EMERGENCY MEDICAL SERVICES WEEK, 2017
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BY THE PRESIDENT OF THE UNITED STATES OF AMERICA
During Emergency Medical Services (EMS) Week, we express our gratitude for the hundreds of thousands of skilled personnel who help save lives in communities across the United States each year. Through the hard work and dedication of these career and volunteer first responders, Americans receive the finest emergency medical treatment in their most vulnerable moments. We also honor those EMS providers who have made the ultimate sacrifice and given their lives in the line of duty.
Day or night, in every city, suburb, rural community, or wilderness area, our Nation relies upon EMS providers to respond to every kind of emergency situation to save lives and reduce suffering. In January, when more than 70 tornadoes touched down in Georgia and Mississippi, injuring many, EMS responders were there to help. In March, when wildfires threatened Kansas, Colorado, Oklahoma, and Texas, taking lives and forcing thousands from their homes, our EMS personnel were there providing urgent medical care and patient transportation. Last month, when flooding and tornadoes ravaged Missouri, Arkansas, and Texas, EMS personnel once more came to their neighbors’ aid. Whether they are assisting during natural disasters or providing lifesaving care after car accidents, heart attacks, sports injuries, or violent crime, EMS personnel respond to tens of millions of requests for help each year in our country. We rest easier knowing that they stand ready to answer the call.
Over the past 50 years, our Nation’s EMS system has evolved with ever-developing medical, transportation, and communications technologies to meet the changing needs of our communities. The EMS Agenda 2050 project — a joint effort by the National Highway Traffic Safety Administration, the Department of Health and Human Services, the Department of Homeland Security, and the EMS community — will help develop a vision for meeting our communities’ future emergency medical services needs and improve the health of all Americans. We commend these efforts to develop innovative new treatments, advance and adapt medical skills, establish stronger professional standards, and promote public education and health. This week, we thank our EMS professionals for their sustained commitment to excellence and dedication to service, and share our hopes for a bright future that will make us all safer and healthier.
NOW, THEREFORE, I, DONALD J. TRUMP, President of the United States of America, by virtue of the authority vested in me by the Constitution and the laws of the United States, do hereby proclaim May 21 through May 27, 2017, as Emergency Medical Services Week. I encourage all Americans to observe this occasion by showing their support for local EMS professionals through appropriate programs, ceremonies, and activities.
IN WITNESS WHEREOF, I have hereunto set my hand this nineteenth day of May, in the year of our Lord two thousand seventeen, and of the Independence of the United States of America the two hundred and forty-first.
DONALD J. TRUMP
CALS extends its gratitude to all Nurses!!
By Dina Fine Maron on February 15, 2017
By the time the pregnant woman arrived at the nearest hospital with a maternity ward—90 minutes after leaving her home in Winfield, Ala.—she was ready to deliver her baby. She made it just in time, recalls Dan Avery, an obstetrician–gynecologist who tended to patients in rural Alabama and elsewhere until his recent retirement. Too often, he says, patients are not so lucky. Some have ended up delivering on the side of the road. Winfield, located in the northwestern part of the state, does have its own hospital—but, like many rural hospitals, it no longer offers obstetrical services, Avery says, so women in labor must travel about 60 miles to Tuscaloosa. When hospital budgets get tight, Avery explains, obstetrical wards are often one of the first things to go.
The problem has metastasized across the state and the nation. In 1980, 45 of Alabama’s 54 rural counties had hospitals providing obstetrical services. Today only 16 of them offer such care, and doctors say that means many, many women need to drive an hour or more to deliver their babies or even get basic prenatal care from an ob–gyn. Too many women cannot make such a long monthly trek, so they simply do without. Others seek care from their family physicians.
Such extreme access problems lead to difficult decisions. Some women in Alabama preemptively choose caesarean section births because they fear they will not make it to the hospital in time, says Dale Quinney, executive director of the Alabama Rural Health Association. Although there have been no studies proving it, Quinney believes the access issue helps explain why his state has one of the country’s highest caesarean rates—35.4 percent of its births in 2015. (The national average was 32 percent that year).
The disappearing maternal care problem is common across rural America. Only about 6 percent of the nation’s ob–gyns work in rural areas, according to the latest survey numbers from the American Congress of Obstetricians and Gynecologists (ACOG). Yet 15 percent of the country’s population, or 46 million people, live in rural America. As a result, fewer than half of rural women live within a 30-minute drive of the nearest hospital offering obstetric services. Only about 88 percent of women in rural towns live within a 60-minute drive, and in the most isolated areas that number is 79 percent.
Maternal mortality is also significantly higher in rural areas. Scientific American analyzed public mortality data from the U.S. Centers for Disease Control and Prevention, and found that in 2015 the maternal mortality rate in large central metropolitan areas was 18.2 per 100,000 live births—but in the most rural areas it was 29.4. Exactly why this happens is unclear. Underlying health conditions such as hypertension or diabetes could be factors, alongside poor prenatal care and geographic access. But the numbers are troubling, and the same trend holds true for infant mortality rates, according to the analysis of CDC figures.
Credit: Amanda Montañez; Source: CDC
New analysis from the University of Minnesota Rural Health Research Center puts the situation in dire terms: “More than two thirds of rural counties in Florida, Nevada and South Dakota have no in-county obstetrical services,” says one of the study’s authors, Carrie Henning-Smith, a research associate at the center. The analysis, which has not yet been published, finds that this was true from 2004 through 2014 (the latest year analyzed). That means these counties had absolutely no hospitals providing obstetrical care—forcing women to travel to other counties.
Unfortunately, family physicians are not moving in to fill these care gaps in high enough numbers. And the number of family physicians offering obstetrical services has dropped by half in recent years, although many still offer basic prenatal care: In the year 2000, 23 percent of family physicians offered obstetrics—but when they were surveyed in 2010 it was only about 10 percent.
Some women manage to cobble together a workaround. Maren Webb, who lives just outside Grand Marais, Minn. (population about 1,350) lives two hours from the nearest hospital that does planned deliveries (in Duluth, Minn.). In the five years that she lived and worked in the area before giving birth to her daughter in October, she had heard countless horror stories about women in labor in the back of ambulances on the way to Duluth or those who had to deliver in the emergency room at a local hospital. To avoid those fates she says she decided to “camp out” at her parent’s house—about half an hour from the hospital in Duluth—in the days ahead of her due date. Webb and her husband ended up staying with her parents for a week before she finally went into labor. “We were thankful that we had the option,” she says, but they wished they could have been at home, preparing for their newborn. Still, they were grateful she had not gone into labor early while they were still at home. Her family has a history of fast deliveries—two or three hours—she says, so she might not have made it to the hospital in time.
Searching for More Answers
To understand how the U.S. got here is not a simple task. Rural health care in general has taken a hit in the past few decades as hospitals have closed and fewer doctors have sought to practice in rural areas. Eighty rural hospitals have been shuttered nationwide since 2010, and about a third of the country’s remaining rural facilities are vulnerable to closure as they continue to operate under tight margins, according to findings from the latest annual Rural Relevance Study. Half of Mississippi’s rural providers operate at a loss, for example, according to the report, which was presented last week at the annual National Rural Health Association (NRHA) conference in Washington, D.C. Rural communities, however, are in desperate need of care: They tend to be poorer, older and less healthy than their urban counterparts.
But obstetrics–gynecology care is particularly vulnerable because delivering a baby is such a pricey business, accounting for more than 5 percent of hospital costs . Why is it so expensive? Unlike a hip replacement, it is hard to anticipate exactly how long it will take to deliver a baby, so the number of nurses, doctors, surgeons and anesthesiologists that must be available throughout delivery adds up. Rural Americans are also less likely to be insured, and more likely to pay for their care using Medicaid—which reimburses doctors at lower rates than private insurance, making it difficult for doctors and hospitals to recover costs and make profits. Low birth volumes make the economics of obstetrical units harder still: Rural communities are generally graying, a demographic fact that reduces the number of births and makes it difficult for hospitals to financially justify having maternity wards at all. And when those wards cannot make adequate money, it leads to their shutdown.
The problem also has a multiplier effect. “It’s a quality of life issue. You don’t want to be the only ob–gyn in a 150-mile radius. You’d never sleep!” Michael Kennedy, associate dean for rural health education at the University of Kansas Medical Center said at the NRHA conference.
The blueprint for addressing the situation remains obtuse at best. Some medical schools think part of the solution is to train more doctors for rural work. The University of Wisconsin School of Medicine and Public Health is launching the nation’s first official obstetrics–gynecology residency program for “very rural” areas, with the first resident slated to be selected next month. “Increasing the physician workforce is important,” says Ellen Hartenbach, residency program director for the school’s Department of Obstetrics and Gynecology. “A large percentage of people practice in the same area after residency, so the theory behind our new training track is to get people training in the smaller communities and increase their exposure,” she says. (ACOG says about half of all residents practice in the state where they trained.)
There are already other ob–gyn residency programs in rural areas, Hartenbach says, and there are rural tracks in family medicine for doctors in other specialties. But official definitions of rural often just mean “not urban,” she says, and the Wisconsin residency program will make sure that communities considered “very rural”—those serving fewer than 20,000 people—will be the focus. “You would be hard-pressed to find that elsewhere,” she says.
Yet this is only one program, with only one resident expected for 2017. Rural health care advocates are also pushing for policy action to help fuel further changes and to incentivize work in rural America. The Improving Access to Maternity Care Act, which has already passed the House but has not yet been introduced in the Senate, would require further data collection by the Department of Health and Human Services about which geographical areas need these maternity care professionals and provide student loan forgiveness for ob-gyn work there—a benefit that is currently offered for dentists and primary care physicians in some underserved communities.
Telemedicine—offering online video call access to patients—for prenatal care could also be part of the solution, rural health experts say. But a lack of broadband internet access continues to keep that from becoming a reality in many rural areas in Alabama, says Hillary Beard, a legislative assistant for Rep. Terri Sewell (D–Ala.). “I don’t think this is unique to Alabama,” she says. “This is a problem for many rural areas.” And too often, she says, people in Sewell’s district report that they had to deliver on the side of the road because they could not make it to the hospital in time, she says.
Changing state laws to let certified nurse–midwives and nurse practitioners perform more clinical tasks might help, too, Henning-Smith says. But other cultural changes may be needed to really lure more clinicians to move to rural areas, she adds. One analysis she conducted found that rural areas—at least in the state she studied, Wisconsin—were less likely to offer child care services than their urban counterparts. That matters, of course, for working parents and their quality of life.
Yet, despite these widespread ob–gyn shortages, there is still little hard data on the long-term effects of these health access gaps. “We know a lot about the closures and about the workforce challenges, but we don’t really know how these things impact women and the health of their infants,” says Britta Anderson, a senior research scientist at NORC’s Walsh Center for Rural Health Analysis at the University of Chicago. “We need more data on if women who travel longer distances to get care suffer more negative outcomes—emotionally and physically.”
Webb, the new mother from Minnesota, says knowing about this potential harm—and reducing the burden of these distances—is essential. “No one has done this research about if these distances are increasing bad outcomes,” she says. The emotional burden, however, is apparent. “If the roads aren’t clear and there’s a blizzard, it could take a lot longer than two hours from my house—and that, too, adds to the stress,” she says. “You don’t want to have this extra stress when you are in labor! You want things to flow.”
Carfentanil is a synthetic opioid approximately 10,000 times more potent than morphine and 100 times more potent than fentanyl. The presence of carfentanil in illicit U.S. drug markets is cause for concern, as the relative strength of this drug could lead to an increase in overdoses and overdose-related deaths, even among opioid-tolerant users. The presence of carfentanil poses a significant threat to first responders and law enforcement personnel who may come in contact with this substance. In any situation where any fentanyl-related substance, such as carfentanil, might be present, law enforcement should carefully follow safety protocols to avoid accidental exposure.
Officer & Public Safety Information
Carfentanil and other fentanyl analogues present a serious risk to public safety, first responder, medical, treatment, and laboratory personnel. These substances can come in several forms, including powder, blotter paper, tablets, patch, and spray. Some forms can be absorbed through the skin or accidentally inhaled. If encountered, responding personnel should do the following based on the specific situation:
- Exercise extreme caution. Only properly trained and outfitted law enforcement professionals should handle any substance suspected to contain fentanyl or a fentanyl-related compound. If encountered, contact the appropriate officials within your agency.
- Be aware of any sign of exposure. Symptoms include: respiratory depression or arrest, drowsiness, disorientation, sedation, pinpoint pupils, and clammy skin. The onset of these symptoms usually occurs within minutes of exposure.
- Seek IMMEDIATE medical attention. Carfentanil and other fentanyl-related substances can work very quickly, so in cases of suspected exposure, it is important to call EMS immediately. If inhaled, move the victim to fresh air. If ingested and the victim is conscious, wash out the victim’s eyes and mouth with cool water.
- Be ready to administer naloxone in the event of exposure. Naloxone is an antidote for opioid overdose. Immediately administering naloxone can reverse an overdose of carfentanil, fentanyl, or other opioids, although multiple doses of naloxone may be required. Continue to administer a dose of naloxone every 2-3 minutes until the individual is breathing on his/her own for at least 15 minutes or until EMS arrives.
- Remember that carfentanil can resemble powdered cocaine or heroin. If you suspect the presence of carfentanil or any synthetic opioid, do not take samples or otherwise disturb the substance, as this could lead to accidental exposure. Rather, secure the substance and follow approved transportation procedures.
Carfentanil is used as a tranquilizing agent for elephants and other large mammals. The lethal dose range for carfentanil in humans is unknown; however, carfentanil is approximately 100 times more potent than fentanyl, which can be lethal at the 2-milligram range (photograph), depending on route of administration and other factors.
For additional safety information, please use the resources below:
- CDC Health Advisory (#CDCHAN-00384); http://emergency.cdc.gov/han/han00384.asp
- CDC Health Update (#CDCHAN-00395); http://emergency.cdc.gov/han/han00395.asp
- DEA Fentanyl Warning Video; https://www.dea.gov/video_clips/Fentanyl%20Roll%20Call%20Video.mp4
Grand Marais nurse earns $100,000 fellowship
By John Lundy on Mar 21, 2017 at 9:00 p.m.
As an advocate for rural health care, Kristin Wharton could hardly live a more rural existence herself.
“We’re off the grid,” said Wharton, 38, who lives with her husband and three children on a vegetable farm 17 miles northeast of Grand Marais. “We don’t have broadband. We don’t even have plumbing.”
Wharton, a registered nurse at the Sawtooth Mountain Clinic in Grand Marais, is impassioned about health care for rural areas, something she partly traces to two years ago when the board of Cook County North Shore Hospital voted to discontinue obstetrics.
“I think for me personally it was the first time I realized how vulnerable rural communities are without strong health care systems,” Wharton said Monday.
Wharton will have a chance to develop that passion over the next two years as a recipient of one of 24 Bush Foundation Fellowships bestowed among people across Minnesota, the Dakotas and the 23 Native American nations sharing their geography. The fellowship, publicly announced on Tuesday, will provide Wharton with $100,000 over two years.
The honor places Wharton in an elite group of individuals who came through a rigorous, months-long process that started with 639 applicants, said Anita Patel, who heads the Bush Foundation’s fellowship and leadership programs. Past recipients have included former Minnesota Gov. Arne Carlson; Karen Diver, former chairwoman of the Fond du Lac Band of Lake Superior Chippewa; and Pulitzer Prize-winning playwright August Wilson.
It was another previous recipient whose selection inspired her, Wharton said. That was former Grand Marais Mayor Sue Hakes, part of the 2014 fellowship class.
“Seeing someone who I knew receive the fellowship, it made it seem possible,” Wharton said. “I realized it wasn’t just a fellowship for people in the metro area or people that sit on governors’ policy panels.”
Patel said the foundation isn’t necessarily looking for people who have earned a lot of awards, but for people who have established that when they have a vision, they can inspire others around that vision.
“You are an influencer; you’re making change in your community,” Patel summarized.
Wharton said that when the hospital’s board was mulling whether to close obstetrics, she didn’t want to take a position on the issue, but she did want people to be aware of it. So she started a Facebook page calling attention to the matter.
The decision to end obstetrics made Duluth the closest place for planned deliveries in a hospital setting.
“That was really impactful for me,” Wharton said. “And I think that that definitely played a role in me wanting to have to take more of a leadership role in protecting and strengthening rural health care in our community, but also — we’re not alone. Communities all over the country are facing these kinds of issues.”
Wharton plans to use her fellowship to qualify as a family nurse practitioner through a distance learning program from Frontier Nursing University in Kentucky, she said. The program will allow her to remain on the North Shore while working toward her degree.
“As far as legitimacy to be able to advocate for rural health as well as to provide primary care to people, there’s just really no path to that outside of this kind of educational program,” Wharton said.
Wharton was among those who emerged from the largest field in more than 60 years of the fellowship program, Patel said.
What stood out about Wharton?
“She’s thinking not just about her own growth, she’s thinking about, ‘how do I create or contribute to a better environment for the people I care about, a better health care system,’ ” Patel said.
Wharton learned on March 2 that she was one of the fellows, but now that word is out, the reality is sinking in, she said.
“I … looked on my own name in disbelief on this list of fellows,” she said. “It still feels surreal.”
HOW TO APPLY
If you’re interested in seeking a Bush Fellowship, the first step is to check out the website bushfoundation.org/fellowship, said Anita Patel, director of the foundation’s fellowship and leadership programs. Contact information is listed there, if you have questions.
The deadline for applications for the 2018 fellowships is Aug. 15.
“We look for all types of leaders, different backgrounds, so if anyone even has an inkling of ‘could that be me?,’ I would love for them to reach out,” Patel said.