoing invasive hemodynamic monitoring.  Like a former mentor of mine once said, “damped if you do, and damped if you don’t”.

Be well and stay safe out there!!

 ** (all pictures taken from Deltex Medical Limited, 2015)

Peer Review: 

I think this can be a very difficult concept to grasp especially for those who may not have much experience with hemodynamic monitoring.  However, I also feel it is one of those concepts that is imperative to understand in order to fully provide competent care.  It is important to understand that these dynamic response artifacts (overdamping and underdamping) are encountered commonly in patient’s undergoing hemodynamic monitoring and being able to troubleshoot and fix the presenting problem (artifact) is imperative.  Bruce noted the differences in the SBP and DBP with each dynamic response.  I think it is important to note that despite the over- and underestimation of each, the patient’s MAP normally remains unchanged and is less sensitive.  From a clinical standpoint, this is relevant as medication changes and titration should not be based upon hemodynamic monitoring interpretation alone. The MAP is going to be less subject to errors of measurement in comparison to the artifacts discussed above.  The SBP and DBP should not be used alone to titrate therapy based upon these findings.  Therefore, if all steps have been taken to try and correct the damping issue but it still remains, then consider following your patient’s MAP or another alternative method of monitoring.

Ashley Bauer, MSN, MBA, APRN, FNP-C, CFRN 

  144974 Hits
NOV
05

anger

 

Anger is one of the great emotional equalizers.  Chances are you’ve felt it; acted on it; regretted it, or even denied it.  It is estimated that one out of every 10 persons’ experience anger and, additionally, have troubling controlling it.  Anger can cause some serious issues, if not channeled in an appropriate and timely manner.  It has been said that anger is only one, prefixed letter away from DANGER – and putting ourselves in harm’s way, is no good.  Perhaps it is because of this, that anger gets such a bad rap; simply because we associate it as something bad, wrong or dangerous.  Like many things in life, it can really swing either way; used for better or for worse.  I propose that there is a healthy and creative side to anger; and if guided correctly, can be a significant game changer in any applicable situation.

Diane Cameron, a New York based columnist and author (among many other things) muses on the words of Bessel van der Kolk – emotions have a function; they effect movement – they make us jump, run or act.  Anger, being an emotion, is capable of just that; it can affect our movement.  It would be unwise to assume that anger is automatically going to “effect movement negatively” or “significantly limits movement”; it only affects movement, which means that we have full control over it.  Instead of wasting all that energy in small, “safe” doses, channel it – all of it – to creativity.  Be proactive; not lethargically passive-aggressive.  Assert your anger and make it come alive.  Embrace anger; let it be the fuel that throttles and moves you to your next big moment.

The slow release of anger in sanctuary safe zones provides for eventual relief but very rarely helps us to accomplish anything note-worthy.  It is like going around a corner in a car and only making small adjustments – sooner or later you’ll be in the wrong lane – and in a much great predicament.  Creative anger helps us to focus on what needs to happen to maximize the next step to get there efficiently, and often, sooner.

Let’s put this into a clinical context and reality.  As a flight paramedic, the last five missions you have flown have all been IFT / ICU patient transfers.  On every single flight, the ventilator keeps auto-triggering, despite the maxed-out sensitivity, causing you some issues with ventilation and patient care.  On each return to base, you politely fill out an incident / equipment report and then get ready for the next flight.  Let’s evaluate the emotional process: passive approach, makes you feel “kinda’ good” because you reported it.  Now, let’s look at outcome: no change – there will literally be no immediate change, and you are highly likely to experience the issue again, on the next flight.  How might creative anger help with this?  Well, let’s say on your final return to base, you stop by your manager’s office and talk to them about the issues you were having in flight.  Your conversation concludes with permission to construct and scribe a proposal detailing the problem and offering a resolution (new ventilator…!! J).  Paired with a timeline, this has potential to turn the issue around!  Evaluating again, the emotional process: total pro-action, you feel empowered and engaged.  The outcome: change is well on its way to becoming a reality.  Consequentially, you’ll have more appropriate equipment, leading to an improvement in patient care; and eventual job satisfaction.

It would be disheartening if this were to be mistaken as overt permission to become angry AND take it out on anyone and anything that we find in close proximity, in a way that is destructive and deconditioning.  Not at all.  Quite the opposite.  In fact, I recommend that you “Get Mad [and then] Get Glad”!!

Be well and stay safe out there!!

 

Bruce

 

PEER Review

Klint Kloepping Comments

Bruce makes many valid points regarding a lesser talked about emotion, anger.  It is true that people focus a lot of time and energy on the emotion in a negative way, perhaps.  This article sheds light on something that I feel is needed in the world today.  It almost brings a Star Wars like feel to the conversation.  When we think about the force and how it can be used for both good and evil, anger is the same.  Master Yoda says,” fear leads to anger, anger leads to hate, and hate leads to the dark side.”  This is very much true of anger in our society as we know it today.  Anger can be channeled in such a way that it may actually be used for good.  There is a cautionary side to that coin.  There is a delicate balance between anger used for good and anger being channeled in a bad way.  If you are unsure where you stand on that spectrum, ask a trusted colleague or friend.  They should be able to tell you where you stand on that spectrum.  Anger is one of the emotions that I have used in my personal life.  Being able to channel anger to get things accomplished or to achieve a goal is the best part of anger.  If you don’t know how to channel your anger properly, ask a professional counselor or someone recommended by employee assistance at your service.  The point is, we all have some anger that comes up within us.  How you channel that into something useful is a choice I leave to you.

 

Mike Verkest’s Comments

I think Aristotle said it best:

 

 “Anybody can become angry — that is easy, but to be angry with the right person and to the right degree and at the right time and for the right purpose, and in the right way — that is not within everybody's power and is not easy.”

I have had my share of and displays of emotion. What I have found is that anger, is a clever little devil. Oh yes, it can disguise itself and come across in ways you may not recognize (or intend).  For me, when I get scared, it comes across as anger.  When I see my wife climbing up a 10-foot ladder which is precariously perched, I come across angrily! She says, “why are you yelling at me?” I have to catch myself, apologize and check my emotion. I don’t want her thinking I am mad at her, I just don’t want her to fall and end up a trauma entry! I guess that’s the other thing about anger…you may not perceive yourself as angry at all, but the others around you? Ya, you are a raging lunatic. Just check yourself and as Klint mentioned, find a mentor or someone to talk to. I’m sure it will be uncomfortable, but there is no growth in the comfort zone.


  5869 Hits
SEP
18

listen

 

On a recent flight back to Connecticut, I had the opportunity to reflect a bit on listening.

I talk. A lot. It is rare the day that I, or anyone other healthy human, is deprived the gift of speech.  I realized my understanding of essential communication rested in the verbal.

Boy, did Mr. Larson (keep reading) have a lesson waiting for me…

As we cruised through 30,000 feet, I wrestled, tossed, mulled, chewed and analyzed a quote I recently read.  It’s by Doug Larson and it reads “wisdom is the reward you get for a lifetime of listening when you’d have preferred to talk”.  As educators, mentors, leaders and consultants, we often spend more time speaking than we do listening; all done with the intention of imparting pearls of wisdom and sharing the experiences of the experienced.

Rachel Naomi Remen reminds us that “the most basic and powerful way to connect to another person is to listen; just listen – perhaps the most important thing we ever give each other is our attention”.  Research (1) demonstrates that an average of 45% of communication is spent listening, while only 30% is dedicated to speaking.  Mastering the ability to talk is great; but to effectively listen is a characteristic left only to those who choose to pursue it – a timely lesson for those of us that have the gift of gab….

Be well and stay safe out there!!

 

 

bruce

Bruce is a critical care registered nurse and paramedic who has worked in Connecticut, Massachusetts and Maryland.  His clinical background includes the ICU, ER, Trauma, Cardiology and Flight.  His graduate degree is in Education.  He is happily married to Stephanie, after meeting her while working at the Johns Hopkins Hospital in Baltimore, MD.  They currently live in Connecticut with their daughter Ava Mae and their 160 lb. English Mastiff, Maggie.  In addition to being an active volunteer and officer with the Ellington Volunteer Ambulance Corps, Inc., Bruce enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.

  7753 Hits
AUG
04

Picture1

I recently had an experience with a co-worker who seemed “off”; distracted; consumed by something other than what he was supposed to be doing.  In typical fashion, I bit, queried and then listened.  He unpacked several latent issues that had been bothering him – some about his work, others about his personal life and still more about a recent hang up he had with another (not me) co-worker.  The last bit really got me thinking and I finally blurted out “dude, let it go”.  I kind of surprised myself – and probably more so, my poor co-worker.  I think he needed to hear it though – like, enough was enough.  Get over it, I thought to myself.  I likened his woeful issues to attempting to roller skate through wet cement.  It’s messy, difficult and irritating – a lot of expended effort for little reward.  This is exactly what holding onto things can do to you – keep you in the cement; bogged down with unnecessity!  I was grateful to be able to get to the bottom of this guy’s pent up and caged anger.  I was also a bit disheartened by the fact that he was carrying so much of this unnecessary burden.  How many of his patients suffered because of the weight?  How many of his co-workers were put “off” by his demeanor – causing them their own distraction from work.  Not good man.  Deal with it and make it better; or let it go!

Jack Kornfield once wrote:

“To let go does not mean to get rid of.”

“To let go means to let be.”

“When we let be with compassion, thigs come and go on their own”

Why is it so hard to let something go?  Whether it is a desire, a personality trait, a human quirk, a mistake, a good friend, a dying family member, a habit, a resentment, a relationship, a cherished piece of clothing, a lack of faith, a style of communication or a (fill in the blank)….the list goes on and on.

I found this historic, but relevant analogy helpful when thinking about the behavior involved in not being able to let something go.  Here it is:

“Tie a coconut to a tree, hollow it and put some rice in it.  The hole in the coconut should just be large enough for a monkey to put its hand in it.  The monkey will grasp the rice but meanwhile its hand has gotten so big, that it can’t pull it hand out anymore. But it wants to hold on to the rice no matter what and thus it remains captured.”

A conclusive comment by Havelock Ellis seems appropriate: “All the art of living lies in a fine mingling of letting go and holding on.”

Let it go – and have a better day –  you, your co-workers, your family and your patients!!

Be well and stay safe out there!!

  8032 Hits
JUL
07

teacher

Peter Klein, the founding director of the Global Reporting Centre, recently published an article via The Globe and Mail about teaching (1).  He reminisces on his early days as a student and hearing the expression “those who can’t do, teach and those who can’t teach, teach gym”.  He quotes Mr. Woody Allen, a character in the screenplay Annie Hall.  Mr. Klein goes on to offer a challenge to those who believe in that quote’s validity…He writes “those who do not have the chance to be challenged by curious, bold young minds are often relegated to doing things the same old way.”  He summarizes with this – “those who can’t teach, just do – and that’s a shame”.

Peter Klein is just one of the many educators that have expressed their deep displeasure with the notion that teaching is a fallback, a catch-all-net that traps the unsuccessful.  History reminds us that some of world’s greatest minds were teachers.  Richard Feynman, noted to be one of the world’s most brilliant physicists, was a teacher.  Salman Khan, founder of Khan Academy, vested his life’s interest in changing the minds of those willing to learn.  Walter Levin - a science professor at MIT, Marie Curie – one of the first women to teach at the Sorbonne, Stephen Hawking – renowned for intelligible work with mathematics, embracing a position once held by Sir Isaac Newton.  And if that isn’t enough there is Galileo, Aristotle, Mozart, etc.  One thing is for sure – those who can do, teach – and those who teach, undoubtedly, can do.

Teaching is serious business – not for the faint-hearted or those seeking to settle in comfort.  More importantly, there is no such thing as “just a teacher”.  Remember – you are NOT just anything; you are what you are.  Period.  We are not just paramedics, we are not just nurses, we are not just teachers – we ARE paramedics, we ARE nurses, we ARE teachers – Recognize and OWN IT.  JUST is crappy scapegoat; a word that rides on the end of fluffy and excuse-laden coattails.  If you teach, then know that what you do, what you have done and what you will do are all part of the teaching and learning experience – and student’s love it!  Embrace what you do; and do what you embrace.

Embedded in the very venue of teaching lies this, says Peter Klein – “Question the way we do what we do, and improve it”.  Critical care education thirsts for this.  In a world where 30 years of experience is discredited; and things change at near-daily pace, a call to an open mind may be the drastic difference between life and death.  Student’s deserve to hear and see our experiences; presented in a way that captures their thoughts, shifts their perspectives and engages their critical thinking.  We do not, and more importantly, should not, stop until we rest in the context of Albert Einstein’s epic wisdom – “If you can’t explain it simply, you don’t understand it well enough”.  To this end, continue the pursuit of excellence in teaching – it will come back and thank you one day!!

Be well and stay safe out there!!

bruce

Bruce is a critical care registered nurse and paramedic who has worked in Connecticut, Massachusetts and Maryland.  His clinical background includes the ICU, ER, Trauma, Cardiology and Flight.  His graduate degree is in Education.  He is happily married to Stephanie, after meeting her while working at the Johns Hopkins Hospital in Baltimore, MD.  They currently live in Connecticut with their daughter Ava Mae and their 160 lb. English Mastiff, Maggie.  In addition to being an active volunteer and officer with the Ellington Volunteer Ambulance Corps, Inc., Bruce enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.

  8528 Hits
JUN
11

prol

I don’t know that there is anything that gives me an insta-aneurysm more than the casual educational cliché “yea – that’s the way we teach it in here, but when you’re out there, its totally different”.  Pardon me, but…really?!  Statements like that belong nowhere, and I mean NO WHERE near critical care transport (or any other medically associated entity for that matter).  If what we teach is not how we practice – then – we got’ problems – BIG PROBLEMS!

I can’t imagine a more confusing and muddled way to completely and utterly destroy an innocent student’s motivation and desire to progressively learn.  By demonstrating such a massive mismatch between what we teach in the classroom and our expectations in the field, we not only (and very effectively) eliminate the principle of educational integrity, validity and authority.  Why embrace and “culturize” concepts such as active learning, return demonstration and critical thinking, if we abandon the same, when we punch the clock and buckle our belts.

 

Eric Westervelt recently scripted an interview he had with Stanford Physics and Education Professor Carl Wieman.  During the interview Wieman passionately describes the benefits of “active learning” and argues that “a well implemented active learning approach can substantially improve understanding and retention of the material” (1).

As an inspiringly true progressive, Wieman, nailed it.  Active learning encompasses the whole picture – taking the same form whether in the classroom, the lab or the streets.  Why even teach the right way, if we are NOT going to support it in practice?

I acknowledge that there is always room for the clinical application of classroom knowledge, but it should not (and does not) replace the need to consistently hold standardized methods from classroom to chopper.

It kills me that I even have to write about something like this… it gives me more chest pain than ACS.  Someone please pass me an Aspirin!!

Be well and stay safe out there!!

 

bruce

Bruce is a critical care registered nurse and paramedic who has worked in Connecticut, Massachusetts and Maryland.  His clinical background includes the ICU, ER, Trauma, Cardiology and Flight.  His graduate degree is in Education.  He is happily married to Stephanie, after meeting her while working at the Johns Hopkins Hospital in Baltimore, MD.  They currently live in Connecticut with their daughter Ava Mae and their 160 lb. English Mastiff, Maggie.  In addition to being an active volunteer and officer with the Ellington Volunteer Ambulance Corps, Inc., Bruce enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.

Reference:

  1. http://www.npr.org/sections/ed/2017/06/07/530909736/hey-higher-ed-why-not-focus-on-teaching
  8880 Hits
FEB
22

 

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I recently listened to a five-minute-ish Ted Talk given by Ric Elias on the “3 things I learned while my plane crashed”.  If you haven’t had the pleasure of listening to it, just click here and engage!  I won’t spoil the storyline of his talk, but there were a few key points that I can easily recall; each one relevant to questions posed by this post - “Is Change the Cause of My Bad Attitude?”.  The question begs a necessary and timely discussion that could be had in any profession, but for the purposes of this one, we’ll apply it to the emergency medical and critical care service(s). 

As aforementioned, there are three pearls that require dissection and application.  Number one, change does not take as long as you think it does.  Number two, stop wasting time in things that do not matter with those who matter.  Number three, if you are happy, dying is not scary; it is sad.  While you chew on those, let’s explore each a bit more… 

Number one: change does not take as long as you think it does.  As if any of us in the pre-hospital world need to be reminded of this!?  But do we?  It is easy to apply this directly to our patients – their lives change in a split second.  The mother of four who just picked her kids up from school, gets hit head-on by a texting teen on his way home from soccer practice.  One second, they are as described above; a second later they become victims – alive or dead, they immediately join the ranks of those we, as providers, interact with most.  Their data will support public service announcements, resource funding for continued prevention and intervention; and provide lessons to those that can still see and hear.  My point, things change really, really quickly.  So what is it about change that seems to take forever.  It’s how we deal with it.  Our ability to cope with said change is what splits the difference.  In the paraphrased words of late Carnegie Mellon Professor Randy Paucsh – it’s not about the cards you’ dealt, it is how you play the hand! Ditch the common sense thought that change takes a long time.  Beat the negative by understanding the rapid-fire nature of change.  It will make your life easier; guaranteed.

That pretty much sets the stage for number two: stop wasting time in things that do not matter with those who matter.  Embracing the fact that change can change very fast, it would behoove each one of us to carefully consider how much time we spend belaboring something menial with a person that really matters to us!  As Ric Elias would say “I no longer try to be right, I try to be happy”.  Contextually, I can only imagine him referring to how easily we are able to let things go.  Harboring envy, jealousy, defensive correctness, or even spite can wreak havoc on our bodies – emotionally, physically and psychologically.  Let it go.  Do not build an internal prison – it can take years to break out.  The one caveat that I would offer is this – we have an obligation to those patients for whom we care for.  Employing strategies such as diplomatic candor and professional behavior can allow us to convey a point of correctness even when faced with the arch-nemesis of arrogant incorrectness.

 Number three: if you are happy, dying is not scary; it is sad.  I interpret this both literally and figuratively.  A happy life which is cut short is sad; very rarely, if ever, scary.  Assuredly, happy folks tend to innately follow the two previously mentioned thoughts.  By way of logic, it would only stand that they might embrace number three.  Regardless, I offer this – happy people tend to live in the moment, constantly aware of how quickly life may change; thereby concentrating on the meaningful and impactful – with those who matter most.  Sad would be this life if it were to end.  I’m not sure that I know too many practitioners who would want to die in fear; scared of the very moment their life’s work clashes with whatever lies beyond the light.  I might propose that if we, as providers and clinicians, subject our mind to these three nutritious nuggets – we may start to see a dramatic change in not only our attitude, but also our life!

So, to answer the question “Is Change the Cause of My Bad Attitude?” – maybe, or maybe not, but now there are no excuses – get on the train; drink the juice; and CHANGE YOUR ATTITUDE!

Be well and stay safe out there!!

 

Bruce is a critical care registered nurse and paramedic who has worked in Connecticut, Massachusetts and Maryland.  His clinical background includes the ICU, ER, Trauma, Cardiology and Flight.  His graduate degree is in Education.  He is happily married to Stephanie, after meeting her while working at the Johns Hopkins Hospital in Baltimore, MD.  They currently live in Connecticut with their daughter Ava Mae and their 160 lb. English Mastiff, Maggie.  In addition to being an active volunteer and officer with the Ellington Volunteer Ambulance Corps, Inc., Bruce enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.

  15999 Hits
JUN
03

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A few weeks ago while I was in a notable healthcare facility, I overheard a provider say “I’m so sick and tired of hearing that “it’s all about the patient”.  Not trying to create a scene I casually glanced over at the individual, locked eyes with her for a hot second, and then continued on my way.  Not being one to mince my words, I have to say that I don’t completely disagree with her.  I’ve always been for analysis – and throughout my career as a critical care, transport/flight nurse and paramedic, I’ve probably coined that same statement (or something very similar) in my own head.  “Is everything we do in medicine, nursing, EMS really all about the patient?”  For years, I have been taught about teamwork, collegiality, inter-personal relations, etc. – and yet, at the core of all healthcare lies the patient – in disconnected yet peaceful repose.  Reeling in thoughtfulness and reflection, I tried to understand what I was feeling.  I did not feel conflicted; I was not mad or angry; I was not awestruck; instead, ironically, I was somewhat relieved – to hear someone else say, out loud – I’m sick of hearing that it’s always, all about the patient”.

Let me provide some background which might offer some clarity as to why that statement both intrigues and relieves me.  Having spent much of my adult career in the critical care and transport settings, I have never fully understood why there is not more emphasis on the team – patient and provider.  Let’s look at a scenario.  I am covering a flight shift for a sick colleague.  The paramedic and I don’t get the opportunity to work together very often as I am traditionally on an alternate shift.  It is 3AM and we have just been dispatched to a rural clinic for a post cardiac arrest patient with ROSC having an anterior wall STEMI.  Let’s stop there and just look at the obvious, as it relates to the comment above.  There is one patient, two medical providers and one pilot.  There are four souls on that aircraft – not only one.  Yes, for sure, there is only one patient, but doesn’t it behoove us to include the medical and operational crew here as well? Since when did everything revolve around “just the patient”.  I can remember for as long back as my original EMT-Basic class (a solid 13 years or more ago) being told – “you can’t help anybody else, if you become incapacitated”.  If that’s not the truth, I’m not sure what is…

I feel somewhat compelled to offer another perspective.  That sarcastic healthcare provider, you know, the one who made that off-the-wall comment, might NOT be that far from unearthing a huge misunderstanding in healthcare.  Healthcare should be making guidelines, regulations, policies, and rules to assure that the ENTIRE team is safe.  Solely focusing on the patient may be guiding our system way, way off course.  When an air medical evacuation mission is requested, all that the pilot and crew initially know is that there has been a request for service.  It is only in flight that the pilot and crew receive landing coordinates and patient information, respectively.  There is a reason for that – to ensure safe and objective decision making.  This same concept should be globally applied to healthcare – and in some ways it is already happening.  However, there are still some areas that are lacking significantly.

I want to assure you that my position here is NOT to forget about the patient and their ultimate and successful outcome.  Rather, it is to suggest that a more balanced approach be used when considering the needs of both the patient and team.  Assuring that health regulations, policies, guidelines, etc. are supportive of both the patient and the team, will undoubtedly add a necessary and objective safety layer, a provision of quality healthcare.

Be well and stay safe out there!!

 

 b2ap3_thumbnail_Bruce.jpg

Bruce Hoffman is a critical care nurse and paramedic.  He works as both a clinician and educator in Connecticut, Massachusetts and Maryland, with background in the division of critical care (ICU, ER, Cardiology, and Flight).  He enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.  He is a frequent and national lecturer for a host of Emergency Medical Services and Critical Care continuing education programs. He remains a member of his hometown ambulance service where he has served in a variety of administrative and operational roles. In his spare time, Bruce enjoys spending time with his wife Stephanie as well as traveling, hiking and biking.

  13084 Hits
FEB
28

 

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I can remember, with distinct clarity, the first few calls that I was involved with during my paramedic internship.  Specifically, I can recall hearing the phrase “now you get to see how we really treat patients”.  I remember being confused and not quite sure what to do.  On one hand I had just completed one of the most intense training courses in pre-hospital care; and yet, what did that education matter, if we don’t actually use it? 

One case in particular that stands out was an elderly woman complaining of chest pain and shortness of breath.  I remember being taught that a cardio-respiratory assessment included the auscultation of both heart and lung sounds.  I clearly remember my preceptor telling me that, “doing that (auscultation) is useless in the back of the rig”; and that “we’re not freakin’ cardiologists – why do we have to do that anyway – it’s not like it’s going to change our treatment”.  Closing my eyes, I can see the familiar script running through my head…“are you serious”; of course, we’re not cardiologists or pulmonologists- we ARE paramedics, and YES, we should be including auscultation in our assessments; and YES – it does (or it better) make a difference in our patient care!

Ok; Ok; Ok; – everybody just hold on; take a deep breath – let’s explore what the evidence says.  The Journal of the Society for Simulation in Healthcare offers some great information - and frankly, I’m in their corner on this one – all the way.  Not only have they debunked the theory that auscultation plays an important role during the “in-transit” phase of patient care, but they also made some exciting and evidence-based discoveries that are sure to bring attention, focus and resolution to this issue.  In April of 2014 they (the Journal of the Society for Simulation in Healthcare) published an article titled “A Simulator-Based Study of In-Flight Auscultation”.  A comparative clinical study, using two different types of stethoscopes (conventional and electronic) as a McNemar test, concluded that “flight practitioners involved in aeromedical evacuation [were] better able to [correctly perform] lung auscultation on a mannequin with an amplified stethoscope than with the traditional one” (1).  Specifically, the data regarding lung sounds demonstrated that conventional stethoscopes were accurate about 10/20 times, versus the electronic stethoscope which yielded 18/20 correct diagnoses.

Despite the study’s barriers, there are a few things to consider.  One, the study does not discuss how ground transport affects auscultation, but there is certainly a high likelihood that the data would be similar.  Second, auscultation should never be used as a single diagnostic tool.  It should be paired with the patient’s clinical presentation along with other medical monitoring devices such as skin color, pulse oximetry and end-tidal carbon dioxide measurements.  Third, it is important to note that there was no suggestive evidence that heart sounds were better heard with either stethoscope.  For those that love statistics – the P value for heart sound testing was 0.13, versus lung sound examinations at 0.013.  Fourth, the study was conducted in a C-135 fixed wing aircraft using a mannequin-based SimMan who had everything from crackles, wheezes, pneumothoraxes as well as several different variants of cardiac murmurs.  Five different practitioners were evaluated in a sequential and scientific manner.

From a professional standpoint, a few of us critical care practitioners here at FlightBridgeED, started out (and continue to use) the Master Cardiology (bell) stethoscope.  This particular flavor of scopes is useful for initial learning as well as ground transport.  This is especially true with the assessment of bowel sounds.  Eric Bauer, CEO of FlightBridgeED, in reference to auscultation during transport, says that “I think it takes time to block out some of the noise”; especially on the ground.  He also reminds us that if you suspect that you are not going to be able to hear anything during transport, that you should do a thorough assessment prior to moving the patient.  Even though the conventional scope seems to be the go-to-choice, this article certainly brings a challenging perspective to traditional practice.

Soooo – here is the “who cares” moment; “what does any of this have anything to do with me?”, you might ask.  Well, its simple.  The message is clear – the inability to provide proper medical treatment is severely handicapped in a high ambient noise environment.  At the cost of a moderate price, the solution lies in the purchase of an electronic stethoscope, not a conventional one.  We may never know that outcome or impact it may have, until we start regularly collecting data and information on these scenarios.  Think about it; do some of your own research and most importantly; let’s start gathering, mining and analyzing some of this readily available data!!

Stay safe and be well… 

References:

(1) http://journals.lww.com/simulationinhealthcare/Fulltext/2014/04000/A_Simulator_Based_Study_of_In_Flight_Auscultation.2.aspx

 

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Bruce Hoffman is a critical care nurse, paramedic and current graduate student.  He works as both a clinician and educator in Connecticut, Massachusetts and Maryland, with background in the division of critical care (ICU, ER, Cardiology, and Flight).  He enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.  He is a frequent and national lecturer for a host of Emergency Medical Services and Critical Care continuing education programs. He remains a member of his hometown ambulance service where he has served in a variety of administrative and operational roles. In his spare time, Bruce enjoys spending time with his wife Stephanie as well as traveling, hiking and biking.

 

  8274 Hits
JAN
28

 

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There has been a recent upsurge in the numbers and personality types of private and commercial social media platforms.  These include, but are not limited to blogs, twitter handles, podcasts and facebook pages.  Simultaneously exciting and scary, these (at times) bold and controversial domains can be the breeding ground for the good and the bad.  With the rapidly changing front of medicine, and its diversified application to basic and advanced medical services as well as critical care support teams, clinicians today must possess and use a high degree of discernment when providing patient care.

 

This came to light for me during a recent conversation I had with my good friend Eric Bauer, the CEO of FlightBridgeED.  As the key architect to his successful work, Eric relayed an important and concerning concept that he has watched trend to popular status.  This is the realization that more and more clinicians and providers, are turning their medical ear to his insight and recommendations.  During the course of our conversation it became clear to both Eric and I that we must (along with the many other reputable sources of clinically trendy info) make it clear to the subscribers and supporters that they STILL NEED TO FOLLOW their local protocols or guidelines, especially during the provision of patient care.

This is not unique to one establishment or the other, but a kind and gentle reminder that the pursuit of current data trends, the use of evidence-based practice and absorption of all things medically amazing, is praise-worthy and good.  However, changing the way you deliver care is still guided by your local policies, protocols, regulations and leadership.  It is perfectly OK to arm yourself with the myriad of available knowledge and present recommendations or proposed changes to your local administration, but it CAN NOT replace the current guidelines that you practice under in your local jurisdiction.

A recommendation that I might suggest is using the things that you see, hear or read to present a legitimate, data driven change project to your local leadership.  Take the knowledge you learn and use it to drive change within your specific area.  Not all ideas, thoughts, words, etc. are going to be right for you or your team, but often the curiosity that is ignited can be the catalyst to the “new and improved” in your neck of the woods…

Be well and stay safe out there!!

Bruce

 

Bruce Hoffman is a critical care nurse, paramedic and current graduate student.  He works as both a clinician and educator in Connecticut, Massachusetts and Maryland, with background in the division of critical care (ICU, ER, Cardiology, and Flight).  He enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.  He is a frequent and national lecturer for a host of Emergency Medical Services and Critical Care continuing education programs. He remains a member of his hometown ambulance service where he has served in a variety of administrative and operational roles. In his spare time, Bruce enjoys spending time with his wife Stephanie as well as traveling, hiking and biking.

 

 

  9095 Hits
JAN
13
 

A Blurb from Bruce: Do You Autopsy?

by Bruce Hoffman

b2ap3_thumbnail_scalpel.jpgAn autopsy, also known as medical obduction, is a surgical procedure used to perform a thorough and comprehensive examination of a dead body.  This is done to determine the cause and mechanism of death and to evaluate the presence of any disease or injury.  As part of my continuing medical education, I have participated in a number of pseudo-autopsy activities (cadaver lab, etc.) and have come to realize the dramatically relatable and close allegorical correlation that it has to the growing niche of EMS and Critical Care leadership.  The process of an autopsy could be a safe model to follow during the analysis of any type of leadership failure.

In 1999 the Institute of Medicine published a title page with this slogan – “To Err Is Human: Building A Safer Health System”.  This report correctly stated that “health care [is] not as safe as it should be – and can be” (Institute of Medicine, 1999).  The question begs – why? - and what does an autopsy have to do with any of this anyway?

At some point during their career, EMS and Critical Care providers are subjected to this nasty truth.  However, through diligent and safe practice, we do our best to limit “the err”.  I have often said, yes, the error is bad, but not learning from the error is far worse.  To prevent errors from reoccurring, we can morbidly turn to the autopsy model; by this I mean do we thoroughly examine the failure or error and determine the cause and mechanism by which it happened?  In addition, are we probing further to ascertain the presence of any more diseased or disease-prone areas?  Areas that have failed or areas that are prone to failure can be regarded with equal importance.  Similar to the autopsy, this can provide for (most of the time) a definitive rationale for the cause of death, or body system failure.  Additionally, an autopsy can confirm not only the causation of systemic collapse but also specific data on each individual organ (that which supports the system).  Taking this out of the realm of death and applying this similar logic to a professional scenario, you can quickly discover that a more robust evaluation is possible.

It is often said that systems are completely unfixable – unless there is a massive overhaul - the tables turned upside down and the entire infrastructure demolished.  For the most part, I would politely disagree.  Even though an autopsy can be painfully intricate, the resulting data is an impressive cash cow of really good information that, after a rigor-laden analysis, can be applied towards a reachable and realistic solution.

Great – now we have a solution; but, what’s next?  Keep following the autopsy model – publish a report based on the data learned and begin the process of changing behaviors or practice.  This is very similar to the database of human demise – we pull data from this bank and make recommendations that allow for a healthy and sustaining life.  Do this in professional leadership and WOW – you’re onto something big.  Don’t believe it – do it.  What’s the worst, you fail?  If so, do another autopsy…


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Bruce Hoffman is a critical care nurse, paramedic, and current graduate student.  He works as both a clinician and educator in Connecticut, Massachusetts, and Maryland, with a background in the division of critical care (ICU, ER, Cardiology, and Flight).  He enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation, and blogging.  He is a frequent and national lecturer for a host of Emergency Medical Services and Critical Care continuing education programs. He remains a member of his hometown ambulance service where he has served in a variety of administrative and operational roles. In his spare time, Bruce enjoys spending time with his wife Stephanie as well as traveling, hiking, and biking.
 


 

 

 

  4332 Hits
DEC
30

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Have you ever worked with someone who thinks they are always right?  I know I have.  They think they are right…about everything…all of the time.  As a life long (so far) student, I have embraced the blended emotions associated with learning – unimaginable joy and labored challenge.  Whether it is hearing new ideas, creating a new plan or simply (or not so simply) acknowledging that we, just might, be wrong – it’s a tough battle, especially for the type A personality – and we all know a few those!

So, is it right to think that we are always right – or is this the one area where we might be wrong?  In order to understand more, I did some digging; some self reflection; some intelligible conversing and what an awesome experience it has been.  Inexcusable and unprofessional as you may think it is, I would encourage you to read on for some shared insight on how to handle that special someone in your life who is “always right”.

Living in the nebulous cloud of self-induced correctness can make you “uneducable”, in other words unwilling or unable to learn.  Being uneducable can lead you to become an isolated and lonely person, as represented, pictographically, above.  Even though the clouds and colors are nice, YOU ARE ALL ALONE!  Combine an uneducable person with an uncomfortable topic and WOW – can someone say defensive!  Right?

Before we jump to conclusions or manufactured opinions about this – let’s lay down a few more thoughts.  Striking the delicate balance between a few of the forces at work in an uneducable person can help bring awareness and understanding to this frustrating personality.  Are you (or they) assertive and bold, or arrogant? Selectively passionate or ignorant?  Sometimes the small difference between those characteristics lies in the very essence of being or NOT BEING uneducable.

So are there ways to help those who seem uneducable?  ABSOLUTELY!  Here are a few easy ways to help:

1.  Rejection or dismissal of an idea or project IS NOT a rejection or dismissal of you. Every time you feel your idea is getting rejected, remember that it is not a rejection of you as a person!!  Although your initial reaction to rejection might be rejection, remember this - we all have different opinions; and this is perfectly allowable.  Rejecting someone because of an opposing opinion is wasteful and unnecessary.  This emotional and circular response needs to be interrupted; take any chance you have for resolution.

2.  Always being right can make people feel worthless. Think about it like this; you make me feel worthless, so I start to feel worthless.  Because I feel worthless, I make you feel worthless, which in turns makes you feel worthless, which then makes me feel worthless and so it continues.  Perhaps a picture is worth a thousand words… (see below)

Diagram

3.  As the author, and subsequent authority in YOUR life, YOU can allow access to and open up gateways to others; others that may know a bit more of a particular subject than you. This does not devalue and deconstruct you and your profile, but rather empowers you to expand and engage the person you currently are.

4.  In a stressful moment, when you feel the urge to claim your correctness –STOP and THINK – assume for a minute that everything you have learned may be wrong! Surprisingly, you may just open yourself up to learn and treat new experiences as they are.

5.  Remember, the opinions of others have been shaped by their learning and their experience – that they have lived. It, in no way, shape or form, needs to reflect your learning or your lived experience.  Lending an ear probably won’t kill you, and it just might, in some small way, allow you to learn from their channeled experience – from them to you.

6.  Attacking the channel or its source (aka the other person), only devalues yourself; not them. In the words of Lishui Springford “embrace every contact as though it is well-meaning and helpful”; “just enjoy the attention, and learn from the experience”.

The world we live in, especially EMS and critical care, is far from utopia.  That is what makes us special – recognize and realize it.  You are a part of this profession, for better or for worse.  No one is ever right, about everything, all of the time.  Relax; take a big breath, let go of whatever it is that is holding you captive to the force of chronic correctness!

References:

  1. http://mindtreehealth.net/why-youre-always-right-even-when-youre-wrong/

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Bruce Hoffman is a critical care nurse, paramedic and current graduate student.  He works as both a clinician and educator in Connecticut, Massachusetts and Maryland, with background in the division of critical care (ICU, ER, Cardiology, and Flight).  He enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.  He is a frequent and national lecturer for a host of Emergency Medical Services and Critical Care continuing education programs. He remains a member of his hometown ambulance service where he has served in a variety of administrative and operational roles. In his spare time, Bruce enjoys spending time with his wife Stephanie as well as traveling, hiking and biking.

 

 

  13383 Hits
DEC
16

 

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Here may be another reason why you should.

I’m not sure about you, but when I went to school to become a paramedic (and a nurse for that matter), one thing I never really understood was heart sounds, or heart tones, depending on who taught you.  My attempt at learning such resorted to scouring textbooks, journals, online editorials, watching clips on YouTube and listening…lots of listening to sound bits from the CD’s, you know the ones that come free with a new stethoscope. Instead of tuning into digital media, I should have been listening to the hearts of my many patients.  Needless to say, hindsight is 20/20, especially in this case.  All of my self-guided education yielded little result - kind of discouraging to say the least and because of such, I let it slip from my list of competent skillset – that is, until I took care of Henry.

Henry is a 68-year-old gentleman; (and I say “is” with bit of guarded breath)… only because for a short time, Henry was quickly falling off the cliff – you know that seemingly short height that separates life from death; but don’t worry, we’ll get him back by then end of this story.

I met Henry, after he summoned 911 EMS for some concerning symptoms – a near syncopal episode, shortness of breath and chest discomfort.  On arrival, a “standard” assessment revealed the following:

  • Objective Assessment and Vital signs:
    • Alert and Oriented, No jugular venous distention or pressure, Lung Sounds mid to base rales, palpable pulses, 2+ pitting lower extremity edema, skin is pink, warm and dry
    • Heart Rate / Rhythm: 90 beats per minute, correlating with ECG
    • Blood Pressure: 164/70 mmHg
    • Respirations: 24 breaths per minute
    • SpO2: 91% on room air
    • ECG: Sinus Rhythm, BBB pattern and (ECG criteria that met LVH)
  • Subjective Assessment:
    • “I was here in my chair, and got up to go to the bathroom and I felt like I was going to pass out”
    • “I didn’t really pass out, I just got kind of dizzy… but the pain in my chest and breathing hasn’t been real good for the last few weeks”.
    • “I can barely make it up the three steps outside the house without getting winded”
    • “my chest just hurts, I’m not sure if it’s my heart or my breathing”
    • “the pain seems to be in my chest, but sometimes I feel numb in my head”
    • “oh, if I had to give it a number, I would say its about a 5 or 6”
    • “the last time this happened my doctor told me to call 911, they did some tests in the hospital on my heart and told me that I should be around for a little while yet”
  • Allergies: None Known
  • Medications:
    • Aspirin 81 mg Daily
    • Lasix 20 mg Twice Daily
    • Potassium Supplement (20 mEq Daily)
    • Coreg 6.25 mg Twice Daily
    • Prevacid as needed
  • Medical History:
    • Heart Failure, last Ejection Fraction (two months prior) 35% - 40%
    • Hypertension
    • Aortic Stenosis (he says it’s pretty bad)
    • GERD

As a provider, I’m feeling somewhat prepared; I have some decent information and my partner and I form a game plan – place the patient on oxygen (nasal cannula), position of comfort, Aspirin 243 mg by mouth (since he already took his 81 mg this morning), 12 lead ECG, establish a peripheral IV (saline lock), Nitroglycerin spray (one dose – 0.4 mg sublingual), repeat 12 lead ECG, monitor five lead ECG and hopefully (fingers crossed) by then we’ll be at the hospital.

I preface the next part of this story with this; plans are great to have, but they very, very rarely (especially in EMS) are executed as initially desired.

Things were going really well, until that Nitro spray.  Shortly after administration, and by shortly I mean 20-30 seconds, Henry complained of worsening chest pain and when I looked over at him – he looked, uh, different…he appeared to have been sprayed with a can of grey paint.  Ever have that feeling…that gut sinking feeling that your Hippocratic obedience may have just gone out the window?!  A quick glance at the monitor confirms my worsening fear.  As if guided by an internal computer, the heart rate display is surrounded by a yellow box and I hear the distant sound of an alarm… treat the patient, not the monitor – the words are remote, but retrievable.  I look back at Henry – he looks the same, except this time, he has turned his head and is looking directly at me – almost staring right through me – as if he see’s something in the distance – like “the bright light”… or my shredded paramedic license.  A quick shake from my partner, and I’m back to reality.  Rhythm, I mutter to myself, slow rate, wide complex…CRAP; what just happened?  Recap time, I just gave Nitro and apparently, very apparently, it wasn’t tolerated well.  I ask my partner to check a pulse, while I cycle his blood pressure and simultaneously grabbing a bag of normal saline, spiking and hanging it.  I connect it to his IV and open it wide – ml’s/hr…who the heck knows; just get it into him STAT.  My partner gives me the first good news I’ve had in the last minute – “he has a pulse”…HORRAY!  Relief surrounds my personal space, and I audibly announce the blood pressure, “74/30”…hmmm; seems low, but lets watch what this IV fluid does.  My partner increases Henry’s oxygen, a nasal cannula gone from low flow to high flow with the turn of a knob.  I give Henry a sternal rub and those wandering eyes return to center, and he mumbles something incomprehensible.  His heart rate is coming up and his repeat blood pressure is better than before.  Finally, the magical moment when Henry asks the question that we all are craving to know – that beautiful moment when both patient and provider are on the same page…”what the heck happened?”.  I reassure Henry, telling him we are taking good care of him and that we will soon (sooner than before – lights and sirens please!) be at the hospital.  The rest remains routine; 200 ml’s of IV fluid in, hospital notified, a reduced flow of oxygen and Henry, dried out nostrils and all, arrive at the hospital, turn over care, and say a happy good bye to our friend.  And as every good EMS provider, I return to the truck and start writing - trust me, it was thoroughly documented that the receiving NURSE was aware of his “reaction” to Nitro.

Now for the debrief; which I’ll keep short and sweet, because I enjoy when articles, like this, provide some information, but allow me to be a knowledge constructivist; assembling my own knowledge with that which I have just learned.

Most healthcare providers are aware of the effect that Nitro has on the human physiology.  Through relaxation of the muscle layer surrounding the blood vessels, the patient may experience hypotension.  Essentially this increases the space with in the vessel, meaning the vessel diameter becomes greater.  With a patient who is euvolemic, this can create less tension on the vascular wall, hence hypotension.  But again, what does any of this have to do with heart sounds?  This peripheral vasodilation, when experienced systemically, can be reasonably tolerated in a patient with normal cardiac valvular function; and if not, easily treated by changes in position, volume repletion, etc.  The valve can support and compensate for the change in systemic tension or pressure.  However, in a patient, like the one above (Henry), who has aortic stenosis, in conjunction with heart failure, the valve is not able to do this.  The calcified and stenotic aortic valve relies very heavily on peripheral vascular impedance or resistance, in order to maintain a fixed forward flow.  The fixed forward flow is directly derived from the failing valve; as the valve becomes more calcified the jet stream evacuating from the left ventricle is essentially fixed and is not tolerant to changes in systemic circulation.  In a way the systemic vascular network is assuring an adequate cardiac output, specifically the stroke volume.  Any changes within the peripheral circulation and its associated pressure is going to dramatically tank the patient’s afterload, thereby directly impacting the patient’s preload and hence the downward spiral of the blood pressure and the patient’s condition.  It is imperative to remember that patients with aortic valvular stenosis are significantly dependent on preload.  In order to maintain preload in the prehospital and critical care transport setting, fluid is one of the better and more prudent options.  This can be akin to treating a low flow state in a ventricular assist device.  Low flow states in these devices cause the ventricular outflow mechanism to pull against the endocardium and myocardium resulting in ventricular irritation or ectopy.  Rather than chasing blind alleys it may be worth several boluses of a balanced intra-venous solution; you just may be surprised by the result – a calm ventricle and a better functioning ventricular assist device.  Contrasting this aortic valve stenosis, the similarities become understandable and the rationale plausible.  I guess the short of the long is this - patients with aortic stenosis are particularly sensitive to drugs that affect the vascular network and are significantly reliant on optimal preload – which can make them and their diagnosis tricky to treat.

One might wonder how competence in assessing heart tones may have had an impact on this case.  Well, as you may have guessed, you can hear the dysfunction of the valve.  This is accomplished by placing a stethoscope (preferably a clean one and using the diaphragm) on the patient’s chest and listening – very, very carefully.  The turbulent blood flow through the faulty valve is heard and recognized as a systolic murmur.  In a normal patient you will hear the traditional “lub dub”.  However, in a patient with aortic stenosis you will often hear lub-swish-dub”, meaning it starts after the first heart sound, and ends (usually) before the second heart sound.  This is best heard by placing the patient in an upright / seated position and listening over the upper right sternal border, also known as the aortic area (pretty handy, right?).

As mentioned earlier, this case was an impactful learning experience for me and thankfully the outcome was favorable for both patient and provider.  If I might offer some advice – listen to heart tones – a lot!!  Do you hear what I hear?

Until the next time…Be well and stay safe.

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Bruce Hoffman is a critical care nurse, paramedic and current graduate student.  He works as both a clinician and educator in Connecticut, Massachusetts and Maryland, with background in the division of critical care (ICU, ER, Cardiology, and Flight).  He enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.  He is a frequent and national lecturer for a host of Emergency Medical Services and Critical Care continuing education programs. He remains a member of his hometown ambulance service where he has served in a variety of administrative and operational roles. In his spare time, Bruce enjoys spending time with his wife Stephanie as well as traveling, hiking and biking.

 

  5124 Hits
DEC
01

 

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Provocative title, I know, but it may be time for a gross reality check.  I know I was; and boy, was I glad for the experience; I think the question has heightened my awareness to the integral role that honesty has in our profession.  The following is not meant to be punitive, derogatory or malicious, but rather the musings of a fallible provider of humanitarian aid.

As critical care providers we are subject to a lot of chatter; a lot of “the speak”.  Often, this comes in short bursts of catchy or easy to remember phrases.  For example, “our day begins when yours is about to end” or “you gotta be sick to fly with us”.  One that struck a particularly curious tone within me went something like this – “data out is only as good as the data going in”.  I must confess I’ve never really been a huge fan of numbers, statistics, calculations, etc., but throughout my academic and clinical experience, I have come to acknowledge and embrace its role in our profession.  You’re probably thinking, how on earth does the collection of data interface with being a truthful and honest provider? Allow me to share…

Many of the current, electronic patient care documentation platforms available are nothing more than aggregates for collecting, mining, sourcing and analyzing pools of data.  This data is then compiled and reported in a variety of charts, graphs, tables and publications; specifically targeting a proposed change or clinical issue based on a known trend – as derived from the data.

This is great!  We now have a bunch of nicely colored information, perfectly displayed and ready for all to feast upon.  We tear into this information, sinking our teeth into the disparities, the trends, THE KNOWLEDGE.  But wait; is there a catch to all this greatness?

All of those colorful and organized reports are a direct reflection of what the clinical provider has entered, at the very beginning when the patient care record was generated – the very genesis of said data.

I’ll come right out and say it, or in other words…get straight to the point.  If the clinical provider has fudged his or her documentation and entered it into the record – that’s the same data that will be reviewed by the powers that be – on the other end.  And it is on that “other end” where weighty decisions are made; decisions like protocol development, medical guideline changes, clinical practice augmentations, etc.

I have been a provider for about ten years now and have been witness to this very phenomenon, but its impact never really moved me past the fact of frank untruthfulness.  Putting aside the ethical deviation for a moment, let’s focus on the effect it has on the evolution of “evidence based practice”.  Let’s stage a case scenario - the patient is complaining of 6/10 pain.  According to our medical guidelines this is considered moderate pain and we can administer 15 mgs of IV Ketorolac.  However, during the administration process the provider “actually” gives 30 mgs, a dose that is outside of protocol, but is safe and justified according the clinician’s medical judgment.  Miraculously the patient tolerates it really well and is pain free on arrival to the hospital.  Its decision time – do we chart 15 mgs and let the chart pass the QA process, demonstrating that we “followed” protocol?  Or do we chart that we gave 30 mgs and risk having our clinical judgment and medical justification questioned?  Perhaps you yourself have experienced, witnessed or even done this – or maybe not.  I can assure you that this exists in practice, and I don’t think it is exclusive to critical care or EMS…

Let’s say that the above scenario happens once a day, every day for one month.  At the end of the month, we run a report and find that WOW – 6/10 pain is treated really well with 15 mgs of IV Ketorolac – therefore, there is no need to alter the guideline…because our protocol / guideline seems to be effective…!  But is it really?

Whether you are charting the number of IV attempts, or the dose of an administered medication, I would urge that all providers visit their inner sanctum for a moment; and ask themselves, am I a truly, truthful provider?  It makes a way bigger deal than we may think!!

EMS and critical care providers are some of the best people on the planet – they will do almost anything for anyone at anytime – I don’t think any of us deliberately would ever do something to harm a patient, family member or fellow provider – let’s make sure that we are daily, and actively engaging integrity as routine in our clinical practice!!

Until the next time…Be well and stay safe.

Notes:

This article was not written in response to a known or growing concern, but merely intended as a timely reminder - stressing the importance of truthfulness in patient care documentation and understanding its impact on data collection and analysis.

b2ap3_thumbnail_Bruce.jpg 

Bruce Hoffman is a critical care nurse, paramedic and current graduate student.  He works as both a clinician and educator in Connecticut, Massachusetts and Maryland, with background in the division of critical care (ICU, ER, Cardiology, and Flight).  He enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.  He is a frequent and national lecturer for a host of Emergency Medical Services and Critical Care continuing education programs. He remains a member of his hometown ambulance service where he has served in a variety of administrative and operational roles. In his spare time, Bruce enjoys spending time with his wife Stephanie as well as traveling, hiking and biking.

 

  4691 Hits
NOV
17

 

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Dr. Carol Dweck is internationally renowned for her inspiring work in the field of motivation.  Her book, Mindset, has generated lots of interest particularly in the area of "growth mindset".  Teachers from around the world have capitalized, expanded and interpreted her work through catchy slogans, creative bulletin boards and colorful posters.  After taking a look at some of them, I'm not sure they are only appropriate for the school setting...perhaps putting a few of these in our workplaces might help to shift the negative culture of a disparaged work environment.  Here are just a few:

- I will never do it like they do.  What can I learn from them?

- It is good enough.  Is this really the best that I can do?

- I am not good at this.  What am I missing?

- This is way to hard.  This might take some effort and time.

- I give up.  I'll use strategies that I've learned to handle this.

- I can not do any better.  I can always improve.

So how does this relate to rocks or plants.  The sentences above are "mindsets".  Rocks (non-growth) are the bolded, black text and the plants (growth) are the bolded, red phrases.    I tend to think of rocks as those who believe intelligence and ability is fixed and boxed.  It defines who and what they are - and not succeeding inhibits them from pursuing new challenges.  They also believe they possess a certain set of capabilities and skills - and they are really good at doing them.  However, there are a lot of other skills that they do not have - those on the outside of their box - and they are comfortable letting them stay there.

Plants tend to have a growth mindset.  They are able to receive nourishment, resource it and use it to grow and develop.  They believe that they can control when and what they learn.  They embrace challenges as another opportunity to spread their branches and extend their roots.

Whether rock or plant, the choice is yours...

 b2ap3_thumbnail_Bruce.jpg

Bruce Hoffman is a critical care nurse, paramedic and current graduate student.  He works as both a clinician and educator in Connecticut, Massachusetts and Maryland, with background in the division of critical care (ICU, ER, Cardiology, and Flight).  He enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.  He is a frequent and national lecturer for a host of Emergency Medical Services and Critical Care continuing education programs. He remains a member of his hometown ambulance service where he has served in a variety of administrative and operational roles. In his spare time, Bruce enjoys spending time with his wife Stephanie as well as traveling, hiking and biking.

  4462 Hits
NOV
04


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I’m not sure about you, but I love learning (and teaching) with the use of metaphors.  They help me associate difficult subjects with something that I interact with on a more regular basis.  For example, when I first learned about the autonomic nervous system and its effects on the heart, it was bulky and complex, making it difficult to understand.  Figuratively I needed a hammer – to break this convoluted mess into chunks – and then, with the help of a metaphor, put it back together in a way that made sense to me.  The metaphor that did it was the concept of a moving car (the heart) and how it responds to the gas and break pedals (autonomic nervous system neurotransmitters).

Let me share it with you.  The moving car is like the beating heart – its already in motion and responding to the controls.  Let’s say we want to increase the car’s speed.  There are two options (given the car is an automatic).  We can push on the gas pedal – and the car will respond by going faster.  This is like the sympathetic nervous system.  Using epinephrine, dopamine and norepinephrine, the heart responds by increasing its rate.  Examples of drugs include Epinephrine, Norepinephrine and Dopamine (you could have guessed that was coming…).  You could also try taking your foot off of the break pedal (or removing the break’s influence on the moving vehicle).  This is like the parasympathetic nervous system.  Removing the affect of acetylcholine, will reduce the amount of parasympathetic innervation to the heart – further allowing it to speed up.  Can anyone say Atropine?!  To make things a bit more interesting, think about how much you can push the gas pedal versus how much you can remove your foot off the break – way more room to manipulate the gas pedal than the break.  Perhaps that explains why there is a max dosage of Atropine, but not so for epinephrine.  However, as is the case, as soon as we hit a speed limit that becomes difficult for the car to handle, we realize we should slow down, before we are ARRESTED (insert morbid joke here).

So how do we this moving car to slow down.  As you might imagine, we will use the break pedal as well as the gas pedal, but this time in opposite manner.  In order to slow the car down we want to push on the break pedal.  This is like flooding the nervous system with acetylcholine which causes the heart rate to drop.  An example of a chemical that will do this is an organophosphate.  A term you might be familiar with is vagal tone – acetylcholine blush is just that – too much of this is a bad thing.  Stomping on the break pedal may sound like a semi-reasonable and effective way to slow the vehicle, but in essence it is much better for the car if you ease off on the gas pedal, versus jamming the break.  The same holds true for the heart – easing off of the gas pedal would be like limiting the amount of sympathetic innervation to the heart.  Drugs like beta blocking agents would be an example of this.

I could probably go on and on about this, but let’s wrap this up.  As I mentioned at the start, this was a very helpful way for me to visually remember the major components of the autonomic nervous system – perhaps it will be the same for you!!

As always, stay safe and be well.  Until the next time…

 b2ap3_thumbnail_Bruce.jpg

 

Bruce Hoffman is a critical care nurse, paramedic and current graduate student.  He works as both a clinician and educator in Connecticut, Massachusetts and Maryland, with background in the division of critical care (ICU, ER, Cardiology, and Flight).  He enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.  He is a frequent and national lecturer for a host of Emergency Medical Services and Critical Care continuing education programs. He remains a member of his hometown ambulance service where he has served in a variety of administrative and operational roles. In his spare time, Bruce enjoys spending time with his wife Stephanie as well as traveling, hiking and biking.

 

 

  12818 Hits
AUG
22

 

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With the onslaught of data, research, evidence based practice there seems to be one thing that WE are not addressing; and by WE I mean healthcare providers - nurse, paramedic, emergency medical technician, respiratory therapist, physician or medical assistant.  Are WE connecting with each other?  I know that we are connected to our patients.  I know that we are connected to the internet (most of the time).  I know that we are connected to our employers.  But what about each other?  Are we really connecting with each other?  I suppose I should stop using the word CONNECT, but I mean, come on already, WE need to get a handle on this.  WE tend to be so supportive and nice to our patients and their families, but when it comes to each other, it seems like we exchange the kind smile for the dagger stare of death.After thinking about such, I turned to the Institute of Healthy Visiting.  This organization is dominantly focused on assisting patient’s and families, however their model seems to provide really good guidance on how WE might connect with each other.  Let’s take a look at some of the salience found within this organization’s developmental tool for promoting compassionate resilience.Compassionate resilience is centered around self-compassion.  Sprouting from self compassion are six domains that support and assist “one” (you) in becoming more compassionately resilient.  Self compassion essentially recognizes six pillars of stability.  They are:
  • maintaining a work-life balance
  • identifying your values and strengths
  • plan for challenging situations
  • practice positive coping strategies
  • focus on things you can change
  • connect with a supportive person

In order to turn these ideals into realities, the Institute of Health Visiting, recommends embracing six domains, in sequential order, for the true realization of compassionate resilience, particularly as it concerns self-compassion.  Ironically, WE talk about many of these as if they are principled nebulae – existing is some other fantasized world.  FOLKS, wake up and smell (and drink) the coffee or cool aid; which ever satisfies your need (and yes WE ALL NEED IT).  The six steps are:

  1. Being in the now.
    1. We do this on a regular basis, lets keep it up
  2. Expressing vulnerability.
    1. Its actually way more liberating than one might rationalize or figure
  3. Forming supportive relationships.
    1. A drink, after a stressful shift, with a good friend…just saying
    2. How many of you read “drink” – and thought wine, or beer??! – not the best coping mechanism, but substitute as you will!!
  4. Foster hope.
    1. We know how to do this.  Proactive listening, positivity, teamwork, etc.
  5. Enhancing self-awareness.
    1. How well do you know yourself?  What do YOU actually believe?
  6. Developing acceptance.
    1. Ahhh, finally.We need to take care of each other; or else who will be there for ALL of us?  Let's start now; peer to peer, peer to leader, peer to supervisor, peer to student – whatever the role, whatever the relationship – perfect practice yields practice perfect.

 Bruce

Bruce Hoffman is a critical care nurse, paramedic and current graduate student.  He works as both a clinician and educator in Connecticut, Massachusetts and Maryland, with background in the division of critical care (ICU, ER, Cardiology, and Flight).  He enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging.  He is a frequent and national lecturer for a host of Emergency Medical Services and Critical Care continuing education programs. He remains a member of his hometown ambulance service where he has served in a variety of administrative and operational roles. In his spare time, Bruce enjoys spending time with his wife Stephanie as well as traveling, hiking and biking. 

References:

Institute of Health Visiting. Developing Compassionate Resilience. Available at: http://www.ihv.org.uk

 

  4546 Hits

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