As in Incident command...

IC established!
We'll have several different sections reporting in - recent research, local topics, or highlighting areas of the Sponsor Hospital Council of Greater Bridgeport protocols.

*** Keep in mind - this website does not replace your protocols, and these posts do not reflect SHCGB or Bridgeport Hospital policies. This is a place to discuss research, controversies, or discuss possible future protocols. When in doubt, check your current protocols through the official source.

Tuesday, December 17, 2013

¿Se puede... (parte 2): Èske ou ka pale ak pasyan ou a?

In case you can't read the title, it asks "Can you speak with your patients?" In Haitian Creole.

Prehospital medical providers pride ourselves on creative ways to deal with obstacles in the field. But when it comes to communicating with patients who can't speak English well, too many EMS providers only have one back-up solution:

"Dolor? Dolor?"
(image credit)
And even that sure-fire method falls apart if the patient speaks Mandarin. Three recent articles highlight different aspects of the problem.

1. Dispatching EMS takes longer for non-English speakers
The authors of The effect of language barriers on dispatching EMS response looked at 272 calls to 911 that were felt to involve some sort of language barrier (not just Spanish). They showed that, either with or without the use of interpreters, 911 calls take longer to dispatch and are less accurate about the chief complaint and need for ALS. 

ALS call took almost 3 minutes longer to dispatch.
In particular, chest pain calls often took much longer to dispatch than many other chief complaints. Since there is so much emphasis being placed on prehospital identification of STEMI, this represents a potentially significant source of delay to treatment.

The authors also found that calls involving a language barrier were far more likely to be downgraded to BLS after ALS was initially dispatched. Unfortunately, they are unable to comment on whether this downgrading was later proven to be appropriate.

2. EMS care is slowed down by language issues
This study isn't quite as recent as the other two, but it points to the next step in prehospital care - how quickly EMS can get to the scene, evaluate and package the patient, and then transport to the hospital. 

A 2008 study reported on how often EMS providers reported various causes of delay. Bad weather was the most common reason, but the second-most common cited problem was language. Note that Hazmat and safety are both far less frequently cited than language as a source of delay.

Of course, this only applied to a small number of EMS calls - only about 3.3/1000 calls cited language as a problem. 

However, this study was done in Minnesota, a state where only about 8% of the population speaks a language other than English at home, while in Connecticut, this figure is > 18%! Even more locally, > 38% of the Bridgeport population is of Hispanic origin, suggesting this issue might even be more prominent here.

3. Language barriers affect EMS clinical decision-making
In-hospital data has shown that patients with limited English-proficiency are far more likely to get blood tests, imaging, and more invasive procedures. A recent case study shows that this can happen in EMS too, leading to absurd and wasteful decisions.

The authors of Triage in the Tower of Babel: Interpreter Services for Children in the Prehospital Setting report on the case of a infant whose parents spoke only Amharic

                                                    ፖሊስጥራ ጥሪ።    (Call 911!)

Evidently, this child, while attempting to walk, fell onto his butt. Frustrated at this outcome, he started crying, but immediately had (in retrospect) a breath-holding spell. A very unfunny game of telephone followed when a non-English/non-Amharic neighbor called 911: EMS was subsequently dispatched for "baby not breathing." 

Apparently at least 3 ambulances were dispatched (Tom Bouthillet would approve!), and found a fully recovered, well appearing child. Since they were unable to obtain a clear history, due to the language, they decided to err on the side of caution by treating him as a pediatric trauma. 

So what happened when they strapped this kid to the backboard? He cried and promptly had another breath-holding spell! Must have looked something like...

... which must have scared the scat out of everyone.  (Breath-holding spells are actually benign, common, and easy to recognize.)

Long story short, the infant received complete packaging, was declared a pediatric trauma code, and directly transported to a trauma center. He received an IV,  a femoral blood draw, and 2 CTs of the head. Eventually, an RN of Ethiopian heritage was able to clarify the history, and the child was discharged with no (non-iatrogenic) injuries.

The authors go on to discuss the problem of language barriers in EMS, and draw a few conclusions. Apart from any legal or regulatory requirement, they consider it to be an ethical obligation to provide translation, even for EMS patients. This misdiagnosis and mistriage caused the patient and parents distress, as well as radiation and pain, and perhaps much of this could have been avoided had communication been clearer. Of course, there are legal obligations to provide translation in the hospital, and the authors highlight how the same laws also apply to EMS. Apart from laws and ethics, they also lay out the economic rationale to provide translation, since the over-triage and over-treatment of these patients ends up costing quite a lot of money!

The bottom line
If you can't talk to your patients, your care will be incomplete, delayed, and possibly dangerous. If a foreign language is very common in your community, you should consider ways to tackle that challenge ahead of time.

Monday, December 9, 2013

¿Se puede aprender CPR en el internet?

(UPDATE 3/24/14: Dr Sasson's work has helped drive the production of a quality, up-to-date CPR video for hispanohablantes. Skip to the bottom for the video!)

Say you want to learn CPR, but you only speak Spanish. What would you do? 

It looks like some organizations in the area offer CPR classes in Spanish (good outreach Stamford!), but not everyone can make it to these, and they may not be offered often. 

On the other hand, you can learn about anything on the internet these days, so why should CPR be any different? After all, going to a class is so 1980's. These days, you should be able to Google a few good websites for CPR, or even better, some videos on YouTube!

Or just watch some 80's videos on YouTube. Whichever.
We have a lot of people in this country who speak mostly or only Spanish. Heck, we're the second-largest Spanish-speaking country in the world! We should be able to choose from a plethora of on-line resources to learn CPR. 

Unfortunately, it turns out that the information available to Spanish speakers is usually out-dated, incomplete, or confusing. 

The study design
The authors of Availability and quality of cardiopulmonary resuscitation information for Spanish-speaking population on the Internet looked through Google, Yahoo, and YouTube for instruction on " resucitacion cardiopulmonar," and similar terms. They analyzed the websites and videos, and assigned quality ratings for 6 key elements.

After sifting through > 300,000 websites, they came up with 116 results that fit with the study's focus.

The results
They found that most websites, 86%, didn't teach hands-only CPR. That's cool - it's only been in the AHA guidelines for laypersons for 5 years...  Only half of the websites described activating 911. Other aspects, like scene safety or depth of compressions, were also missing in many, if not most, internet resources. 

The importance
Stop the presses - some health-related websites are wrong?!

Lots of internet information is iffy - Why is this a big deal?

* Chain of survival
Well, while researcher are busy wondering if we can eek out a higher survival rate by using hypothermia, or steroids, or vasopressin, or "leg-compression" CPR, none of this matters if bystanders don't do CPR in the first place. While it's fun to hash out the evidence regarding the ResQPOD, the first link in the chain for survival will always be bystander CPR.

* Bystander CPR
This is why it so concerning that at least one study has found that Hispanics are far less likely to get bystander CPR, and the reasons why aren't clear. If 10% fewer Hispanic patients are getting CPR, a bolus of prednisone isn't going to save their brains! Part of the reason the AHA switched to "hands-only" CPR was to encourage bystander CPR, and this study suggests that website quality may affect this effort. (Strangely enough, 3 out of the 5 bilingual websites taught hands-only CPR.)

  * Barriers to accessing 911
The Latino community does not need any further obstacles in dealing with medical emergencies. It's  been shown that many people in the Spanish-speaking community have doubts and fears when considering calling 911. (And no, it doesn't just have to do with a fear of "la migra," or the cost of the ambulance. Given that many people had experience with EMS in countries with far different systems than ours, they are confused about when it would be appropriate to call 911 versus drive to the hospital.)

The bottom line
In the last month we've seen good evidence that the LUCAS device doesn't save lives, and that prehospital therapeutic hypothermia probably doesn't help either. Early and effective CPR still remains our most important tool. 

Keep in mind that successful prehospital resuscitation programs don't just involve "pit-crews" or regional cardiac-arrest centers. The best programs also put a lot of work into the true first responders, the bystanders. Bobrow et al. showed that intensive public outreach in Arizona was associated with a doubling in cardiac arrest survival.

If your EMS catchment area includes many Spanish speakers, you have to figure out how to communicate with them, and enlist them in your efforts to improve cardiac arrest management. Sure, it's easy to do CPR classes in English, down at the high-school or community college like we've always done. But how are we going to reach the non-English speakers, and those that can't make it to a class? 

These days, this outreach is probably going to involve the internet - make sure it's a quality effort!

The AHA has a new, up-to-date, and complete video on performing CPR in Spanish. Check it out!