Faith, Family, Forests and the Field: 2012

Sunday, December 23, 2012

My Thoughts On Christmas 2012

This entry will be an interlude between parts one and two of why I am an LCMS Lutheran... but at the same time, I believe it will compliment that subject well.

Egg Nog... That is usually the first secular thing that comes to mind when I think about Christmas. I obviously don't need it... none of us do. There is enough cholesterol in a cup of it to make your coronary arteries spasm at the mere thought of drinking it. Warm up the cath lab, because here comes Egg Nog! Then don't forget the Nutmeg... I stand there at the kitchen counter with the small Nutmeg container in my hand... I probably dust the surface of the Egg Nog four to five times while I am drinking it. Every time it starts to disappear, I dust it again. Then the dog has to come in and sit down in the middle of the floor and stair at me. I guess he knows it has eggs in it. Maybe he smells it. Giving him some would be bad though... Nutmeg is highly toxic to dogs.

So...

My next thought is in regard to Christmas trees. I would love to have a house with just enough extra space where I could have a different themed Christmas tree in every room... you know, so that they could be seen through the windows and add to the exterior decorations that way.

Here is a quote from History.com that I liked:

"Germany is credited with starting the Christmas tree tradition as we now know it in the 16th century when devout Christians brought decorated trees into their homes. Some built Christmas pyramids of wood and decorated them with evergreens and candles if wood was scarce. It is a widely held belief that Martin Luther, the 16th-century Protestant reformer, first added lighted candles to a tree. Walking toward his home one winter evening, composing a sermon, he was awed by the brilliance of stars twinkling amidst evergreens. To recapture the scene for his family, he erected a tree in the main room and wired its branches with lighted candles."

The many Christmas trees at Santa's Workshop at the Vanderburgh County 4H Center 2012

That is only a small part of the entry which in its entirety is fascinating due the history of the Christmas tree before and after the above citation. I will post the link to the entire article at the end of this blog post.

Most people in my little part of the world tend to get "holiday cheer." I only say it that way because I am sure there are quite a few who don't grasp or care about the reasons Christians celebrate Christmas. Don't get me wrong... I kind of like the blue pointed Christmas hats with the fluffy white ball on top and the Christmas ornaments that were available at the Evansville Icemen game tonight. Those things, even though commercial, can be quite fun.

Rhiannon and the Christmas Pig

Then we could talk about my youngest daughter's lighted holiday yard decoration... a pink, winged, red ribboned Christmas pig. Don't ask, because I am not sure what connection it really has with Christmas. It has a halo, so I guess it is an angelic pig?

So, I have digressed... Even though those things above are on my mind this Christmas, they deal with the every-day worldly facet of our lives. These things are not what I truly long for this Christmas.

I long for the peace and warmth that we feel when we look at Christmas trees, or a snowy Christmas themed piece of art, to shift to the peace that passes understanding in that of our Lord Jesus Christ. There are so many places that I could start, but I will start simply.

One of my Scouts told me something that I greatly admired while we were on a five-mile hike with Troop 310. He told me that his family celebrates St. Nicholas Day and Christmas separately. St. Nicholas Day was December 6th. To understand the significance, you will need to read up on a bit on the history of the REAL St. Nicholas. I will post some links for that below as well.

This is how I think of a St. Nicholas or Santa Claus

Needless to say, the Scout advised me that his family celebrates St. Nicholas Day and Christmas and this helps them separate the two dates to where they where in the first place... one celebrating the things that St. Nicholas had done, and far more importantly the other being the birth of God as man in Jesus Christ.

I think our family will start with this practice in the coming year. It makes perfect sense to me.

Another thing I long for this Christmas is the same thing I long for around Easter... to be able to attend as many of the services being held at our church as possible. I have my favorite services: Palm Sunday, Maundy Thursday, Easter... Reformation Day, and then of course... the candlelight Christmas Eve service. But, there are many others I have never attended. I would love to attend all of the Christmas Eve services or the several services of Good Friday including Tenebrae.

I am looking forward to Communion this year at the 11:00pm Christmas Eve service.

My daughter Kat and her dog Mal

So, why am I here writing to anyone who will read my thoughts on Christmas tonight? It is simply a statement of what is the most important thing in my life, what I believe. If you haven't already stopped reading because maybe Christianity isn't a topic you like to explore, or my faith may differ from yours, I understand... but... for me Christmas has more meaning each year. I used to hate this "holiday."

In high school, I had several friends die around this time. So Christmas always brought back memories I wasn't ready to face. It always brought sadness. I have learned that I was the problem, not Christmas. If nothing else, Christmas is the great affirmation that should destroy all sadness as nor greater gift has ever been given than that of God's own son.

Want to dissect my thinking? I will help. First, I want to start with the Nicene Creed. I do not view this (or either of the two main creeds) as "vane repetition" as some would like to call it. I consider a core statement of what I believe... a concise, complete means of relaying what my heart knows to be true. And when I am in a room of several hundred saying it boldly with the same conviction? I feel at home. Let's start there and I will back track to my thoughts on Christmas.

The Nicene Creed:

"I believe in one God, the Father Almighty, maker of heaven and earth and of all things visible and invisible.

And in one Lord Jesus Christ, the only-begotten Son of God, begotten of His Father before all worlds, God of God, Light of Light, very God of very God, begotten, not made, being of one substance with the Father; by whom all things were made; who for us men and for our salvation came down from heaven, and was incarnate by the Holy Spirit of the virgin Mary and was made man; and was crucified also for us under Pontius Pilate. He suffered and was buried. And the third day He rose again according to the Scriptures and ascended into heaven and sits at the right hand of the Father. And He will come again with glory to judge both the living and the dead, whose kingdom will have no end.

And I believe in the Holy Spirit, the Lord and giver of life, who proceeds from the Father and the Son, who with the Father and the Son together is worshiped and glorified, who spoke by the prophets.

And I believe in one holy Christian and apostolic Church. I acknowledge one Baptism for the remission of sins, and I look for the resurrection of the dead and the life of the world to come. Amen."

It says what I believe, but for this topic I want to explore a portion of the second paragraph: "And in one Lord Jesus Christ, the only-begotten Son of God, begotten of His Father before all worlds, God of God, Light of Light, very God of very God, begotten, not made, being of one substance with the Father; by whom all things were made; who for us men and for our salvation came down from heaven, and was incarnate by the Holy Spirit of the virgin Mary and was made man." I want to look at this only as it leads us, as does scripture, to a small town in Israel called Bethlehem.

St. Paul's LCMS taken by Von Fuchs

So how can we be sure that this person is the Messiah? For me it must start with the fact that I believe that scripture is the inerrant word of God. Scriptura alone shows us.

Let's look back at some passages where God has told us all we need to know about who Christ would be and where to find him (all references are English Standard Version - ESV).

Micah 5:2 -

But you, O Bethlehem Ephrathah,who are too little to be among the clans of Judah, from you shall come forth for me one who is to be ruler in Israel, whose coming forth is from of old, from ancient days.

Matthew 2:1 -

Now after Jesus was born in Bethlehem of Judea in the days of Herod the king, behold, wise men from the east

came to Jerusalem.

Matthew 2:5-6 -

They told him, “In Bethlehem of Judea, for so it is written by the prophet:

“‘And you, O Bethlehem, in the land of Judah,

are by no means least among the rulers of Judah;

for from you shall come a ruler

who will shepherd my people Israel.’”

Luke 2:4 -
And Joseph also went up from Galilee, from the town of Nazareth, to Judea, to the city of David, which is called Bethlehem, because he was of the house and lineage of David,

John 7:42 -
Has not the Scripture said that the Christ comes from the offspring of David, and comes from Bethlehem, the village where David was?”

Matthew 1:17 -
So all the generations from Abraham to David were fourteen generations, and from David to the deportation to Babylon fourteen generations, and from the deportation to Babylon to the Christ fourteen generations.

Isaiah 7:14 -
Therefore the Lord himself will give you a sign. Behold, the virgin shall conceive and bear a son, and shall call his name Immanuel.

The very meaning of Immanuel is "God with us." We can go on a bit further here (and I am not pointing out all of the references and fulfillment of the scripture), but lets look at one relaying directly to Christ's own purpose and death:

Isaiah 53:5 -

But he was pierced for our transgressions; he was crushed for our iniquities; upon him was the chastisement that brought us peace, and with his wounds we are healed.

This verse says it all. Where the Law, as given to Moses, shines a spotlight on sin, Christ is the very methodology by which our sins are forgiven. Christ paid the price.

This Christmas, we exist in a time of uncertainty. We are still freshly mortified by a great act of evil in Connecticut with the killing of children and teachers. The news and the focus of our days do not seem to be stable.

Christ is certainty. Christ is stable. Through Christ's birth as God and Man, and His death and resurrection (cross and tomb as Pastor Eckels would say), we are blameless and may enter into the presence of God.

Ree and Michael waiting to see Santa

This is all that I know need to know so that I may look forward to Christmas each year. Reaching back two thousand years for the foretold birth of a savior for mankind through the Advent season is what I now look for in Christmas. It is a celebration.

My job is to lead my children to see this much earlier in their lives than did I. It is also to enable my wife to celebrate the season with the fervor by which she wishes to do so. We grow a little each year.

I have included some pictures from our Advent season this year. I hope you enjoy. My God bless you and keep you.

I will leave you with this, the lyrics of an Advent essential:

O come, O come, Emmanuel,
And ransom captive Israel,
That mourns in lonely exile here
Until the Son of God appear.
Rejoice! Rejoice! Emmanuel
Shall come to you, O Israel!

Taken by Von Fuchs

O come, our Wisdom from on high,
Who ordered all things mightily;
To us the path of knowledge show,
and teach us in her ways to go.
Rejoice! Rejoice! Emmanuel
Shall come to you, O Israel! O come, O come, our Lord of might,
Who to your tribes on Sinai's height
In ancient times gave holy law,
In cloud and majesty and awe.
Rejoice! Rejoice! Emmanuel
Shall come to you, O Israel! O come O Rod of Jesse's stem,
From ev'ry foe deliver them
That trust your mighty pow'r to save;
Bring them in vict'ry through the grave.
Rejoice! Rejoice! Emmanuel
Shall come to you, O Israel! O come, O Key of David, come,
And open wide our heav'nly home;
Make safe the way that leads on high,
And close the path to misery.
Rejoice! Rejoice! Emmanuel
Shall come to you, O Israel! O come, our Dayspring from on high,
And cheer us by your drawing nigh,
Disperse the gloomy clouds of night,
And death's dark shadows put to flight.
Rejoice! Rejoice! Emmanuel
Shall come to you, O Israel! O come, Desire of nations, bind
In one the hearts of all mankind;
O bid our sad divisions cease,
And be yourself our King of Peace.
Rejoice! Rejoice! Emmanuel
Shall come to you, O Israel!

Links I promised above:
http://www.history.com/topics/history-of-christmas-trees

http://en.wikipedia.org/wiki/Saint_Nicholas

http://www.history.com/topics/santa-claus

Wednesday, November 28, 2012

Why am I a Missouri-Synod Lutheran? Part I (did you really think I could do this in one blog entry?)

This one might be long. I am going to try and answer a question that I get asked quite a bit.

This particular blog is not being written to raise any one's ire that my beliefs may differ from anyone else's. I hold many Christian brothers and sisters who are strong in their faith in great regard as I believe does our triune God.

Logo of the LCMS (not an endorsement of my blog)

To simply put it, I have found what I believe the scripture has taught me to believe. Of course that simple description will not do at all. so I must expound. By the way... this is as much for me as it is for those who ask me, "Why Lutheran?" I think it does someone immense good to say why they believe any given fact in their lives.

An answer could be "that it feels right." It does indeed feel right, but I would risk acquiescence to the fact that many today actually look for a good feeling or even entertainment from "church." So that answer does not apply well to my intent at all.

The easiest answer would have been to say, "I married one." Indeed easy to say, as well as being quite true, but it was actually much more than that alone. Let us say that my wonderful, beautiful wife (who shows a great deal of restraint by not killing me in my sleep) led me to the level of faith I had searched for or maybe even ran from since the days of my youth.

Like I said, this could get long... and deep... and doctrinal... but it is an expose of the Theology that I believe as strongly as the fact that I breath air. It will get scriptural.

Every day, I wish that I had the deep understanding of the pastoral men such as synod President Matthew Harrison, Pastor Chad Eckels, Pastor Walter Ullman, Pastor Michael Paul, Pastor Martin Keller, Pastor Steve Kieser, Pastor Mark Moog, Pastor Keith Knea, Pastor Martin Noland... not to mention Pastors Wiist, Wenig, Esterline, Horstmeyer, Schneider, Smith... All different men. One faith. And all capable through the grace and empowerment of God to teach us God's inerrant word. I would dearly love to be able to follow Matthew Harrison around for a day just to be able to hear his clear teachings on the scriptures (have watched several videos) and just listen and learn.

There are people I define as "moral compasses" as well. They display the fruits of the spirit. People like (if you are local to Evansville) Charlie McMahon and Don Diekmann. Another layman of this calibre with vast theological knowledge and the ability to write about it is Scott Diekmann, a pilot for Alaska Airlines, who has written a blog called "Stand Firm" in more recent times.

Since story telling is the easiest way of expression for me, I have to start with my relationship to God. I was raised as a Southern Baptist. My church was for many years right down the street from my house (Vann Avenue Baptist Church). To this day, I will always remember the Pastor of that church, Brother Nall. Throughout my life, there have been intersections of meeting with him. I first learned of our Lord through this man. I first learned of the bible through the church he led and their vacation bible school. I still remember as a seven-year-old child learning the pledge to the Christian flag. This was my first immersion in Christianity. Those memories are still strong. Over those years that followed, I went as children of houses not firmly rooted in Christ do... at my whim. Sometimes I rode the bus to church, sometimes I went to vacation bible school, enjoying the stories, Cherry Kool Aid and cookies. I was a kid.

Later on, as a paramedic, I would be kneeling in a strangers floor, giving cardiac arrest medications to an unconscious, pulse less person while Brother Nall would sit close by comforting the family. This happened at least three times on the south-east side of town during my career. He has now retired after a very long time in the pulpit.

I believed at the most rudimentary level: as a child. My theology was and would remain for sometime extremely nebulous. Christ was my Savior. I could say that clearly later on, but the different versions of many faiths on the hows and whats and whys of being a Christian always stormed in my head.

I spent my early teen years in a non-denominational Christian church. I went to services more regularly. Grew a little. Spent a lot of time pondering Revelations (that church was consumed with this for about half a year back then). I was also in the church's traveling choir. At the same time, I went from attending a public grade school to starting my freshman year in high school in a Christian environment. I attended all four years of high school at a local Independent Baptist School. I did not know it then and would have disagreed with myself now... but I learned the true value of a Christian education experience.

I visited a Catholic church a few times (where I must say that I saw what I would define as worship evidenced... I think this was my first experience with a liturgical worship environment). I attended a Presbyterian church quite regularly toward the end of my high school years (although I do not remember much of those services). Then, through a close friend who later became my wife, I returned to my roots as a Southern Baptist. Pastor Erlich led Calvary Baptist in downtown Evansville. He was an instructional, heavily scriptural, calmly passionate church leader. I learned from him. I grew in faith for short periods of time and fell away at others. I was newly married, an active working EMT, a volunteer firefighter, in paramedic school and totally ate up with anything dealing with firefighting, rescue and prehospital medicine.

I honestly think at that time that I could have told you that salvation was by grace without having a clue what that meant and thinking that what I was doing daily was important enough to God to simply ignore anything more than attending an average of two services a month (sometimes more, sometimes less). Today, I would say I had works-based faith... not due to fault of the church, but through my failure to listen over many years, failure to study God's word, failure to even care at times. My sinful nature was actually still holding the reigns fully (not implying that it still doesn't try to steer the horse today, because it does).

I stalled my search for where I should be spiritually with a bandaid of the thrills of EMS.

EMS taught me a lot. It showed me daily that people could not care about others, kill their children, spend huge amounts of money on drugs, have senseless accidents, live off others and see it as an entitlement, and almost always choose what best suited them over any definition of "good" or "right."

It also showed me the reality of what a wall collapse, a tornado and other disasters do to lives. What you see in the media is never even 10% of what you see or feel being there. To say that this has marked me is an understatement. I always have to remember that my definition of an emergency most likely has a far higher minimum threshold than where most people would call 911 and deploy the cavalry. I must always remember that the definition of an emergency is in the eye of a beholder and I have to respond with compassion to their definition of an emergency.

But this is not about emergencies... it is about faith... my faith... and why I have chosen this path (I use choice here figuratively and not theologically). To quote the title of a book by a Lutheran author, "This Faith Is Mine."

So after great study and as it turns out, my beliefs mirror things written in the 1500's, during the Reformation. For a guy that is an extreme science-fiction fan (I hide it well), that may not jive with your view of me if you think you know me well. I am a tech progressive, evidence-based medicine kind of dude that dabbles in Six Sigma statistical analysis and improving patient outcomes.

The fairly rough and tumble world of EMS and firefighting led to an internal view of marriage that allowed me to devalue it. Christ was only involved in my marriage on Sunday mornings and then only when I was convicted enough to listen. For this I am truly sorry. I also have to admit that God has a plan for me, "a poor miserable sinner." I am not fixed of this sin. I cannot be fixed of this by anything that I do. I have a sinful nature that will always affect my judgement.

This nature has been there since the Garden and has a spotlight shined upon it by man's inability to keep the Law as given to Moses. Only by focusing on the Cross and the Tomb do I make the change in behavior... but even when I cannot, it is by grace that I am saved, not by any degree of my trying or my success but through the sacrifice of Christ alone... Solus Christus.

If you were expecting more theology, stand by... it will be coming in the next installments. I'll give you more of the "why" next time.

Wednesday, October 24, 2012

A Trip To The State House - Indiana SEA 224

Once again, I am putting a planned, very long blog entry on hold regarding beliefs. It is hard not to continue with my scheduled blog as the church choir is practicing "Thy Strong Word" in the background and it stirs my heart (I am writing this from the church library while my oldest son is in class). I am doing this entry instead because I have made a promise that as Chairman of the Indiana EMS Commission, I will use every possible method at my disposal to keep Indiana EMS informed of what is happening. When we are educated, we make better decisions and our patients and our profession are better served.

So here goes...

On October 23rd I was able to do something for the second time in my life that I honestly thought would never happen again. I had what I consider a great opportunity... a chance to speak before a group of Indiana legislators.

If you have never heard how I feel about Indiana as a State, let me enlighten you. I love Indiana. I love our state flag and I hold it with 99.9% of the regard that I have for our nation's flag. I love how our EMS is structured... in such a way that it allows the provider medical director and the local community to decide how to provide evidence-based medicine and not be tied to only what the lowest common denominator provider can provide (as what happens in some states using state or regional protocols). I love the majority of our laws as they actually make sense. I love how our current administration has made costs a focus and requires fiscal impact studies... it is good stuff.

I am also a firm believer in the concept of state sovereignty in regards to federal government. The will of the State comes first (that topic may be saved for another blog entry).

As many of you know, it was my ultimate career goal to be a member of the Indiana EMS Commission, let alone spend any time as Chairman of this group. Fire Chief John Buckman once told me several years ago after I was first placed on the Commission, "You have a designated amount of time to make a difference. Use it well." Those sage words ring in my ears every day.

As Chairman, I have one of the greatest Vice Chairs anyone could ask for, Deputy Chief Chuck Valentine of Decatur Township Fire Department. He is the very definition of a true paramedic with the patient's best interest at heart. Most of all I consider him a friend. It is very easy for us to come to consensus and find a path that works for the majority and makes sense. He believes in data and evidence-based medicine just as I do.

Indiana House Chamber

With all of this said, I had the opportunity just over two years ago to testify before the Indiana Health-Finance Commission regarding my beliefs on paramedic licensure. I was awed that I got to stand on the floor of the Indiana House Chamber and deliver this testimony. It may not seem like much, but for me it was a very humbling and inspiring experience to speak to these Representatives and Senators and have them ask questions regarding my profession. I enjoyed the opportunity even though I think most people would call it stressful unless they did it every day. It gives you the chance to see how government works.

I never expected to get the opportunity again.

Well... during a whirlwind of working as a simple member of the committee drafting the report required by SEA 224 (the committee itself was not a whirlwind, but most of you know what I juggle every day)... I was made Chairman of the Commission by Governor Daniels and would actually get to be a signatory of the report alongside State Fire Marshal James Greeson.

Indiana Senate Chamber

I then learned last week, that I would get to be the one to deliver the high points of the report verbally to the same Health-Finance Commission. This time it would be from the floor of the Indiana Senate Chamber. Again, I was awed. For a paramedic to get to speak in just one of these venues regarding EMS is a once in a life-time experience, but to get to speak in both... well, I still feel humbled. I also feel better educated as to how to help others understand the intricacies of what we do and the level at which we do it.

So what was this all about?

SEA 224 required that the Indiana EMS Commission to answer eight questions within a specified time frame. Those questions were:

1. Policies and procedures for calling and responding to 911 calls for emergency medical services, including the determination of what type of health care emergency service provider should respond to the call

2. Any requirements or guidelines for equipment that should be on an ambulance or other emergency services vehicle that is necessary to respond to the emergency medical needs of an individual.

3. Ambulance response time for emergency calls.

4. Ambulance transportation procedures.

5. Procedures or policies for health facilities to obtain emergency and non emergency medical transportation for health facility residents.

6. How ambulance coverage is affected by ambulances that are subject to geographic or jurisdictional limits within a county, city, town, or township.

7. Procedures or a policy for determining to which hospital a patient is transported.

8. A review of the state trauma care system.

Understand that these questions may seem a bit tough, but remember that they are not being asked from a perspective inside EMS. Think about them as being asked by any member of the public.

If you would like to read the detail of the report, I will place the link at the end of the blog.

I want to concentrate here on the evidence behind question number three, "Ambulance response time for emergency calls." This gets into issues of when does the clock start? What constitutes arrival on scene? Is the data collected manually or via computer time stamping? You get the point.

Let's talk about the "eight minute rule." If you have been in EMS any length of time, you have probably heard that response times of less than eight minutes are best for the patient. This all stems from a 1979 JAMA article by Dr. Mickey Eisenberg (I will post the link to the abstract below).

EMS accepted this for many years, nearly without question. The problem is that science marched on. First response became more prevalent and gained more capabilities. Fire Departments jumped on being EMS responders. As fires decreased, an increase was recognized by fire departments in the need to be on EMS scenes. AEDs became very prevalent. Life saving care became prevalent before the arrival of a transporting ambulance.

This has called the eight minute response time into question. There are many entities looking at this today. I will put a handful of links at the bottom so you can do your own reading. The point is that it is time for enhanced local system development. We need to assure that:

1) First responders and ambulance providers are working together to collect and review local data.
2) National level evidence-based outcome data is being utilized to direct what is being done.
3) First responders and ambulance crews must train together and review calls together.
4) Implement care that evidence-based.
5) Ensure quality CPR.
6) Train bystanders in hands-only CPR and forget about issuing a CPR card.

These things have been shown to make a real difference in outcomes.

Dispatch prioritization of calls can also assure that shorter response time preference is given to calls of a more critical or time sensitive nature.

If we can get these things to happen, we find that the response time of the ambulance does not matter near as much. We still have to educate and understand public perception, but adherence to a mythical eight minute standard will cost communities millions in resources. The less the resources are used, skills degrade. We know this. I can post links on that too if anyone wants to do the reading. More runs per unit means better caregivers and better skills performance.

I just wanted to give everyone reading an idea of what goes on behind the scenes. Our legislators really do want to know what is going on and that the people they represent are being protected. They worry about what is right. They worry about cost I am sure also.

With these things being said I would be remiss if I did not mention the people who I shared this recent experience with, all of whom are committed individuals working toward the same ultimate goal... advancing EMS toward better patient outcomes: Mike Garvey (IDHS), Rick Archer (IDHS), Mara Snyder (IDHS Legal Counsel), John Zartman (EMS Commissioner), Tony Murray (Indiana Fire Alliance) and Art Logsdon (ISDH Trauma). All of these people have devoted themselves to the service of the State and EMS.

The authors of the report are on page two. The report was built through consensus. That to me is the best part.

Let me close with Rick Archer's drafted conclusion that was also agreed upon via consensus: Indiana's "Emergency Medical Service providers are a passionate, dedicated group of people who work tirelessly for long hours and at personal hardship to be there for their friends, family and fellow Hoosiers in their time of need. Hoosiers want and expect a timely, professional emergency medical response to arrive when they perceive a medical emergency is occurring. Public perception of “timely” response vs. what is really needed is a difficult dichotomy to address. Because of unmeasured and uncontrollable factors, a fast “response time”, despite public perception, can be irrelevant to the outcome of seriously ill or injured patients. What occurs before arrival of an ambulance is more predictive of successful patient outcomes. Better public education on signs and symptoms of true medical emergencies and when to call EMS is needed. Better utilization of the many resources in the community to collaborate with ambulance services to create a true “systems approach” to EMS is needed including better collaboration with law enforcement, public health, schools, business and industry, and neighborhood and civic organizations. AED availability in businesses, industrial complexes, schools, and other venues where large crowds gather should be an integral part of the EMS system. A dynamic “first response” capability, using the closest public safety unit, be it fire, law enforcement or EMS provider, to respond in those cases where quick intervention with a simple medical procedure could mean the difference in a positive patient outcome. Such an approach is more cost-effective and reduces the need to have expensive ambulances racing from long distances while nothing is being done to assist the patient."

Here are the links to the report and supportive info on response times (not all there is of course):

http://www.state.in.us/legislative/igareports/agency/reports/HOMESEC04.pdf SEA 224 Report.

http://www.co.portage.wi.us/EMS/Portage%20Co%20EMS%20Stategy%202012%20and%20beyond.pdf Excellent Powerpoint on one communities view on response times.

http://jama.jamanetwork.com/article.aspx?articleid=364653 JAMA Abstract from original 1979 Mickey Eisenberg article – applies to ambulance response times in cardiac arrest before robust first response and AEDs.

http://www.usfa.fema.gov/pdf/efop/efo37506.pdf

The Washington, DC 2004 study – This was by FEMA. Found little impact of shorter response times with the exception of public perception.

I hope you find this informative. Thank you for reading.

Saturday, October 13, 2012

1/12th of My Life... (or WHY POPCORN ?)

At the moment, I have four draft blog posts in various stages of completion. I can tell you that the one about my beliefs is going to be a long one… hopefully laden with references and at the same time informative without being inflammatory (although I will warn you in advance that my favorite section of the hymnal is labeled “The Church Militant”).

With that said, back to the title… 1/12^th of my life.

It happens the last week of September every year (I remember doing this as a Cub Scout in the early 1970’s). Boy Scout Popcorn. It runs through what is usually the last weekend of October.

It started again for me in 2005 when Michael became a Cub Scout. We sold a bit the first year (I thought having over $100 in sales was pretty good actually). Then we went to over $300 the next year. Then over $1,000 the year after.

During the 2011 sale, between Michael and Luke, our family sold $6,124 of BSA Popcorn. So, why the family focus on this aspect of Scouting? It is called the “Power of Popcorn” by many in Scouting. It’s a bit pricey (but so is any fundraiser you look at… it has to be to earn money to support the organization doing the fund raiser).

1) 70% goes back to Scouting. 30% pays for the product. The remaining 70% is split between the local Council and the unit selling the product. For us that means we have a Scouting support staff and center locally to help us accomplish what we do as a Scouting unit (whether that unit is Cub Scouts, Boy Scouts, Venturing, etc…). It also means that we as a unit get critical funding. In Cub Scout Pack 310 this goes to support the Program itself (a pinewood derby track can cost $1,500 or more) and a portion goes to each individual Scout’s account to pay for approved items such as uniforms, camping fees, gear, etc… (this helps make possible the ability to participate for low income families). In Troop 310, 90% of our split goes into the individual Boy Scouts account. Why so big a portion? Summer camp is around $200. A good pair of hiking boots is well over $100. If a Scout attends Jamboree he is looking at $1,200. A good backpack is $200. Again, this helps all be able to afford being involved to get the fullest experience out of Scouting. The Scout’s account can be used to help fund a portion of their Eagle Scout project as well.

Annette & Michael

2) The Scholarship. Once a Scout has sold over $2,300 in a single year’s sale, they are a part of the Trail’s End Scholarship program. Every year they sell after that, 6% of their sales) regardless of amount) is donated by Trail’s End to a scholarship for that Scout for College expenses. It earns interest too.

3) The sale teaches responsibility. To make sales they have to talk to people in several ways. They have to ask people to buy face-to-face (salesmanship, confidence and communications). They also have to ask parents to see if they will post a flyer at work and family to gather sales (networking, developing processes). They have to handle and count money (financial management and responsibility). They have to figure out how to make themselves presentable for the sale (grooming, uniforming, presentation, signage and sometimes a gimmick… like a garden cart loaded with popcorn wheeling don your street). It is a big learning experience.

4) Incentives… yes, they earn prizes. But the prizes are big in correlation to a BIG workload. To get good prizes… they have to work HARD.

5) With that said… its exercise. It is exercise for both the parents and the youth. You cannot sell a lot of popcorn without walking a good distance (Michael and I are over 10 miles of residential area this year), loading and unloading boxes and being outside.

Luke in 2010

6) From my point of view… it allows me to teach as a parent. How do you politely knock on a door. Should you walk on a lawn? Do you bother people mowing their grass? Do you thank them for supporting Scouting when they say they have purchased already from another? Time spent in this endeavor is not wasted as a parent.

7) It gives people a chance to ask about Scouting. What rank are you? What is that merit badge for? That is a neat Neckerchief. Some buyers even ask the Scout to say Scout Oath and Law (I love it when that happens).

8) The Scout gets to hear the stories on the door step… I went to Philmont in 1964… I did an elevated trail construction for my Eagle project… I did not make my Eagle and here is why… those stories that customers tell on door steps is a wonderful thing for the Scout to hear.

9) Where do you go to church? When that question comes up it gives the Scout the ability to relay their faith and discuss it.

10) The Troop actually gets a performance bonus back also that pays for almost a full year of awards, rank and advancement related patches.

Those are just a few of the reasons we do this massive endeavor. I know that both of my boys have handled large sums of money now. That experience is invaluable.

It wears me out.

It wears my wife out more…

She works with one of our boys while I work with the other on sales. Sometimes we trade off.

She serves as the “Popcorn Chair” for both the Pack and the Troop which is a huge job… ordering, sorting, distributing, setting up store front sales. All of this plus helping her own sons sell. She also helps the District with sorting the popcorn when it comes in from Trail’s end.

Needless to say, this is why 1/12^th of my life each year, centered around the wonderful Fall month of October, rotates around popcorn. For the part of our lives that is Scouting and a personal ministry through our units. When you buy popcorn from us, that’s the story.

At this time, Michael has walked over seven miles and has sold around $2,200 of his $3,150 goal. Luke is around $1,450 of that same amount.

We were the highest selling family in the Council last year. Michael still has the goal of someday being the highest selling scout… We have not figured out how to get there… yet. Last, year that hard working scout that sold the most had over $6,000 in sales.

So, I am finishing this blog from a McDonald’s on the west side of Evansville on a lunch break from driving Michael all over Vanderburgh County.

Now for the shameless plug… If you would like to help, send me an email to gleeturpenii@gmail.com or message me on Facebook. We deliver anywhere in about a four county area.

If you don’t buy from us… please take a moment and think about the 102 years of impact that Scouting has had and still has today and buy from the Scout that comes to your door to help keep this effort vibrant and strong.

If you are at a distance and would consider buying popcorn for shipment to you, here are links for Michael and Luke:

http://www.trails-end.com/estore/home_alt.jsp?_requestid=2780017# Michael

http://www.trails-end.com/estore/home_alt.jsp?_requestid=2780444# Luke

Luke is currently a bit behind due to two bouts of illness since the start of the sale.

Thank you all, as always for what you do in your many daily vocations. Praise always to our God and his Son Jesus Christ.

God is good, all the time. All the time, God is good!

Till I next get the chance to debrief of the 4F trail… be safe!

Wednesday, October 3, 2012

EMS is a Mixed Bag of Tricks

That's what EMS is: A mixed bag of tricks. Being an EMT or a paramedic is an extremely diverse job. I once heard it said (although non-scientific) that a paramedic must be able to process nearly 300 points of data during their first minute of patient contact.

I never thought about that much until I took part in an experiment with a certifying body. In a room full of doctorate level analysts, myself and four other designated SMEs (subject matter experts) were given a verbal patient scenario. We were asked to openly state at each step what we would do in that situation. It was amazing as to how each of us (different backgrounds and cities) answered relatively the same or readily agreed with a peer. We were of course told that we were picked because of our backgrounds of long term management of EMS and having worked as field paramedics. What struck me in this was that it took hours for us to walk through this process of a single patient contact so that the researchers could analyze how we used critical thinking to arrive at our conclusions... and just as I had been told many years ago, just how many data points and decisions occur in a matter of seconds.

That being said... We are products of how our axons, dendrites and synaptic clefts have developed. What we accept to be truth in training and experience subconsciously directs our critical thinking. This is the engine behind what we do. In a way, however, it is also our greatest flaw.

In taking my Six Sigma training, there was one quote that always stuck in my mind: "What you know is wrong." So many times this has been proven to be true when I look at data. That is a known fact... WRONG. I predict that... WRONG. This is the cause of... WRONG. And so it goes.

And our care and critical thinking is directed BY WHAT WE KNOW. That is why we have to look at data, studies and most of all "true outcomes" (in other words, it doesn't matter if you get a pulse back if the patient does not survive until discharge... Your definition of a save may not be exactly what the patient is looking for here).

My last post was a bunch of links to data, quasi-science and peer reviewed articles. Now, on the scale of validity, peer reviewed is always the best, but even those can suffer from flaws such as inadequate subjects in the test field. Manufacturer studies are always suspect as they may be tainted subconsciously to a desired outcome.

So how do we define "evidence-based." Sometimes that is just looking at real data. At other levels it must be peer-reviewed. It depends on how important it is to mortality and outcomes. In a nut shell, to be called evidence based, it has to address these points:

1) Is the data as clean as it can get?
2) Has bias been removed or at least accounted for?
3) Are the results convincing?
4) Can the data and results be replicated elsewhere?
5) What is the impact?
6) Is the resultant course of action more efficacious and safe than what we have today?

Now, let's look at some examples:

1) Did you know that the relationship between Epinephrine and cardiac outcome had never been studied until recent years? But we blindly want everyone to have Epi because it "saves lives."

MAST or PASG

2) For years we added (what we are told) are precious minutes to trauma scenes by applying MAST (or Pneumatic Anti Shock Garment) to patients that were bleeding to death? Why? It worked to "save lives" in Vietnam so it had to work here. When someone finally decided to measure it, the results were not replicable. The time frames to surgery at MASH units was much shorter and transport was mostly by helicopter in Vietnam. Here, we saw it raised blood pressure and we gave it a big thumbs up. We at the same time prided ourselves on getting two 14 gauge IV lines and pouring liter after liter of fluid into trauma victims. There are plenty of buried bodies to prove that both concepts were wrong... which brings us to number three.

Vietnam Era Bell UH-1b Iroquois

3) "We need intravenous therapy at levels lower than paramedic." Why? "It saves lives." At the services I have worked for during the last decade or so, we have all practiced fluid restrictive resuscitation in trauma. We have known that fluid in trauma has been de-emphasized. Read the opening statement at this link:

http://www.trauma.org/archive/archives/permhypo.html

What does that tell you. It is the current scientific model. Large volumes of fluid simply hinder the bodies ability to compensate for shock. On top of this, with the advent of many nasal administered meds, the RAMPART study showing that IM Versed is faster than IV Versed in seizures, sublingual Zofran... well, you can see that we just don't have an increasing need for IV access in the field.

4) Some of the caregivers finishing the new AEMT program in Indiana desire adult EZ IO. I agree. It makes sense for those rare times when a drug route is needed and cannot be gained with an IV. But has anyone thought what happens if you do an EZ IO on a conscious patient without Lidocaine prior to the fluid push? You might find your patient in pretty intense pain. PRIMUM NON NOCERE! That said, I would say they need Lidocaine for the IO... but not Lidocaine for anything else. Why?

5) Look at the numerous studies on Lidocaine vs. Amiodarone. Fairly inconclusive as to which is better. Some minor arguments exist that the Vasopressin/Amiodarone combination has some additional numbers attached to it.... but, in all of this has anyone looked at the proarrhythmia issue? What is proarrhythmia? It is what happens sometimes about 24-72 hours after you give Lidocaine. Some patients return to their ventricular arrhythmia and cannot be converted easily. This happens less with Amiodarone... far less. So I would argue that this fact alone makes Amiodarone the better antiarrhythmic medication.

6) For years we pushed D50. Then along came a shortage and many of us had to switch to bags of D10. What did we learn? No combative wake ups. Less chance of necrosis. Less incidence of phlebitis. Less incidence of headache upon waking. BUT WE HAD TO BE FORCED BY A PROBLEM TO LOOK AT A DIFFERENT MECHANISM AND CHANGE.

Those are just a few examples... there is getting ready to be a ton of data collection starting on cervical immobilization. Why? Read up on internal decapitation by cervical collar application. Not pretty. Neurologists are already calling for change.

I understand that there are a large number of people who want to keep doing what they are doing now. The problem is that there have been issues nationwide with these skills producing outcomes or increasing numbers of complications due to low initial training hours or infrequent skills use.

I am not opposed to seeing any caregiver get any skill AS LONG AS THEY CAN THROW THE EVIDENCE BASED DATA ON THE TABLE. I want to make one very clear statement:

NONE OF US GET TO DO WHAT WE WANT TO DO IN THE BACK OF AN AMBULANCE JUST BECAUSE WE WANT TO DO IT.

Be very careful when you say your only reason is: "It saves lives."

In many ways, Indiana is ahead of the game. I talk to many EMS operations in a lot of places. Many wish they had what we have on the Paramedic level... local control of the medicine. I personally see many states with drastically stale and outdated protocols because they are on a state or regional protocol that is a lowest common denominator so that all can comply. We do not want that to occur. At the same time, the EMS Commission's charge is to build functional EMS systems. We cannot do this if we ignore evidence-based medicine. We have to start making all providers meet a test of need for a waiver to the rules. And most of all, we need evidence.

This entry could go on for ever, but it does not need to do so.

This train is leaving the station and hopefully it will never return.

What did the Conductor say in The Polar Express?

"The thing about trains... it doesn't matter where they're goin'.... what matters is whether or not you decide to get on."

In this case, we know where the train is going... focusing on outcomes produces better outcomes.

We function by what we believe. Don't you want to make sure you are believing the right thing?

Are you going to get on?

We Interupt Our Regularly Scheduled Program...

I lied. I will discuss my Faith in a blog in the near future.

This is an information laden post as it has been brought to my attention that there may be some who need to have examples of evidence-based medicine. So... here are some links to quasi-scientific and some peer reviewed evidence-based information. Some is data, some is true evidence.

In my next blog, I will give some actual story style examples, but this should keep you busy if you are a clinical animal such as I...

http://gatheringofeagles.us/

http://gatheringofeagles.us/EaglesPresentations.html

http://gatheringofeagles.us/2012/2012Presentations.htm Latest presentations...

http://gatheringofeagles.us/2012/Presentations/Slovis%20IV%20Epinephrine.pdf Epi

http://gatheringofeagles.us/2012/Presentations/McMullan_Eagles_RAMPART.pdf Versed IM

http://gatheringofeagles.us/2012/Presentations/Goodloe%20BLS%2012%20Lead%20ECGs.pdf BLS 12-Lead

http://gatheringofeagles.us/2012/Presentations/Colwell%20Use%20of%20Blood%20Products%20and%20Substitutes.pdf Blood products and substitutes

http://www.ncbi.nlm.nih.gov/pubmed/ Pub Med is storage of all peer reviewed studies

http://en.wikipedia.org/wiki/Permissive_hypotension Wiki on permissive hypotention

http://www.trauma.org/archive/archives/permhypo.html Read the opening statement

http://www.emsworld.com/article/10319458/collar-me-bad The tip of the iceberg on c-collars

https://roc.uwctc.org/tiki/tiki-index.php?page=roc-public-home Resuscitation Outcomes Consortium home page