Thursday, February 24, 2011

EMS Myth #7: System Status Management lowers response times and enhances patient care

Here's an excellent article about the science (actually, the lack thereof) behind System Status Management:

Feel free to read it while en route to your next posting location (and racking up a whopping 46% increase in ambulance maintenance costs).

Don't kill the messenger.

Tuesday, February 15, 2011

From Both Ends: Food Poisoning In All Its Glory

Lately I’ve seen a few references to “food poisoning.” Most recently is an outbreak in Japan where 840 students were out sick. No doubt that you, dear EMS practitioner, have encountered this same malady, either in your patients or yourself. Perhaps your patient asked you if you thought their symptoms could be food poisoning from that restaurant they patronized. You probably recognized the telltale sign of dollar symbols in their eyes ($_$) as the thought of a lawsuit against the establishment occurred to them. Perhaps your experience came after consuming whatever passed for food at the local convenience store at 3a.m., which had been sitting under the heat lamps since the previous morning (which you consumed on the way to the dollar sign patient). By its very name, it sounds like “someone” poisoned your food. I’ve seen people begin plotting their revenge on this unknown individual, perhaps some busboy or salad chef. Even more hilarious have been the times when the “victim” thought he or she knew exactly who had “poisoned” him, and started to hatch their plan for dark vengeance. 

Food poisoning is not the horrendous plague or crime that is commonly imagined. It occurs when food has been improperly prepared. It’s not caused by someone pouring a foul elixir from a vial marked with a skull & crossbones (that would be actual poisoning; or perhaps voodoo). Food poisoning is caused by bacteria, plain and simple. If you’ve ever had diarrhea, and I know you have, you’ve had some form of food poisoning. 

Very commonly, it’s caused by bacteria that we normally lug around with us every day. The problem comes when it gets somewhere it isn’t supposed to be. For example, escheria coli and staphylococcus aureus (e. coli & staph) are two species living in abundance on your body right now. E. coli lives in colonies weighing kilograms within your lower GI tract. When you poop, about a third of its mass is pure e. coli. Staph lives on every inch of your skin. The problem comes when these little critters set up shop in our upper GI tract, between the mouth and duodenum. It’s not supposed to be there and the anatomical structures in your stomach don’t have the mechanisms to accommodate them, so you get sick. 

Generally food poisoning is facilitated from the way food is prepared. In the case of meat, remember that meat comes from animals that have to be killed and chopped up. It is not grown in those little plastic packages in the supermarket (sorry to shatter your illusion). Animals also have an abundance of bacteria in their GI tract. Food inspectors have to check that the bacteria and germs in the guts don’t contaminate the meat in the slaughtering process. But as you can imagine, when there are a thousand tiny, wooly, innocent lambs cowering in fear or  little calves mooing out of sheer terror as they witnessed their brothers and sisters being disemboweled and dismembered, things can probably get a little hectic as your lamb chops and veal begin their way to your table. With lots of creatures you grew to love in Mother Goose fairy tales dying and being drawn & quartered, it’s reasonable to picture that some of  the bacteria in Little Bo Peep's sheeps' guts might get into the actual chops that make it to the plastic packages in the store. 

Now, with that image firmly in your head, keep in mind that bacteria are living things. They consume, metabolize and excrete, just like us. While that meat is waiting for you to purchase it and not think about where it came from, all the e. coli, salmonella, clostridium, staph, listeria and enterococcus is happily consuming the meat and excreting the bacteria version of poop into your lamb chop. Later, if the heat of the cooking process isn’t enough to kill all the bacteria and break down all the bacteria poop, it ends up in your tummy. Even if your body can handle the bacteria, it probably can’t handle the bacterial poop, which is made up of all kinds of fun toxins & chemicals. What doesn’t end up in your tummy winds up in tupperware containers so you can eat it later. The bacteria process starts all over again in the leftovers, so even if the first batch didn’t sicken you, the leftovers might, particularly since microwaves don’t heat evenly. So relatively vast colonies of bacteria and their poop can make it into your belly from the cooked leftovers too.

And for all you vegetarians out there, sitting at your laptop all smug and self-righteous, the same thing can happen with your bean sprouts and tofu. Who's picking and packaging your food? Probably not a bunch of other vegetarians. It's a bunch of undocumented workers trying to hustle a buck or euro by picking your lettuce, arugula, swiss chard and soybeans. They're out in the fields picking and packaging with some foreman yelling at them to hurry up before Immigration catches up with them. So when Juan or Abdullah or Cho needs to go to the bathroom, he'll be hitting the outhouse, or maybe he'll just go right there in the field. With no time or facilities to wash his hands, your broccoli arrives to you with a little staphylococcus souvenir.

How to prevent and treat food poisoning? First, proper handling and cooking is paramount. Unless you work in a slaughterhouse, that part is kind of out of your hands. Wash your food, because God only knows what illegal immigrants with questionable bathroom hygiene handled it between the farm and your table. Cook it thoroughly to kill bacteria and denature the poop chemicals. Store it refrigerated to retard bacterial growth, and reheat it thoroughly. Basically do everything they taught you in grammar school. One other thing - those heat lamps over prepared food or the tiny burners under the chafing dish at a buffet do NOT prevent bacterial growth. In fact, the slightly elevated temperature provides a bacterial paradise for the little guys to be fruitful and multiply. When treating food poisoning, diarrhea and vomiting can cause severe dehydration. If PO fluids can be tolerated, rehydrate that way. Most likely, IV fluids will be necessary. On the streets, there’s not much you can do for the electrolyte imbalances that occur, but expect an abnormal EKG from hypokalemia. Some patients may have burned up all their glycogen reserves since they can't eat without vomiting, and their cells try to consume glucose, so some may experience hypoglycemia. Urine output will be decreased, so be sure to ask your patient about that, as acute renal failure can occur. Be especially suspicious of dehydration in the elderly and the very young. Expect a few rounds of antibiotics to deal with the invading bacteria. 

So no, food poisoning is not fun, but it’s not an insidious crime and it probably should be renamed. It can happen to anyone, anywhere. And if someone in the house gets sick with food poisoning, throw out the offending culprit. Don’t do as I saw, when two people were obviously sick from bad crawfish. When I told them to throw it out, old Grandpa decided to start eating them right there in front of us. New crawfish is cheaper than a hospital visit and no, you won’t win your stupid lawsuit.

Onward and upward...