As I was preparing for this year, I found myself searching WordPress and other Blogging sites for past Watson Fellows’ blogs. In my search I found a lot of helpful tips about packing and departing. I found myself returning to these blogs, searching for their early posts to see if they ever mentioned any of the challenges they faced within the first few weeks along their journey. In my search, I found many posts with the title “Watsoversary” in them. I got a good laugh out of the name, mostly because it was just cheesy enough for me to love it, and also because I knew I would also be using the coined term I found. A Watsoversary is indeed approaching. Today, August 8th at 6:00 pm ET officially marks one month since I took off from the Charlotte Douglass International Airport. If anyone has any idea how a month has come and gone as quick as this one, please let me know.
Two weeks have come and gone as well since I last posted. To those diligently checking everyday (Mom)…sorry for the delay! As were the first two weeks, these last two have also been filled with high highs and low lows; all of which I am learning to celebrate. Many times throughout my life I have been encouraged to keep a journal of my thoughts, feelings, emotions, and memories of a trip, experience, and many times I have been successful for about 4 days. They say it takes time to form a habit. If I were to name one thing that has come close to being a habit, journaling is something that is becoming one. Most times I thought journals had to contain grandiose and illustrious prose, full of thoughtful inquiries of days spent somewhere new and adventurous. At least, this is the image I had built in my head. Most days, if not all, I am seeing that is not the case. It has become the place, whether at the beginning, middle or ending of a day, to document where I am and where I have been. At times the lines are filled with plaintext definitions of my day, other times questions about what I should do next (within the day and within the year), and other times I have verbalized to myself, “what am I really doing?” having reached one month, this is one question I did not anticipate asking myself as much as I have. Last post I mentioned how I have come to recognize the small victories as I continue along a my trail of breadcrumbs. That I am surely still doing, but I haven’t succeeded in doing so every time. It’s a process. As you may be beginning to realize, these posts are both a reflection of my own thoughts and feelings, as well as a recount on all that I have done and learned. Bear with me.
I am finding some structure within these posts. Within them you will find a welcome followed by a general thought about where things are for me. Next is a summary of the days past since I last updated the blog followed by some photos of those days! Part three of my posts will be devoted to updating you all with things I have learned about my project and the progress (however large or small it may be at a time) I have made. For now, I’ll stick with this structure. Keep reading for an update on my days or skip along to the next heading for a project update!
- Monday 7/24: I started off week three by misreading my emails. Traveling to the main fire station for shadowing at 8:00 am, it was only when I arrived that I realized that I wasn’t scheduled until Friday, the 28th. Oops. Instead the day was filled with posting a blog update, touring Copenhagen City Hall (and finding myself near the top of the City Hall tower without a ticket…oops again). In the evening I saw Dunkirk and reflected on the ramifications both World Wars had on Europe.
- Tuesday 7/25: (Happy Birthday, Mom!) I finished my book (Racing the Rain, By John L. Parker Jr.) and bought a new one (Being Mortal, By Atul Gawande)! I also joined a running club, named Sparta. Turns out they are the largest running club in Copenhagen, they run hard workouts every Tuesday and Thursday, they and are very welcoming!
- Wednesday 7/26: I toured Morten’s School and took a trip into the country to pick up Rune. This resulted in surprise project discussion with family friends Rune had been with.
- Thursday 7/27: I discovered new coffee shop and met a new faces. I met someone who is an “Emergency Architect,” who works on the refugee housing crisis. The evening ended back at Sparta for another run.
- Friday 7/28: (The Official) Prehospital Physician Observation Day. I went to the Copenhagen Main Fire station to speak and sit with the Physician and Paramedics on call who drive the “Physicians Ambulance,” a car that additionally responds to emergency calls when serious enough. My time ended with a step towards securing a shadowing opportunity!
- Saturday 7/29: I took a train to Helsingør, where Morten picked me up to go to their camp site. Today was a family birthday celebration for Rune, who was soon to be 11! I got to meet Grandparents, Aunts and Uncles, and extended family friends. Presents, cake, and a cookout ensued and the day/evening was filled with talking about my year as well as hearing different perspectives on what it means to be cared for.
- Sunday 7/30: A Sunday Long-Run followed by a day of documentation (transcribing recent recordings of various conversations)
- Monday 7/31: On Monday I got a MRSA test (I passed!), spoke with a stranger at an open air market, had an introductory meeting with a HR intern at Falck Group, an international emergency response agency, and I finished writing down all of my recordings.
- Tuesday 8/1: (Happy Birthday, Rune!) Tuesday felt a little aimless, but ended with securing some contacts in Bornholm, an Island in the Baltic Sea.
- Wednesday 8/2: I shared a conversation over coffee with an ex-student of Morten’s who happens to now be a medic in Copenhagen. I spent the day learning about life on the ambulance and what his experience has been as a medic here. I also secured a meeting with Falck to learn more and discuss possible work/observation opportunities.
- Thursday 8/3: I raced a 10k! Sponsored by the Sparta Running group, Morten and I had signed up. It poured the entire hour leading up to the race and we stood there waiting, soaking wet and cold. To my surprise, I finished in 9th place!
- Friday 8/4: On Friday I met with an administrative member in Falck. I shared about my project, learned about the history of Falck and discussed different opportunities for working with Falck as I move forward, both here in Denmark and abroad in South America and Southeast Asia! We traveled to Morten’s father’s in Roskilde for dinner and then onward to the camp site again Friday afternoon.
- Saturday 8/5: I took a day trip into Helsingør, toured the city, the Kronborg Castle (where Hamlet is based), and the Danish Maritime Museum. In the afternoon I gazed open golden fields of grain, and celebrated the end of summer with the camp site community.
- Sunday 8/6: Waking up in a quaint, single-person camper, the day clearly started off well. Back home in Copenhagen, I went to Frederiksberg for the Stella Polaris Music Festival. There I met new people and engaged in conversation about my project (It is getting easier to do!).
- Monday 8/7: On Monday I spent 7 hours in the Bispebjerg Emergency Room with one of the doctors I had previously met. I learned more about the Emergecny Room structure and saw patient-care first hand.
After an (maybe not so brief) update, how about some pictures?!
Project UpdateTo those still reading, thanks for sticking around!
To recount, the major events that have occurred since my last post:
- Tour of Pre-Hopsital Physician Center
- Interview with a Copenhagen Medic
- Falck Group Introductory Meeting
- Shadowing at Bispebjerg Emergency Department
What I have shared thus far, and will continue to share about currently focuses on the Capital Region of Demark. The other four regions have their own systems in place, and although they do work together to provide care nationally, their structure varies from place to place. Today I will continue to focus on structure and implementation of care.
There is a strict structure in place for 112 Call Receivers and Dispatchers to ensure the right ambulance and level of care is dispatched to each emergency. 112 Receivers, who are either trained medics or nurses, take each call and determine the need based off of a triage worksheet on one of the monitors. This triage is an extensive and broad application that helps determine the level of care required. This process involves categorization; for example, with chest pain options may include, “doesn’t react to verbal command or applied pain,” or “sudden onset lasting more than five minutes, verbally responsive.” Depending on the response of the caller, the 112 Receiver can choose which tab to select. In choosing, the application provides an auto-suggestion in realtime to the dispatching software. Listed below are the levels in which the software may choose:
- A1: Lights and sirens, with an Ambulance and Physician dispatched
- A2: Lights and sirens, Paramedic Ambulance only
- A3: Lights and sirens, Level 2 Ambulance only (no paramedic required)
- B1: Paramedic Ambulance dispatched with discretion for use of lights and sirens based mostly on traffic conditions
- B2: Paramedic Ambulance dispatched, no lights and sirens
- B3: Level 2 Ambulance dispatched, no lights and sirens
If you can picture it, think about there being three or four monitors for the 112 Receiver to view. You have a map of the region with the location of all ambulances in service and all of the AEDs present. You have a screen that houses the triage application, and you have a screen to document the information on the call. Once documented and the level of care is determine, this information is seamlessly transfered to a dispatcher who determines the closest ambulance and then guides either the ambulance or both ambulance and physician to the call. Additionally, in realtime, this information is transfered to a tablet on the ambulance and physician vehicle and updated whenever there are changes.
I have mentioned before the map containing the location of all registered AEDs in the area, here is a picture of what that map looks like:
As you can see, there are an extremely large amount of AEDs within the city center, however as you move outwards and extend into more industrial or developing areas, you can observe a decrease in the level or presence. An additional fact I learned regards laws in place to protect civialns from legal harm in the instance of an emergency. For example, if someone on the street has a heart attack and a bystander is able to see an AED behind a locked door, but otherwise would be able to get inside, they are at no risk legally if they break the door to enter and obtain the AED. It is the idea of doing something for the greater good. One person’s life is of more value than a glass door.
At the Prehospital Physician Center, I first received a tour of their Physician vehicles, which are essentially a secondary ambulance in regards to what equipment is carried; however, the vehicle does not possess the capability to transport patients. These vehicles are well stocked because they need to be prepared to provide the appropriate treatment on scene if they arrive before an ambulance does. In each vehicle, you have a physician on call and a paramedic who serve together as partners. When calls of enough severity are received, they are also dispatched to the scene along with an ambulance. Typically when this occurs, the physician then rides in the ambulance to the hospital with the other medics and the patient, while the paramedic follows the ambulance to the hospital. This system maintains efficiency and allows for physicians to be immediately back in service upon arrival to a hospital. On a given day in the Capital Region, there are either 5 or 6 physician’s on call, each with their own paramedic partner and vehicle. What is unique about this system is that it is entirely volunteer based. No physician is required to schedule time to work a pre-hospital shift, which lasts for 12 hours. Rather, each physician who is on call has signed up on their own accord because they are genuinely interested in the service. This work is supplementary to the work they do in the hospital and typically accounts for about 20% of the work they do. The other 80% is spent in a hospital. Although it would be quite possible to staff these positions if other’s did not volunteer, but this volunteer mentality speaks strongly for individuals who are working specifically to provide care, not for profit or some other value. When you have individuals who legitimately want to be there, then you have a better work place environment and a better ability to treat patients. This was reflected in my conversations with both physicians and paramedics while observing.
The presence of pre-hospital physicians in the line of emergency care is allowing for a shift in style of treatment. What has been conventional in most places for any ambulance responding to a call is the notion of “load and go,” where medics arrive on scene, load the patient into the ambulance as rapidly as possible, and transport to the hospital. With prehospital physicians arriving on scene with an ambulance, you open up the opportunity for “stay and play,” where you remain on scene and provide interventions without immediate transport. This has typically not been considered the appropriate norm; however, with a physician present and the right materials, it is possible at times that they are able to finish a call and not need to transport the patient to the hospital.
Even within this system, which may seem as public as you can get, there are still competitors. The two main competitors in this region are the Copenhagen Fire Brigade and Falck Group. The former, a public service run and funded by the Copenhagen Commune, the latter, a private company. Both are in competition for acquiring contracts within the city and externally in the region. It is up to the various municipalities to determine which service (or if both) will be provided. After my meeting on the 4th, I learned that Falck serves roughly 70% of Denmark; however, their presence is much lower within the city limits of Copenhagen.
Falck is a Global Company that began here in Denmark in 1906, and acquired it’s first ambulance in 1907. Their motto is “People working for People” and although they are a private company, their presence through the years has often left them regarded as a public group because of how universal their care has become. As time has progressed, Falck has expanded its scope. What was originally an emergency response organization Falck now provides fire response, on-site vehicle and home assistance, clinical care, and healthcare. Today they are the worlds largest emergency medical provider in the world, with ongoing work occurring in 22 countries. They respond to over 4 million calls a year and have thousands of ambulances in service here in Denmark and abroad. You can read more about the work Falck is doing in Denmark and abroad here. If you’d like to read more about their history and their mission, please read more here. Falck’s emergency response extends similarly beyond one’s conventional understanding of emergency response. Just like the presence of pre-hospital physicians, Falck provides assistance to individuals who may not need an ambulance, but are still in need of care and transport. These patient-transport vehicles are staffed by trained personnel and serve the greater community to allow for individuals to have increased access to care.
One final note on the prehospital side of things, I learned of a 4th kind of ambulance present here. As I mentioned, there is the standard ambulance, a psyche-lance, and a baby-lance, but there is also a Social-lance, which staffs both a paramedic and social worker. This ambulance is able to provide adequate medical care while also allowing for a social worker to work with the patient on their current condition. This speaks to a level of care that moves beyond the purely physical and extends into providing well-being for others. The social workers can then help create a plan that works towards decreasing an individual’s need to call 112 and increasing their ability to provide for themselves in a healthy and safe way. All of which, I believe, is outstanding. Most often, as I learned in my conversation with a medic this past week, this vehicle responds and works with the homeless community.
Lastly, I want to provide what I have learned about how the emergency room is structured here. Yesterday I spent the afternoon with the head physician on call. He, as well as three or four other doctors, and countless amounts of nurses, work together to provide the necessary care to those who come. They treat and care for people who have called 112 and have been transported by ambulance as well as those who have walked into the hospital (or have called ahead, but transported themselves). As is structured on the pre-hospital side, the name of the game is efficiency. Similarly to the 112 Receiver’s triage system, the emergency room also has a criteria consisting of five levels that helps them determine the level of care needed. Some may believe that a first come first served structure is best; however, the triage system helps prioritize the conditions and patients who may be in the greatest need at the time. Although this is helpful, it is clear that when a hospital gets busy, this structured system begins to falter, but this is not unique to Copenhagen, or Denmark. People are always talking about emergency room wait times. You often see arguments about which country or which system works better, but at the end of the day, a large limiting factor is space and availability of staff. At some point, every place reaches capacity and is thus strained. Given the strain, Bispebjerg Hospital was running smoothly. Observing the lead physician helped provide a better understanding of how the hospital structures itself. This physician is more of an overseer, who thinks about the big picture, like how to open up space when there doesn’t seem to be space at all. This allows for the other physicians and nurses the time and space to treat more people. Now, I have not had the pleasure of shadowing other emergency rooms, so I cannot go as far to say this is a particularly unique set-up, but it was clear that it was one that is utilizes its resources.
Most things I saw in the emergency room were minor, and I know that this is not always the case. There are times where it may seem as if every possible health disaster is happening at once, but more often than not, the cases received are minor, yet numerous. Emergency Rooms see all of these things and never once question if it should be cared for. In the context of medical emergencies, a doctor or nurse may see something as relatively minor, but for patient, or their spouse, parent, friend, etc. what may seem minor to the health professional my be serious for them. And this is what is at the heart of my project this year. How are these systems able to provide care in such away that allows people to feel safe where they are, to feel well, and to live without stress of the next thing that pops up. Yesterday was a glimpse, and there is a plan to see and observe more, but it was good to start to see first hand how physicians are working.
What’s up for this week? Today has been mostly filled with blogging and taking notes from yesterday. I plan to go running with Sparta later. Tomorrow I’m volunteering at a music festival set-up and Thursday I am planning another meeting with Falck. This weekend I travel to the northern region of Denmark. I’m heading to a wedding with my host family! There is much to be excited about.
If you are interested in reading on for a few more lines, take a look at this poem by Philip Larkin, titled, “Ambulances.” Two lines were featured at the start of Atul Gawande’s Being Mortal. I find the poem in whole to be rather somber, but speaks well of our human condition. Wired towards deterioration, physicians and health care providers are in the midst of it all. “All streets in time are visited,” but it is the way in which they are visited that I think matters.
“Closed like confessionals, they thread / Loud noons of cities, giving back / None of the glances they absorb. / Light glossy grey, arms on a plaque, / They come to rest at any kerb: / All streets in time are visited.
Then children strewn on steps or road, / Or women coming from the shops / Past smells of different dinners, see / A wild white face that overtops / Red stretcher-blankets momently / As it is carried in and stowed,
And sense the solving emptiness / That lies just under all we do, / And for a second get it whole, / So permanent and blank and true. / The fastened doors recede. Poor soul, / They whisper at their own distress;
For borne away in deadened air / May go the sudden shut of loss / Round something nearly at an end, / And what cohered in it across / The years, the unique random blend / Of families and fashions, there
At last begin to loosen. Far / From the exchange of love to lie / Unreachable insided a room / The trafic parts to let go by / Brings closer what is left to come, / And dulls to distance all we are.”
Take care and thanks for following along.
See you. Vi ses.