PULSE Magazine | March 2019 Issue

PULSE Magazine is the interactive monthly news magazine of Austin-Travis County EMS. Click, open, read, share, enjoy!

March 2019 ANAUSTIN-TRAVIS COUNTY EMS PUBLICATION P U L S E

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March 2019

Contents

Featured News

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NATIONAL BRAIN INJURY AWARENESS MONTH

Statistical facts and subtle symptoms of a traumatic brain injury. No brain injury is too mild to ignore or too severe to lose hope.

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WOMEN’S HISTORY MONTH

Women who work in Emergency Medicine are described as strong, independent women who have taken control of their lives and chosen careers in one of the most challenging medical environments on the planet. This issue kicks off an ongoing series to high- light some of ATCEMS’ most inspirational women.

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ALL LIVES ARE PRECIOUS

During a recent shift at M24 Clinical Specialist P. Riefel & Medic B. Jones responded to a structure fire. Upon arrival they were informed a dog was trapped inside the residence.

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A JOURNEY OF SURVIVAL

On March 9th and again on March 18th cardiac arrest survivor JesLeigh Morris and her family met with the team of first responders who gave her a second chance at life.

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Division News

In Every Issue

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ATCEMS TACTICAL TEAM TRAINING

EMPLOYEE RECOGNITION

ATCEMS tactical medics train hard and are ready for any given situation that confronts them. This specialized team of paramedics maintain their skills through rigorous quarterly training.

ATCEMS employees receive kudos, special thanks and congratulations for a job well done.

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WHAT IS:

ARE YOU READY?

The impact of fasting on the human body?

The ATCEMS EMS PIO team conducts another Emergency Preparedness presentation to a local AARP group.

The latest study to explore the impact of fasting on the human body concludes that it increases metabolic activity more than previously realized and may even impart anti-aging benefits.

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CUSTOMER SERVICE SURVEY

Results from the ATCEMS Customer Callback Program.

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IMPORTANT INFORMATION TO KNOW

Clinical Pathology Laboratories (CPL) is no longer in-network for HMO plan partici- pants; however, HMO participants can seek services from Quest Diagnostic or any other in-network lab facility. PPO and CDHP participants have the option to seek services from both CPL and Quest Diagnostic. BLUE CROSS BLUE SHIELD HMO participants will pay out of pocket when using Clinical Pathology Labs. The new In-network lab is Quest Diagnostic.

Important: Employees should confirm that the lab your provider refers you to is in-network prior to receiving services.

HMO participants who use an out-of-network lab will have no coverage. PPO and CDHP participants would be required to meet the deductible.

Steps to locate an in-network laboratory:

 Call BCBS customer service at (888) 907-7880, or Log in at bcbstx.com/coa . If you haven’t registered, you will need your member ID, which is located on your BCBSTX ID card.  Click Doctors & Hospital tab.  Click Find a Doctor or Hospital link.  On the search field, search “Lab.” Select “Lab Technician” from the drop down menu.

Contact: Employee Benefits Division at (512) 974-3284 with any questions.

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OPERATIONAL UPDATE March 25, 2019 OMD PL4 Credentialing

PL3-ILS Technician Additional Approved Interventions for Credential Level PL3 • Peripheral intravenous access (IV) • Intraosseous access (IO) (cardiac arrest) or Critical patient in which initial IV •Tracheal suctioning attempt has failed or is not possible • BIAD (non-cardiac arrest) Additional Approved Medications for Credential Level PL3 • Acetaminophen PO • Dextrose solutions IV • Naloxone (all routes) • Glucagon IM • Ibuprofen PO • Diphenhydramine (all routes) • Ondansetron (all routes) • Lidocaine for eye irrigation only • Epinephrine 1mg/10mL (cardiac arrest) • Non-medicated intravenous solutions • Ketorolac IM OLMC or if on-scene PL5 directs The OMD will begin credentialing providers at the PL4 level starting at the end of March. Please review the below procedures and medications that can be administered by the PL4 provider. The PL4 will still be filling the MEDIC role. The OMD will be sending out dates in the near future for those that are interested in obtaining this credentialing. There will be many opportunities over the next few months. The below descriptions of skills were taken from OMDR-3. PL4-Paramedic Technician All above listed requirements/skills/interventions/medications/patient assist medications PL4 providers may perform procedures and administer medications at the PL5 level if done under DIRECT oversight by PL5 credentialed provider Additional Approved Interventions for Credential Level PL4 Independent of Oversight by PL5 • External jugular vein cannulation • ECG monitoring and interpretation • Manual defibrillation • Alternate vascular access (indwelling catheter) • Gastric tube insertion • Modified Valsalva • FBAO with direct laryngoscopy Additional Approved Medications for Credential Level PL4 Independent of Oversight by PL5 • Epinephrine (additional doses, nebulized) • Tranexamic acid • Atropine sulfate (cardiac arrest & Organophosphate) • Hydroxocobalamin • Magnesium sulfate • Pralidoxime • Calcium chloride (cardiac arrest) • Methylprednisolone • Sodium bicarbonate (cardiac arrest) • Lidocaine (cardiac arrest) • Amiodarone (cardiac arrest)

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No brain injury is too mild to ignore Or too severe to lose hope.

 26,212 non-fatal bicycling related brain injuries occur annually.  2.8 million traumatic brain injuries occurred in 2013, the most recent data from the CDC.  19.5% of high school athletes have had a concussion.  5.5% of high school athletes have had more than one concussion.  $400,000 is the lifetime cost of a severe brain injury.  153 deaths occur each day from injuries that include a brain injury.  53,000 deaths from brain injury occur each year.  47% of ER visits were for brain injuries from 2007 to 2013.  3.2 to 5.3 million Americans are living with a TBI-related disability.  70% of all sports and recreation-related brain injuries were reported in people ages 19 and younger.

BE SAFE

CHILDREN/TEENS

ELDERLY

Clear pathways and secure trip

 always properly buckle your children into the proper fitting car seat

Install grab bars near toilets an

 Wear proper fitting helmets when playing contact sport, riding bikes, scooters, skateboards, hoverboards or horseback riding.

Install handrails at stairs includi

 Always practice good sportsmanship while playing contact sports.

Improve lighting throughout ho

 Install window guards/safety gates to keep small children from falling from great heights or into a pool/body of water.

Wear proper footwear with stur

 Do not dive into shallow water always test the depth first.

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Don’t miss the subtle symptoms

Difficulty concentrating

Severe mood swings

Slower pulse rate

Ringing in the ears

Trouble thinking or “brain fog”

Dizziness

Headache

STAY SAFE

DRIVING

azards such as throw rugs.

 Wear a helmet while riding/driving a motorcycle, bicycle or scooter.

showers.

 Wear seatbelt at all times, even as a backseat passenger.

g single step-up/down areas.

 Never drive while under the influence of mind altering medications, drugs or alcohol.

e to ensure well light areas.

 Do not drive while under extreme fatigue.

y soles and grips.

 Always be aware of your surroundings and watch for potential hazards.

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Community Relations

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BE SAFE

STAY SAFE

The Austin-Travis County EMS Community Relations & Injury Prevention Team helps the public to stay safe by providing injury prevention programming that helps mitigate the risk of preventable injuries; including those that can result in traumatic brain injury (TBI). Our Child Passenger Safety, Safe Baby Academy and Senior Home Safety programs address a variety of safety concerns and issues to help keep our community safe.

SENIOR HOME SAFETY PROGRAM

The Austin-Travis County EMS Injury Prevention team has developed a program that incorporates training and resources for seniors at risk and fall prevention strategies call for patients to change their behaviors by:

• Attending a fall prevention program • Doing prescribed exercises at home • Changing their home environment to identify and eliminate trip hazards

We have partnered with the Seton and St. David’s Hospital networks in Austin to provide the “Stepping On” Program. The Stepping On program incorporates a group setting with individualized follow-up. It covers a range of issues, including:

• Falls and risk • Strength and balance exercises

• Home hazards • Safe footwear • Vision and falls

• Safety in public places • Community mobility • Coping after a fall • Understanding how to initiate medication review

We have a team of trained personnel who conduct FREE in-home safety assessments to identify potential risks and hazards in the home environment. The in-home safety assessment is a room-by- room survey of the client’s living space to identify hazards for trips, slips and falls.

Residents of Austin can request a free in-home safety assessment by calling the EMS Safety Hotline at 512-972 SAFE (7233) or by visiting our website and filling out an electronic Fall Prevention Home Visit Referral Form.

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The ATCEMS Child Passenger Safety program is designed for families and caretakers of small children (infant through 12 years). Our team of nationally certified Child Passenger Safety Technicians con- ducts FREE car seat inspection events every month all over Austin and Travis County. We also partner with communities outside of Travis County to help provide programming in the Central Texas Region. This program requires you to attend an event to have your car seat thoroughly inspected to insure it is the correct type and size of seat for your child, and that it is installed properly in your specific vehicle. We also provide FREE car and booster seats to families in need. In addition you will learn:

How to install child’s car seat

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How to harness your child properly

 How to use the latch system should you have one  How to choose the correct seat for your child's age and weight  The Texas child passenger laws  Best practices for car-seat safety

SAFE BABY ACADEMY

Safe Baby Academy, is a FREE three hour class for expectant parents, parents and caregivers of infants. This class is 3 hours long and provides invaluable education with hands-on practice for help in creating a safer environment for you and your child. This class is taught in a small setting designed to provide you with individual attention. You can expect to learn about:

CHILD PASSENGER SAFETY —Get your Car seat checked by a certified technician and learn the Texas laws and discuss best practices about car seat safety for children of all ages.

SAFE SLEEP EDUCATION – learn details about creating a safe sleep environment for your child

HOME SAFETY —Discuss and review 9hidden) dangers found in homes and how to make your home environment safer

WATER SAFETY – Learn how to keep your child safe around water

INFANT CPR and CHOKING —Learning and practice hands on CPR and choking techniques

Visit our website to sign up for the Child Passenger Safety Program or Safe Baby Academy .

Contact EMSPubEd@austintexas.gov with any questions.

Help keep yourself and your children safe in the event of an accident. ATCEMS Injury Prevention programs can help protect your children and your loved ones from preventable accidents and injuries.

Don’t delay! This is a FREE opportunity for families, parents, grandparents and caregivers to receive up-to-date best practices and safety information and training that can change lives.

BE SAFE

STAY SAFE

THINK

AHEAD

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HISTORY MONTH

One hundred and sixty-eight years ago, Elizabeth Blackwell became the first woman to obtain a medical degree in the United States. Since then, the field of medicine has progressed with important contributions from the many women who followed in Dr. Blackwell's footsteps. Women who work in Emergency Medicine are described as strong, independent women who have taken control of their lives and chosen careers in one of the most challenging medical environments on the planet. At ATCEMS we have an incredible number of strong, successful and inspirational women. We reached out to find those special female medics who have dedicated over 25 years of service to ATCEMS to celebrate women making history within our own system. Elizabeth Campbell responded to the call and just happens to be the most tenured Field Clinical Specialist in our department with almost 30 years of service! Emergency Medical Services is a way of life and Elizabeth is an integral part of that life. Her dedication and knowledge has aided in the growth and direction of our system throughout the years. Today many women have benefitted from her skills and leadership and been given the opportunity to blossom and grow in a thriving career that was once dominated by men. Elizabeth is a refreshing example of women in the top of their career field helping to make the world a better place for everyone, but especially for women of her generation and in the world of EMS. In addition, Elizabeth has made a lifelong contribution to our own department by inspiring, connecting and empowering women to follow their dreams. After reading and learning about this dedicated female role model, perhaps you'll be more inspired than ever to conquer anything and everything. The only thing stopping you is YOU! “ If we stop defining each other by what we are not and start defining ourselves by what we are, we can all be freer.”

Emma Watson

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Elizabeth Campbell

Date of Hire: June 4th, 1990

ATCEMS VETERAN

29 years of service and our most tenured Clinical Specialist in the field

Reflect on your years of service/career.

1. Becoming a member of the TOPS team (Tactical Operations Team) that is now SpecOps, STARflight and the addition of Tactical medics to our medical practice. 2. I used to teach new medics back in the day and as an instructor there were a few of us EMS employees that were able to go to Moscow for several weeks at a time and teach Russian students prehospital medicine. This was a very, very cool thing that I did and so interesting!!! What was the greatest lesson you learned from your time in the field that has helped you succeed in the business today?

I began my career with Austin EMS on June 4th, 1990. My cadet class consisted of about 20 people. I am the only one left from that class. Pete Didonato and Paul Alvarez were my paramedic school classmates and they both later joined the department.

Who have been your role models? What about them do you admire?

ATCEMS retiree Janelle Boone—honesty, integ- rity and a she was a great clinician.

Most remarkable changes/growth within the business/during your tenure?

The greatest change and growth is prehospital medicine. It has become a respected career choice, we’re not just “ambulance drivers”.

Acceptance that my idea of a 911 need may not be the same as another persons.

For the next generation of women who want to work in this field, what would you tell them?

How have your experiences changed/ affected you?

I have become a more tolerant and kinder person.

YOU. CAN. DO. IT. Also, be kind and always do the right thing.

What motivates/inspires/empowers you?

What in your life has brought or given you the greatest satisfaction or fulfillment? Any future dreams? I have had the greatest satisfaction being a parent followed very closely by my career as a paramedic. Future dreams include travel and hopefully grand babies!

My own self love.

Tell me about a project or accomplish- ment that you consider to be the most significant in your career?

There are several actually:

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Describe the barriers you faced as a woman in Emergency Medicine and how you overcame them and/or dealt with them. I have not faced many barriers I suspect because there were several strong women already working as medics at Austin EMS prior to my arrival (Robin Cope, Bonnie Stroud, Bitsy Brooks, Pauline VanMeurs to name a few) AND I never felt that I was any less capable of doing the job than anyone else would be. The women in the fire depart- ment in the early days of my paramedic career certainly had it harder. To this day I still get ”you actually drive an ambulance?” said in a way that a female seemingly wouldn't be able to handle the task. Losing a patient is always difficult, no matter the circumstance or how long you have been practicing. Reflect on your own experiences and your coping mechanisms. I learned long ago to “not look” in other words, when I run on a “bad call” where there may be something horrible, people deceased, etc. I don’t look more than I absolutely have to so that the images don’t “imprint” on my brain. In the old days, EMS workers would take polaroid's to keep looking. I wonder how they’re doing now? My coping mechanisms and what I recom- mend to anyone is to find one or more interest that have or nothing to do with this job. There are healthy outlets for stress that do not include unhealthy addictions such as alcohol, food and drugs, etc. Looking back on your career, what advice would you give to your younger self? What words of wisdom would you like to impart on the new generation of female medics? Celebrate each day as we are not guaranteed tomorrow!

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During recent shift at M24 Clinical Specialist P. Riefel & Medic B. Jones responded to a structure fire. Upon arrival they were informed a dog was trapped inside the residence. The Austin Fire Department and Travis County Fire Rescue /ESD 11 were able to rescue the dog from the house. ATCEMS crew members Pete and Benjamin received the distressed dog from the fire department. The crew was able to successfully revive this much loved dog. Their success was aided by using the pet oxygen masks that ATCEMS stocks on all of their ambulances! Audrey the dog was barely breathing when she was rescued. The quick action of our outstanding medics and the use of the pet o2 mask helped save the life of Audrey the wonder dog. Audrey made a full recovery and was happily wagging her tail as she received hugs from her grateful owner. ALL LIVES ARE PRECIOUS WAY TO GO! Pete Riefel and Benjamin Jones save a BEST FRIEND from smoke inhalation.

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ATCEMS Tactical Medics Quarterly Training:

Junctional Tourniquet

ATCEMS tactical medics train hard and are ready for any given situation that confronts them. This specialized team of paramedics maintain their skills through rigorous quarterly training. The training for this quarter focused on Junctional Tourniquet placement in a SWAT “officer down” situation. Having only been cleared by the FDA for use in 2010, commercial junctional tourniquets are a relatively new arrival to the world of emergency and pre-hospital medicine. ATCEMS tactical medics are proud to be among the few to have this device readily available to them should the need arise.

Junctional Tourniquet for hemorrhage control is designed to control bleeding in areas where standard tourniquets would not be effective, such as IED/Blasts or high level amputations.

The Target Compression Device (TCD) is placed at or proximal to the injury site and inflated until the bleeding stops. Two TCDs can be used to occlude blood flow bi-laterally if needed.

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A Journey of Survival Cardiac arrest survivor JesLeigh Morris meets the team of first responders who saved her life

On March 9, 2019 JesLeigh (Jessica) Morris and her family met with the first responders who forever changed her life. JesLeigh’s fiancée Matthew called 9-1-1 when he found her pulseless in her home back In November 2018. ATCEMS Communication Medic J. DeLong took the call and provided pre-arrival and CPR instructions to Matthew. APD officer C. Turi arrived first on scene and continued chest compressions until AFDs Engine 10 crew arrived and took over. Care was transferred to ATCEMS Commander R. Migl and Clinical Specialists L. Nudelman and H. Garcia who provided advanced patient care during transport to Seton Medical Center Austin. CS Nudelman and Garcia were unable to meet JesLeigh on 3/9 so on Monday, March 18th they got another chance when she and fiancé Matthew drove to Medic 21 to visit with them at the station. They couldn’t resist the great photo opportunity in the bluebonnets! JesLeigh had an incredible team of doctors and nurses during her hospital stay and her fighting spirit never gave up. She managed to pull through a very tough recovery to be standing with her rescuers just a few months after a very traumatic incident. Congratulations are in order as JesLeigh and Matthew will be married in June! We love happy endings!

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The “Chain of Survival” refers to the chain of events that must occur in rapid succession to maximize the chances of survival. Immediate recognition of cardiac arrest and activation of the emergency response system. Early CPR with an emphasis on chest compressions and rapid defibrillation. This call was a great example of the perfect execution of the “Chain of Survival”.

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Employee Recognition

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Random Fun Pics

KUDOS

F. Garcia & M. Rawn I would like to pass along Kudos to M30 Felipe Garcia and Madison Rawn for a call they ran at ABIA (they are still on scene as I’m typing this). The patient had an episode of respiratory difficulty but after his sat’s came back up to his norm the airline refused to allow him to board the plane to Atlanta without an O2 con- centrator. They went above the norm to assist this patient being able to catch his flight, including being patched to on call MD twice and calling an SAH social work- er. While the patient wasn’t able to make his flight, the care he received was truly awesome. While I am sure these two do outstanding work every shift, them doing that little bit extra today was noticed.

Captain Angela Vorhies

Paramedic, EMD-Q

Austin-Travis County EMS

SETON’S Medic of the MONTH Captain David Curvin

 “He is always pleasant to work with”  “Dave takes outstanding care of our patients”  “His reports are thorough and complete”  “He has a smile that makes others smile”  “He is a joy to work with”

CONGRATULATIONS DAVE!

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Are You Ready? The ATCEMS EMS PIO team conducts another Emergency Preparedness presentation to a local AARP group. Recently the EMS PIO team conducted an Emergency Preparedness presentation to a local AARP group in Austin. The PIO team spoke to over 100 AARP members who were in attendance. This group of Austinites inquired about ATCEMS operations, responses, and partner- ships with other local first responder agencies. In addition, they also received some important information about the national Vial of Life program, Do Not Resuscitate (DNR) protocols, accessing homes in emergencies and much more! To request a safety presentation visit the Injury Prevention & Outreach section of our website to fill out an EMS Event Request Form.

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WHAT IS... The impact of fasting on the human body ?

Fasting Boosts Metabolism and Fights Aging

The latest study to explore the impact of fasting on the human body concludes that it increases metabolic activity more than previously realized and may even impart anti-aging benefits. Studies have shown that intermittent fasting can help certain people lose weight. Although researchers are still debating exactly how effective fasting can be for weight loss, new research hints at other benefits. In rats, for instance, studies show that fasting can increase lifespan. Although exciting, evidence of this in humans has yet to be seen. The most recent study which the authors have now published in the journal Scientific Reports takes a fresh look at fasting in humans and provides new insight. " Recent aging studies have shown that caloric restriction and fasting have a prolonging effect on lifespan in model animals," says first study author Dr. Takayuki Teruya, "but the detailed mechanism has remained a mystery." In particular, scientists at the Okinawa Institute of Science and Technology Graduate University in Japan examined its impact on metabolism. By understanding the metabolic processes involved, the team hopes to find ways of harnessing the benefits of fasting without the need to go without food for prolonged periods. To investigate, they fasted four volunteers for 58 hours. Using metabo- lomics, or the measurement of metabolites, the researchers analyzed whole blood samples at intervals during the fasting period.

What happens during fasting?

As the human body is starved of food, there are a number of distinct metabolic changes that occur. Normally, when carbohydrates are readily available, the body will use them as fuel. But once they are gone, it looks elsewhere for energy. In a process called gluconeogenesis, the body derives glucose from non carbohydrate sources, such as amino acids. Scientists can find evidence of gluconeogenesis by assessing the levels of certain metabolites in the blood, including carnitines, and butyrate. As expected, after fasting, levels of these metabo- lites had increased in the participants' blood. How- ever, the scientists also identified many more metabolic changes, some of which surprised them. For instance, they saw a marked increase in products of the citric acid cycle. The citric acid cycle happens in mitochondria, and its function is to release stored energy. The hike seen in the metabolites associated with this process means that the mitochondria, the fabled powerhouses of the cell, are thrust into overdrive. Another surprise finding was an increase in levels of purine and pyrimidine, which scientists had not yet linked to fasting. These chemicals are a sign of increased protein synthesis and gene expression. This suggests that fasting causes cells to switch up the type and quantity of proteins that they need to function.

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The scientists believe that a hike in antioxidants might be a survival response; during starvation, our bodies can experience high levels of oxida- tive stress. By producing antioxidants, it might help avoid some of the potential damage caused by free radicals. Next, they want to replicate the results in a larger sample. They also want to identify possible ways of harnessing the beneficial effects of fasting and find out whether they can trigger the effects of caloric restriction without having to restrict caloric intake. Although it will be some time before we can reap the benefits of fasting without the effort, the current findings provide further evidence of the health benefits of fasting.

Fasting promotes anti-aging compounds

Higher levels of purine and pyrimidine are clues that the body might be increasing levels of certain antioxidants. Indeed, the researchers noted substantial increases in certain antioxi- dants, including ergothioneine and carnosine. In an earlier study, the same team of researchers showed that, as we age, a number of metabo- lites decline. These metabolites include leucine, isoleucine, and ophthalmic acid. In their latest study, they showed that fasting boosted these three metabolites. They explain that this might help explain how fasting extends lifespan in rats. In all four subjects, the researchers identified 44 metabolites that increased during fasting, some of which increased 60-fold. Of these 44, scien- tists had linked just 14 to fasting before. The authors conclude that "collectively, fasting appears to provoke a much more metabolically active state than previously realized." "These are very important metabolites for maintenance of muscle and antioxidant activity result suggests the possibility of a rejuvenating effect by fasting, which was not known until now." Dr. Takayuki Teruya

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Customer Service Response:

235 calls were made during January The questions asked focused on measurable

customer service actions.

Patient Comments:  “All I can say at the moment is, they were excellent, professional, personal, compassionate and did a very good job.”  “They explained everything and helped hold me in a position to help me feel more comfortable. They were very hands-on with helping me feel better anyway possible, and with a kind and caring attitude. In a world that is hard to get the medical attention you need, even with a doctor's appointment, it was wonderful to have such kind and caring medics to help me.”  “They took care very good care of both me and my wife, I'm blind and they lead me around, explained everything to me and treated us like family.”  From the patient’s care taker: “They were attentive, polite, very caring and took the time out to assure her roommate that she would be O.K. They were as near perfect as could be. Their caring attitude almost made me want to cry.” Respondents were asked to rate the customer service provided by our medics on a scale from 1 to 5, with 5 being the best 72.86% of the patients rated the customer service they received at a 5 and 17.14% rated their service at a 4. The average rating overall was 4.59 out of 5 for customer service. The response we obtained from our customers is evidence of the great medics we have and the tremendous job they do each and every day.

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Customer Service Response:

209 calls were made during February The questions asked focused on measurable

customer service actions.

Patient Comments:  “They were excellent!! Please extend my gratitude for their thoughtfulness and being here when we needed them. As a mother, they made me feel better about what was going on, how they cared for her, and I want them to know that.”  “They did everything so nicely. Ask pertinent questions. They worked very well with AFD, and was very informative and help to me as well. They were excellent.”  “They were wonderful. I was in pain and at times I was not very nice, but they treated me with the most respect.”  “They came in, and did what they had to do. They were awesome, explaining everything, and transported him where he needed to go.” Respondents were asked to rate the customer service provided by our medics on a scale from 1 to 5, with 5 being the best 74.55% of the patients rated the customer service they received at a 5 and 18.18% rated their service at a 4. The average rating overall was 4.64 out of 5 for customer service. The response we obtained from our customers is evidence of the great medics we have and the tremendous job they do each and every day.

 “They came quickly and they were wonderful, my kids warmed up to them very quickly.”

 “I would give them a 10, there is nothing they could have done better.”

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29 Confidential line 855-321-3332 “Shoulder to Shoulder we will NEVER walk alone”

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